Deficiencies (last 3 years)
Deficiencies (over 3 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
155% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 3
Jul 9, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, medication administration, food safety, and infection prevention at Cherokee Park Rehabilitation.
Findings
The facility was found deficient in securing urinary catheter tubing for a resident, resulting in potential harm; medication administration errors were identified with a medication error rate of 11.11%; and food safety violations were noted due to unlabeled and expired food items in a resident nourishment refrigerator.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide appropriate care for residents with indwelling urinary catheters, specifically not securing catheter tubing to prevent pulling or dislodgement. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure medication error rates were 5 percent or less, with 3 errors out of 27 opportunities resulting in an 11.11% medication error rate. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to label and discard expired food items in the resident nourishment refrigerator, including unlabeled and undated food items. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 11.11
Medication errors: 3
Medication administration opportunities: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #10 | Registered Nurse | Named in medication administration errors including failure to prime insulin pens and failure to administer ordered insulin dose |
| CNA #12 | Certified Nurse Aide | Mentioned in relation to catheter tubing securement practices |
| CNA #13 | Certified Nurse Aide | Mentioned in relation to catheter tubing securement practices |
| RN #14 | Registered Nurse | Observed and corrected unsecured catheter tubing |
| LPN UM #15 | Licensed Practical Nurse Unit Manager | Provided information on catheter tubing securement and care planning |
| Director of Nursing | Director of Nursing | Provided expectations on catheter securement and medication administration standards |
| Administrator | Administrator | Provided administrative oversight comments on catheter securement and medication administration |
| Pharmacy Consultant | Pharmacy Consultant | Provided expert information on insulin pen administration procedures |
| Culinary Manager | Culinary Manager | Mentioned in relation to food labeling and storage responsibilities |
| LPN UM #17 | Licensed Practical Nurse Unit Manager | Discussed responsibilities for food labeling and refrigerator checks |
| Assistant Director of Nursing | Assistant Director of Nursing | Discussed food labeling and removal policies |
Inspection Report
Routine
Deficiencies: 2
Jun 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' activities of daily living (ADLs), restorative care services, and documentation of care in a nursing home setting.
Findings
The facility failed to provide restorative care services to maintain residents' highest level of functioning, resulting in decline for two residents (R55 and R58). Additionally, the facility failed to ensure appropriate documentation of personal hygiene and incontinence care for two other residents (R144 and R241). The restorative nursing program had been discontinued, impacting residents' functional abilities and transfers.
Severity Breakdown
Level of Harm - Actual harm: 1
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide restorative care services to maintain residents' highest level of functioning, resulting in decline in ADLs for residents R55 and R58. | Level of Harm - Actual harm |
| Failure to ensure appropriate documentation of personal hygiene and incontinence care for residents R144 and R241. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for ADLs: 23
Residents affected by restorative care deficiency: 2
Residents affected by documentation deficiency: 2
Therapy periods for R55: 4
Therapy period dates for R55: Most recent therapy from 04/10/2024 through 05/09/2024
Therapy period dates for R58: Most recent therapy from 04/16/2024 through 05/15/2024
Documentation missing days for R144 ADL care: 8
Documentation missing days for R144 ADL care: 14
Documentation missing days for R144 ADL care: 11
Documentation missing days for R241 ADL care: 6
Documentation missing days for R241 ADL care: 14
Documentation missing days for R241 ADL care: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 6 | Registered Nurse | Interviewed regarding resident R55's ADL limitations and restorative program discontinuation |
| PT | Physical Therapist | Interviewed regarding therapy services and restorative care for residents R55 and R58 |
| LPN/UM 2 | Licensed Practical Nurse/Unit Manager | Interviewed regarding resident R55's condition and restorative program status |
| CNA 5 | Certified Nursing Assistant | Provided information about restorative services previously provided to resident R55 |
| CNA 6 | Certified Nursing Assistant | Interviewed about resident R58's ADL status and transfer methods |
| LPN 1 | Licensed Practical Nurse | Interviewed about resident R58's ADL decline and therapy |
| DON | Director of Nursing | Verified restorative program discontinuation and documentation deficiencies |
| Administrator | Facility Administrator | Provided statements about therapy and restorative program status |
| UM 2 | Unit Manager | Interviewed regarding documentation of incontinent care |
Inspection Report
Routine
Deficiencies: 11
Jun 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident equipment, honor resident choices, address resident grievances, ensure accurate assessments, provide restorative care, deliver safe respiratory care, maintain medication storage standards, ensure palatable and safe food service, document care appropriately, and implement infection control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Level of Harm - Actual harm: 1
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure one resident had a properly functioning bed, including a sunken mattress and non-functioning electric bed controls. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to honor resident choices regarding shower times, resulting in resident distress and refusal of care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to promptly resolve resident grievances regarding removal of microwave for reheating food, impacting resident satisfaction and quality of life. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents were aware of where to locate state survey inspection results and ensure accessibility for review. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure accurate Minimum Data Set (MDS) assessment for one resident regarding insulin use. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide restorative care and services to maintain highest level of functioning for two residents, resulting in decline in function. | Level of Harm - Actual harm |
