Cherokee County Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, recipe review and facility policy review, the facility failed to serve food that was palatable and at an acceptable temperature to four of five residents (Resident (R) 5, R47, R144, and R139) reviewed for food palatability out of 36 sampled residents. This failure had the potential to affect 156 residents who consumed food prepared from the facility's kitchen and could result in residents skipping meals and experiencing weight loss. Findings include:Review of the facility's policy titled, Timely Meal Service, dated 02/05/2024, indicated, Policy: Food will be delivered promptly to ensure safe, palatable, and high-quality food served at the proper temperature. Procedure . 6. Food will be served at preferable temperatures (hot foods hot and cold foods cold) as discerned by the patients/residents and customary practice (not to be confused with proper holding temperatures). Review of the facility's undated policy titled, Standardized Recipes, indicated, Policy:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and facility policy review, the facility failed to ensure two kitchen ovens, and two kitchen drawers' housing food preparation and service equipment were kept clean. Additionally, the facility failed to ensure food was stored off the floor and failed to label, date, and cover stored food. These failures had the potential to create an environment for food-borne illnesses which could affect 156 residents who consumed food prepared from the facility's kitchen.Findings include:Review of the facility's policy titled, Dietary Cleaning and Sanitizing Dietary Areas and Equipment, revised on 03/29/2010, indicated, Policy: All kitchen areas and equipment shall be maintained is [sic] a sanitary manner and be free of build-up of food grease or other soil. The facility will provide a sanitary foodservice that meets State and Federal regulations.Review of the facility's undated policy titled, Cleaning Instructions: Ovens, indicated, Policy: Ovens will be cleaned as needed and according to the cleaning schedule (at least one every two weeks). Spills and food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of facility policy, the facility failed to identify a concern as a grievance for one of 36 sampled residents (Resident (R) 178). Family Member (F) 178 requested a meeting with the facility and voiced a concern on behalf of R178 related to the physical condition of the resident upon the resident's discharge from the facility; however, the facility did not identify the concern as a grievance and did not provide any resolution to the concern. The failure has the potential to affect resident and/or family members by not having their grievances/concerns resolved in a timely manner. This was cited as a result of the investigation of complaint #474077.Findings include:Review of the facility's policy titled Grievance Policy and Procedure – Investigation Procedure, dated August 2024 reads as follows .Any resident, their representative, sponsor, advocate, or family member may file a concern, complaint, or grievance regarding a resident's treatment, medical care, behavior of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure the resident and resident representative (RP) received a written notice of transfer that included all required information for two of three residents (Resident (R) 6 and R60) reviewed for facility initiated emergent transfer to the hospital out of 36 sampled residents. In addition, the transfer notice document did not identify the specific reason the resident was being transferred to the hospital. This failure had the potential to affect the resident and/or RP not having the knowledge of where and why a resident was transferred.This was cited as a result of the investigation of complaint #474077.Findings include:Review of the facility's policy titled Transfer and Discharge including Against Medical Advice (AMA) dated 03/16/2025 indicated, .3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure an accurate Minimum Data Set (MDS) was submitted to include the correct PASSAR Level II status for two of 36 sampled residents (Resident (R) 10, and R35). The failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements, and inaccurate assessment and care planning of the residents.Findings include:Review of the facility's policy titled, Resident Assessment - Coordination with PASARR Program, revised 11/28/17, indicated Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. Review of the RAI manual, dated 10/2024 and located at https://www.cms.gov/files/document/finalmds-30-rai-manual-v1191october2024.pdf, revealed .It is important to note here that information obtained should cover the same observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy, the facility failed to follow professional standards of practice when a Licensed Practical (LPN) Nurse prepared a resident's medications, and then another nurse administered the medications to the resident. administered medications that he/she did not personally prepare Additionally, the LPN documented on the medication administration record (MAR) the administration of the medications even though the LPN was not the nurse who administered the medications. The deficient practice could result in medication errors.Findings include:Review of the facility's policy titled, Medication Administration, dated 11/2022, revealed Observe the five R's [rights] in giving medications: Resident, Medication, Dosage, Time, and Method / Route of administration. The policy does not specify a strict policy that medications can only be administered by the nurse who prepared them or that the nurse who administered the medications was document the administration in the eMAR. Review of the Alabama Board of Nursing, Administrative Code,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to