Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cherrelyn Healthcare Center during CMS and state inspections, most recent first.
A resident with hepatic encephalopathy and other conditions did not receive multiple doses of prescribed medications, including Xifaxan, due to the facility's failure to have the medications available. Despite the resident's family providing a supply of Xifaxan, the medication was not administered as ordered, and there was no documentation that the provider was notified of the missed doses. Medication administration records and staff interviews confirmed that several medications were missed because they were not delivered from the pharmacy.
The facility failed to ensure proper infection control practices, including the use of PPE for a resident on enhanced barrier precautions and offering hand hygiene to residents before meals. Staff inconsistently wore gowns when required, and residents were not provided with accessible hand sanitization options. Interviews revealed a lack of understanding and consistent practice among staff regarding these protocols.
A resident with dementia and other health conditions was not provided with activities that matched her interests, such as music and group activities, as outlined in her care plan. Observations showed she was often left in bed without engagement, and staff interviews revealed inconsistencies in understanding and executing her activity preferences. Documentation indicated she missed several one-to-one activity sessions.
A resident with vision problems did not receive new eyeglasses for over eight months due to a lack of coordination between social services and the business office. Despite having a prescription and Medicaid coverage, the facility failed to ensure timely processing and follow-up, leaving the resident unable to see clearly and frustrated.
A facility failed to ensure a resident with a feeding tube received appropriate treatment as per physician's orders. The resident, diagnosed with pneumonia and cerebral palsy, was supposed to receive tube feedings for 22 hours daily. However, the RN disconnected the feeding tube early for physical therapy, resulting in the resident being off the feeding tube for four hours instead of the prescribed two hours. The RD confirmed the deviation and emphasized the importance of following the physician's orders.
Two residents receiving hospice services lacked a coordinated care plan that included both hospice and facility services. One resident expressed confusion due to poor communication between the facility and hospice provider, while another resident's care conference was missed without proper documentation. The facility failed to ensure comprehensive, person-centered care plans for these residents.
Failure to Provide Physician-Ordered Medications Due to Unavailability
Penalty
Summary
The facility failed to provide physician-ordered medications as prescribed for one of the sampled residents. Specifically, the facility did not have the medication Xifaxan, which is used to treat hepatic encephalopathy, available for administration to the resident on multiple occasions. The medication was not available in the facility from the pharmacy between the time the initial supply ran out and the refill was delivered, resulting in missed doses. Additionally, other medications such as lotilaner ophthalmic solution and midodrine were also not administered as ordered due to unavailability from the pharmacy. The resident involved had diagnoses including hepatic encephalopathy, hepatitis C, and hepatomegaly, and was cognitively intact at the time of the incident. Interviews with the resident and her representative revealed that the representative had brought in a supply of Xifaxan from the previous facility and left it with the nursing staff. Despite this, the medication was still not administered as ordered on certain dates, and there was no documentation that the provider group was notified when the medication was unavailable. Staff interviews confirmed that the resident's family provided a supply of Xifaxan and that the facility experienced delays in obtaining the medication from the pharmacy, partly due to insurance approval issues. Nursing staff were expected to notify the provider if a medication was unavailable, but there was no record of such notification for the missed doses. The medication administration records and nursing progress notes documented multiple missed doses of Xifaxan, lotilaner ophthalmic solution, and midodrine due to lack of availability.
Inadequate Infection Control Practices in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to maintain and follow infection prevention and control programs, specifically in the use of personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP). Observations revealed that staff did not wear the required gowns while transferring a resident with an indwelling urinary catheter, despite signage indicating the necessity of gowns and gloves for such activities. Interviews with staff, including CNAs and the Assistant Director of Nursing (ADON), showed a lack of understanding and inconsistent practices regarding PPE requirements, with some staff believing only gloves were necessary unless performing specific tasks like emptying a catheter. Additionally, the facility did not ensure residents were offered the opportunity for hand hygiene prior to meals. Observations during meal services in the dining rooms showed that staff did not offer hand sanitization to residents, and the mounted hand sanitizer dispensers were inaccessible to residents with mobility limitations. Interviews with residents confirmed that they were not offered hand hygiene opportunities, and staff interviews indicated a lack of consistent encouragement for residents to use available hand sanitizers. The facility's policies and procedures did not clearly identify when to offer hand hygiene to residents, and there was a lack of documentation for infection control in-service education. The Dietary Manager and ADON acknowledged the expectation for hand hygiene opportunities but noted issues with accessibility and availability of hand sanitizer wipes. The facility's infection control education and audits were mentioned, but the lack of documentation and consistent practice contributed to the deficiency.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the needs and interests of a resident, specifically Resident #35, who was one of three residents reviewed for activities. The facility's policy required activities to be based on a comprehensive resident-centered assessment and the preferences of each resident, aiming to enhance their physical, cognitive, or emotional health. However, observations revealed that Resident #35 was not engaged in activities that she enjoyed, such as listening to music or participating in group activities, despite her care plan indicating these preferences. Resident #35, who had diagnoses including dementia, diabetes, and chronic kidney disease, was observed multiple times lying in bed staring at the ceiling, with no staff engagement to involve her in activities she enjoyed. On one occasion, a music activity was taking place in the main dining room, but Resident #35 was not approached by staff to attend, despite her care plan indicating she enjoyed music. Additionally, during a meal, a CNA assisted her with eating but failed to converse with her, contrary to the interventions outlined in her care plan. Interviews with staff, including the activities assistant and director, revealed inconsistencies in the understanding of Resident #35's preferences and the execution of her care plan. The activities assistant noted that Resident #35 enjoyed talking, physical contact, and music, yet the activities documentation showed she had only received one out of the required one-to-one sessions in the past month. The activities director acknowledged the lack of documentation for these sessions, indicating a failure to provide the necessary activities to meet Resident #35's needs and interests.