| Failure to provide safe and appropriate respiratory care including tracheostomy care and suctioning consistent with professional standards for two residents, resulting in immediate jeopardy. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure medication carts were free of expired medications, risking efficacy of medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure food was palatable, attractive, and served at safe and appetizing temperatures for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to document appropriate care and services for two residents related to activities of daily living (ADL) care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement infection control guidelines during dressing changes and nebulizer equipment handling, risking resident safety. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Sampled residents: 23
Resident group interview participants: 5
MDS BIMS scores: 14
Medication opened dates: 4
Test tray food temperature: 117
Test tray food temperature: 95
Test tray beverage temperature: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Named in failure to provide proper tracheostomy care and respiratory monitoring |
| LPN 1 | Licensed Practical Nurse | Named in failure to provide proper tracheostomy care and respiratory monitoring |
| Maintenance Director | Named in bed maintenance and audit findings | |
| Director of Nursing | DON | Named in multiple interviews regarding expectations and findings |
| Administrator | Named in interviews regarding facility operations and findings | |
| Certified Nursing Assistant 2 | CNA | Named in interviews regarding shower scheduling and resident care |
| Certified Nursing Assistant 3 | CNA | Named in interviews regarding shower scheduling and resident care |
| Certified Nursing Assistant 4 | CNA | Named in interviews regarding food reheating procedures |
| Licensed Practical Nurse/Unit Manager 2 | LPN/UM | Named in interviews regarding shower scheduling and food reheating |
| Physical Therapist | PT | Named in interviews regarding restorative care |
| Housekeeping/Laundry Supervisor | Named in interview regarding infection control breach with nebulizer equipment | |
| Housekeeper | Named in interview regarding infection control breach with nebulizer equipment | |
| Unit Manager 1 | UM | Named in interviews regarding shower scheduling, infection control, and resident care |
| Unit Manager 2 | UM | Named in interviews regarding documentation and wound care |
| Licensed Practical Nurse 3 | LPN | Named in wound care infection control breach |
| Staff Development Coordinator | SDC | Named in interview regarding tracheostomy care expectations |
| Assistant Director of Nursing | ADON | Named in interview regarding tracheostomy care training and expectations |
Inspection Report
Annual Inspection
Census: 74
Deficiencies: 20
Feb 26, 2019
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with federal and state regulations for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity, failure to provide timely meal service, failure to notify responsible parties of room changes, failure to notify physicians of resident falls, failure to maintain resident privacy, failure to resolve grievances promptly, inaccurate resident assessments, incomplete and untimely care plans, inadequate supervision to prevent accidents, improper catheter care, failure to provide appropriate respiratory and dialysis care, failure to maintain medication labeling, failure to provide appropriate dementia care, and failure to maintain complete medical records.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 17
Level of Harm - Actual harm: 4
Deficiencies (20)
| Description | Severity |
|---|---|
| Failed to treat residents with dignity and respect during meal service. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify responsible party of room change per facility policy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify resident's physician of fall within 24 hours. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident privacy when exposed in room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to make prompt efforts to resolve resident grievances. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate resident assessments and coding. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive, person-centered care plans. | Level of Harm - Actual harm |
| Failed to review and revise care plans after falls and changes in condition. | Level of Harm - Actual harm |
| Failed to provide care and assistance with activities of daily living as per care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide activities to meet resident's interests and needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate supervision and assistance to prevent accidents and falls. | Level of Harm - Actual harm |
| Failed to provide appropriate catheter care and maintain proper catheter tubing placement. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate care for residents receiving dialysis including access site assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care including oxygen therapy as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label medications with open dates and ensure proper medication storage. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain complete and accurate medical records including documentation of ADL and oxygen refusal. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate treatment and services to a resident diagnosed with dementia. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure coordinated care with hospice including delineation of responsibilities. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain effective Quality Assurance and Performance Improvement (QAPI) system to ensure compliance with catheter care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents receiving meals: 74
Residents sampled: 22
Falls Resident #18: 30
Fall Risk Assessment score Resident #75: 75
Pain medication doses Resident #9: 21
Pain medication doses Resident #9: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Assisted Resident #9 alone during bed bath leading to fall |
| CNA #6 | Certified Nurse Aide | Reported dignity issue with meal service plate covers |
| CNA #7 | Certified Nurse Aide | Reported staff should assist in covering resident for privacy |
| CNA #8 | Certified Nurse Aide | Unaware of Resident #76's dirty nails |
| LPN #2 | Licensed Practical Nurse | Notified Resident #21's spouse of fall but failed to notify physician |
| LPN #3 | Licensed Practical Nurse | Failed to report resident medication grievances |
| LPN #4 | Licensed Practical Nurse | Administered medications late and failed to document resident medication concerns |
| RN #1 | Registered Nurse | Unaware of care plan details during Resident #9 fall |
| RN #2 | Registered Nurse | Aware Resident #56 removed oxygen but failed to document |
| RN #3 | Registered Nurse | Described fall protocol and care plan update responsibilities |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding expectations for care and documentation |
| Social Services Director | Social Services Director | Discussed dementia care plan deficiencies and family refusal to discontinue antipsychotic |
| Dietary Manager | Dietary Manager | Expected proper food storage and cleaning of equipment |
| Administrator | Administrator | Discussed catheter care in-servicing and monitoring expectations |
| MDS Coordinator | MDS Coordinator | Discussed assessment and care plan deficiencies and hospice collaboration |
| Activity Director | Activity Director | Failed to create resident's activity care plan |
Loading inspection reports...