honor resident requests to be transferred from the bed to the wheelchair for one of five residents (Resident (R) 7) reviewed for Activities of Daily Living (ADL) assistance out of 36 sampled residents. This failure had the potential for the resident to experience a decline in mobility and increased depression.Findings include:A review of R7's admission Record located in the resident's electronic medical records (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included stage IV sacral ulcer, klebsiella pneumonia, muscle weakness, and difficulty walking. Review of 7's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/23/2025 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven out of 15 which indicated the resident was moderately cognitively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure that one of one resident reviewed for restorative services (Resident (R) 5) out of 36 sampled residents, received the restorative care prescribed by physical therapy (PT) and occupational therapy (OT) during the restorative nursing program. This deficient practice had the potential for the resident to experience a decline in physical abilities.Findings include:Review of the facility's policy titled, Restorative Nursing Documentation dated 06/08/2023 indicated, Purpose: The facility maintains complete, accurate, and organized documentation of restorative treatments and the response to those treatments. Policy, 2. Treatment provided as part of a restorative nursing program will be documented on a daily basis.b. if the treatment is refused or withheld, the documentation will reflect the reason for not providing treatment. During an interview on 12/09/2025 at 11:06 AM, R5 stated that he/she went to rehab; however, they spend 55…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review, the facility failed to document the monitoring and assessing of residents' dialysis access site and failed to document on residents' condition for one of one resident reviewed for dialysis (Resident (R) 5) when he/she returned to the facility post dialysis treatment out of 36 sampled residents. The facility's deficient practice had the potential for the resident to experience a decline in his/her medical condition.Findings include:Review of the facility's policy titled Dialysis dated 09/10/2025 indicated, Purpose: To provide a continuance of care for the resident while he/she is receiving dialysis and promote communication between the SNF [Skilled Nursing Facility] and dialysis center. Procedure: J. Vital signs should be done prior to leaving and on return from dialysis.K. Dialysis access site should be assessed or dressing checked for bleeding, signs of infection and any abnormalities. During an interview on 12/09/2025 at 11:05 AM, R5 stated that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Observations during medication administration revealed 35 opportunities with two total medication errors, resulting in an error rate of 5.71%. During observations, Licensed Practical Nurse (LPN) 2 administered bothR147 and R42 incorrect dosages of medications. These failures had the potential to cause adverse drug reactions in the event of overdosing or lack of effectiveness of the medications in the event of underdosing.Findings include:Review of the facility's policy titled, Medication Administration, dated 11/2022, revealed, Medications are prepared, administered, and documented only by Licensed Nurses in accordance with current Alabama Board of Nursing Licensure, Licensed Pharmacist or other persons authorized by law and regulations as ordered by the physician. 1. Review of R147's Medication Administration Record (MAR), dated December 2025 and located in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure two Certified Nursing Assistants (CNAs) assisted (Resident Identifier) RI #120 with toileting needs on 10/15/19 which resulted in an avoidable fall. This had the potential to affect one of three sampled residents whose falls were reviewed. Findings Included: RI #120 was readmitted to the facility on [DATE] with diagnoses that included Personal History of Traumatic Brain Injury and Contracture of the Left Hand. On 11/18/19 pm, during the initial tour of the facility, RI #120 revealed to the surveyor falling off the bed when the bed pan was being removed on 10/15/19. A review of a fall incident report dated 10/15/2019 at 6:28 PM revealed: . resident on the floor . The fall incident report further revealed: TYPE of Injury Abrasion, Redness and Pain to right Knee . 2 cm x 1 cm abrasion to left great toe, redness noted to top of right foot, redness noted to bilateral knees . A review of a facility document titled, Activities of Daily Living (ADL)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and review of facility's policies titled Dietary _ Food Storage, Dietary Dish Machine, and Date Marking for Food Safety, the facility failed to ensure: 1. chicken breasts and biscuits were wrapped properly in the freezer; 2. a loaf of bread was not expired on a counter; 3. a scoop was not left in the corn meal and; 4. bowls were not wet nesting at the tray line. This had the potential to affect 164 of 164 residents who received meals from the kitchen. Findings include; 1. A review of a facility policy titled, Dietary_Food Storage, with a Revised date of 9-15-15 revealed; .19. Freezer Temperature: g . Wrap product so it is airtight . On 9/18/18 at 10:55 a.m., the surveyor observed twenty three chicken breasts and 20 biscuits were in a medium size box in a plastic bag in the outside freezer. The plastic bag were opened in each box exposing the chicken breasts and biscuits. On 9/20/2018 at 9:37 a.m., the surveyor conducted an interview with (Employee Identifier) EI #1, Certified Dietary Manager. EI #1 was asked what items were not properly sealed in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.