Deficiency Records for Cherrelyn Healthcare Center
Updated as of June 01, 2022
This is not the most recent data for Cherrelyn Healthcare Center. For the most recent information, click here.
A list of the most recent deficiencies for Cherrelyn Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-28 | 2022-04-21 | Y |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-03-28 | 2022-04-21 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-28 | 2022-04-21 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-28 | 2022-04-21 | Y |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-28 | 2022-04-21 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-03-28 | 2022-04-21 | Y |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-03-28 | 2022-04-21 | Y |
Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-03-28 | 2022-04-21 | Y |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-03-28 | 2022-04-21 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-20 | 2022-02-11 | Y |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-01-20 | 2022-02-11 | Y |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-20 | 2022-02-11 | Y |
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-01-20 | 2022-02-11 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-20 | 2022-02-10 | Y |
Provide and implement an infection prevention and control program. | Health | 2021-10-28 | 2021-11-24 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2021-05-27 | 2021-08-26 | N |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-05-27 | 2021-07-08 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-27 | 2021-07-06 | N |
Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-05-27 | 2021-06-22 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-27 | 2021-06-17 | N |
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-05-27 | 2021-06-16 | N |
Provide properly protected cooking facilities. | Fire Safety | 2021-05-27 | 2021-06-16 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-27 | 2021-06-10 | N |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-05-06 | 2021-06-01 | N |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-05-06 | 2021-06-01 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-06 | 2021-06-01 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-06 | 2021-06-01 | N |
Respond appropriately to all alleged violations. | Health | 2021-05-06 | 2021-06-01 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-05-06 | 2021-06-01 | N |
Provide activities to meet all resident's needs. | Health | 2021-05-06 | 2021-06-01 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-06 | 2021-06-01 | N |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-05-06 | 2021-06-01 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-06 | 2021-06-01 | N |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-05-06 | 2021-06-01 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-06 | 2021-06-01 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-06 | 2021-06-01 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-05-06 | 2021-06-01 | N |
Dispose of garbage and refuse properly. | Health | 2021-05-06 | 2021-06-01 | N |
Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-05-06 | 2021-06-01 | N |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-05-06 | 2021-06-01 | N |
Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2021-05-06 | 2021-06-01 | N |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-05-06 | 2021-06-01 | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-06 | 2021-06-01 | Y |
Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-27 | 2021-05-31 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-27 | 2021-05-28 | N |
Have restrictions on the use of portable space heaters. | Fire Safety | 2021-05-27 | 2021-05-27 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-27 | 2021-05-27 | N |
Provide and implement an infection prevention and control program. | Health | 2021-05-06 | 2021-05-07 | N |
Provide and implement an infection prevention and control program. | Health | 2020-04-30 | 2020-05-20 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-12-19 | 2020-01-15 | Y |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-06-03 | 2019-07-09 | N |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-06-03 | 2019-07-09 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-06-03 | 2019-07-09 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-03 | 2019-07-09 | N |
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-06-19 | 2019-07-09 | N |
Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2019-06-19 | 2019-07-09 | N |
Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-06-19 | 2019-07-09 | N |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-19 | 2019-07-09 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-19 | 2019-07-09 | N |
Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2019-06-19 | 2019-07-09 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-19 | 2019-07-09 | N |
Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2018-02-15 | 2018-04-20 | N |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-02-15 | 2018-04-19 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-15 | 2018-04-19 | N |
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-03-14 | 2018-04-03 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-03-14 | 2018-04-03 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-14 | 2018-04-03 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-03-14 | 2018-04-03 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-03-14 | 2018-04-03 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2018-03-14 | 2018-04-03 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-02-15 | 2018-03-28 | N |
Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-02-15 | 2018-03-28 | N |
Honor the resident's right to manage his or her financial affairs. | Health | 2018-02-15 | 2018-03-28 | N |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-02-15 | 2018-03-28 | N |
Keep residents' personal and medical records private and confidential. | Health | 2018-02-15 | 2018-03-28 | N |
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2018-02-15 | 2018-03-28 | N |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-02-15 | 2018-03-28 | N |
Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2018-02-15 | 2018-03-28 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-02-15 | 2018-03-28 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-02-15 | 2018-03-28 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-02-15 | 2018-03-28 | N |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2018-02-15 | 2018-03-28 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-02-15 | 2018-03-28 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-02-15 | 2018-03-28 | N |
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-02-15 | 2018-03-28 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-02-15 | 2018-03-28 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-02-15 | 2018-03-28 | N |
Provide and implement an infection prevention and control program. | Health | 2018-02-15 | 2018-03-28 | N |
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-02-15 | 2018-03-28 | N |