Failure to Assist Resident in Obtaining Eyeglasses
Penalty
Summary
The facility failed to provide necessary assistance to a resident in obtaining new eyeglasses, which was essential for maintaining his vision abilities. The resident, a 68-year-old male with diagnoses including acute and chronic respiratory failure, type two diabetes, and COPD, was cognitively intact and required substantial assistance with daily activities. Despite having an eye exam in May 2024 and a prescription for bifocal glasses, the resident had not received his new glasses by January 2025. This delay left him unable to see clearly, particularly out of his left eye, causing frustration as he could not read his books. The deficiency arose from a lack of coordination and follow-up between the facility's social services and business office. The social service staff responsible for arranging eye exams and completing necessary Medicaid paperwork did not ensure timely processing and follow-up. Although the business office manager indicated that glasses should be received within two weeks of the appointment, the resident's glasses were delayed for over eight months. The social services department failed to track the progress of the Medicaid payment and did not explore alternative payment options, such as using personal needs funds or notifying family members, to expedite the process.
Failure to Follow Physician's Orders for Enteral Nutrition
Penalty
Summary
The facility failed to ensure that a resident with a feeding tube received appropriate treatment and services as ordered by the physician. Specifically, the facility did not adhere to the physician's orders for the administration of enteral nutrition for a resident diagnosed with pneumonia and cerebral palsy. The resident was supposed to receive tube feedings for 22 hours daily, starting at 1:00 a.m. and ending at 11:00 a.m. However, the registered nurse (RN) responsible for the resident's care disconnected the feeding tube at 10:00 a.m. daily for physical therapy, resulting in the resident being off the feeding tube for four hours instead of the prescribed two hours. The facility's policy on enteral nutrition, revised in November 2018, mandates that adequate nutritional support through enteral nutrition is provided to residents as ordered. The policy requires the dietitian, provider, and nurse to collaborate on estimating nutritional needs and ensuring the resident's intake meets these needs. Despite this policy, the RN did not follow the physician's orders, leading to a deviation from the prescribed feeding schedule. The registered dietitian (RD) confirmed that the resident should not have been off the feeding tube for four hours and emphasized the importance of following the physician's orders. Interviews with the RN and RD revealed a lack of communication and adherence to the physician's orders. The RN acknowledged the mistake and admitted to taking the resident off the feeding tube early for physical therapy. The RD stated that she was not informed about the deviation from the feeding schedule and highlighted the need for communication between the nursing staff and the dietitian to make necessary adjustments to the feeding orders. The failure to follow the physician's orders resulted in the resident not receiving the prescribed amount of enteral nutrition.
Deficiency in Coordinated Hospice Care Plans
Penalty
Summary
The facility failed to provide a coordinated written plan of care that included both the most recent hospice plan of care and a description of the services furnished by the facility for two residents. Resident #169, who was admitted with diagnoses including cirrhosis of the liver and a history of stroke, was receiving hospice services. However, her care plan did not include an explanation of the care and services that hospice would provide and those that the facility would provide in relation to hospice services and end-of-life care. The resident expressed confusion about her care plan, indicating poor communication between the facility and hospice provider. The facility's interdisciplinary team had not held a care conference to discuss her medical care plan. Resident #12, who had diagnoses including traumatic brain injury and quadriplegia, was also receiving hospice services. The care plan for this resident similarly failed to include an explanation of the care and services provided by hospice and the facility. A care conference that should have been held in November was missed, and there was no documentation in the resident's electronic medical record explaining why the conference was not held. Staff interviews revealed that the care conference was postponed due to the holidays, but this was not documented in the resident's records. The facility's failure to coordinate and document hospice care plans for these residents highlights a deficiency in ensuring that residents receiving hospice services have a comprehensive, person-centered care plan. The lack of communication and documentation between the facility and hospice provider led to confusion and inadequate care planning for the residents involved.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Littleton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Littleton Care And Rehabilitation Center | 2.2 mi | ★★★★★ | 1 | 0 |
| Wellsprings Care Center | 2.4 mi | ★★★★★ | 15 | 0 |
| Englewood Post Acute And Rehabilitation | 2.5 mi | ★★★★★ | 0 | 0 |
| Julia Temple Healthcare Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Hallmark Nursing Center | 3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.