A list of the most recent deficiencies for Cherokee Trails Nursing Home. 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? |
|---|---|---|---|---|
| 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 | 2024-02-20 | 2024-03-20 | 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 | 2024-02-20 | 2024-03-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-20 | 2024-03-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-20 | 2024-03-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-20 | 2024-03-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-20 | 2024-03-20 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2024-02-20 | 2024-03-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-02-07 | 2024-03-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-07 | 2024-03-07 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-02-07 | 2024-03-07 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-02-07 | 2024-03-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-07 | 2024-03-07 | Y |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-02-07 | 2024-03-07 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-02-07 | 2024-03-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-07 | 2024-03-07 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-02-07 | 2024-03-07 | Y |
| Have policies on smoking. | Health | 2024-02-07 | 2024-03-07 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-02-07 | 2024-03-07 | Y |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-02-07 | 2024-03-07 | Y |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-02-07 | 2024-03-07 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-02-07 | 2024-03-07 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-02-07 | 2024-03-07 | Y |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-02-07 | 2024-03-07 | Y |
| Provide training in compliance and ethics. | Health | 2024-02-07 | 2024-03-07 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-02-07 | 2024-03-07 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-02-07 | 2024-03-07 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-27 | 2023-07-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-27 | 2023-07-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-27 | 2023-07-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-27 | 2023-07-28 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-07-27 | 2023-07-28 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-07-27 | 2023-07-28 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-01-06 | 2023-01-07 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-01-06 | 2023-01-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-06 | 2023-01-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-07 | 2022-12-08 | 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 | 2022-12-07 | 2022-12-08 | 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 | 2022-12-07 | 2022-12-08 | N |
| Keep all essential equipment working safely. | Health | 2022-12-07 | 2022-12-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-10-05 | 2021-10-30 | 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 | 2021-10-05 | 2021-10-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-06 | 2021-10-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-05 | 2021-10-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-18 | 2021-07-18 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-20 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-06 | Not Fixed | N |
