Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Peak Resources-cherryville during CMS and state inspections, most recent first.
A resident's controlled medication went missing from a medication cart in an LTC facility. The incident occurred while the resident was hospitalized, and the medication was last seen during a shift change. The nurse responsible for the cart during the time of the disappearance declined to participate in the investigation and was terminated. The facility's EMR system flaw contributed to the oversight.
The facility failed to follow grievance policies when a resident's dentures went missing and another resident requested a call bell extension cord. The grievances were not properly documented or resolved within the required timeframe, leading to unresolved issues for both residents.
The facility failed to properly label and store insulin medications, including not dating opened multi-dose insulin pens, not discarding expired insulin pens and a vial, and not storing a vial in the refrigerator. These issues were found in two insulin medication carts, and staff interviews revealed a lack of awareness about the expired and improperly labeled insulin pens.
The facility failed to ensure that dishes were clean and dry before being stacked and used. Observations revealed wet and dirty dishes on the clean dish rack and serving line. Staff interviews confirmed that the dishwashing area was humid, making it difficult for dishes to dry properly, and that proper checks were not consistently performed.
The facility's QAA committee failed to maintain procedures and monitor interventions, resulting in repeat deficiencies in areas such as Notification of Changes, Respiratory Services, Label/Store Drugs & Biologicals, and Resident Allergies/Preferences/Substitutes. Specific issues included not notifying physicians of low blood pressures, failing to post oxygen precaution signs, not discarding expired insulin, and not honoring food choices for residents.
A resident with atrial fibrillation, hypertension, and congestive heart failure had their Metoprolol Tartrate withheld multiple times due to low blood pressure without notifying the physician. Nurses used their own judgment to hold the medication based on prior experience and other medication parameters, but did not document the low blood pressures or notify the physician. The Physician Assistant and Director of Nursing were unaware of the frequent withholding of the medication and stated that the physician should be notified if a blood pressure medication is held frequently.
A resident with cellulitis, edema, and lymphedema did not have compression stockings applied as ordered by the physician. Despite documentation indicating they were applied, the resident was observed without them, and staff admitted to not following through with the order.
A resident requiring partial to maximum assistance with ADLs was not assisted with dressing by NA #7, despite requesting to be dressed in regular clothes for a therapy session. The resident remained in a nightgown throughout the day, and staff interviews confirmed the expectation for NA #7 to assist regardless of the presence of a sitter.
A resident with type 2 diabetes mellitus did not have their blood glucose levels checked as ordered due to an error in entering the order into the electronic medical record. The order was incorrectly entered under a flow sheet that did not pull orders to the MAR, leading to the oversight.
The facility failed to maintain infection control by reusing urinary leg drainage bags, bedside drainage bags, and connection tubing, increasing the risk of infection for a resident with obstructive uropathy. Staff admitted to improper storage and cleaning practices, and the facility lacked specific training and policies on the correct procedure.
The facility failed to post precautionary and safety signs indicating the use of oxygen for two residents receiving continuous oxygen therapy. Observations and staff interviews confirmed the absence of such signage in the residents' rooms, with the facility's policy being to post oxygen use signage only at the main entrance due to its non-smoking status.
A resident with a history of traumatic brain injury and other conditions received incorrect meal consistencies twice during a single meal service. Despite established processes, dietary staff failed to verify the meal trays properly, leading to the delivery of non-compliant meals. The nursing assistant detected the errors and returned the meals to the kitchen until the correct meal was provided.
The facility failed to honor food choices for two residents, leading to repeated instances where they received food items they disliked. Despite communicating their preferences, the residents' dislikes were not updated in the meal tracker system, indicating a systemic issue in the facility's dietary management process.
A resident's compression stockings were documented as applied by staff on two occasions when they were not. The resident reported and was observed without the stockings, and staff admitted to documenting the task without verifying its completion.
The facility failed to post accurate nurse staffing information, often combining data for both Skilled Nursing and Assisted Living units, leading to discrepancies in reported census and staff working hours. The DON and Scheduler were unaware of the issue, and the Administrator confirmed the need for daily updates.
Misappropriation of Controlled Substances in LTC Facility
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of controlled substances. The incident involved a resident who was admitted with diagnoses including a fractured hip, pain, and malnutrition. The resident had an order for Hydrocodone-Acetaminophen to be administered as needed for pain. On a particular day, it was discovered that a card containing 6 tablets of this medication was missing from the medication cart. The initial report of the missing medication was made when the nurse medication count revealed the discrepancy. The investigation revealed that the medication card was last seen in the cart when counted by a Medication Aide and a nurse at the beginning of the shift. However, during the shift, the card went missing while under the custody of another nurse who had the keys to the cart. This nurse declined to return to the facility for an interview or drug testing and was subsequently terminated for failing to adhere to company policy. The facility's electronic medical record system had a flaw that allowed the resident's narcotic sheet to be removed from the system when their status was changed to discharge/return anticipated, which contributed to the oversight. Interviews with staff indicated that the missing medication was not found, and the timeline of the disappearance was narrowed down to a specific shift. The facility reported the incident to local authorities, including the police and the DEA, and took steps to address the issue internally. The resident involved was in the hospital at the time and did not miss any medication administrations, and there were no adverse effects reported.
Failure to Implement Grievance Policies and Procedures
Penalty
Summary
The facility failed to implement their grievance policies and procedures when Resident #222's representative reported the resident's top dentures were missing and when Resident #20 requested a call bell extension cord to be added in her bathroom. Resident #222, who was admitted with a diagnosis of vascular dementia, had his upper dentures go missing shortly after admission. Despite the representative reporting the missing dentures on 3/31/2024, the grievance form was not properly completed, and the investigation was not concluded within the required 5 days. The Director of Nursing (DON) and other staff members acknowledged that the grievance process was not followed, and the dentures were never found, leaving Resident #222 without his upper dentures until his discharge on 4/19/2024. The representative was only contacted about the conclusion of the investigation on 4/17/2024, well beyond the 5-day requirement, and no corrective action was taken in a timely manner. Resident #20, who was cognitively intact, had requested a call bell pull cord for her bathroom multiple times, starting with a grievance form dated 11/28/2023. The grievance form indicated that the nursing department had received the request, but it was marked as 'taken care of' without any documented conclusion, corrective action, or required signatures from the DON and the Administrator. During an interview on 4/17/2024, Resident #20 reported that she was still unable to reach the call bell in the bathroom due to the short pull cords. The Maintenance Director confirmed that he had not received any grievance request for a longer pull cord and that no work order had been entered into the system. The DON and the Administrator both acknowledged that the grievance policy was not followed, and the issue was not resolved in a timely manner. The facility's failure to follow their grievance policies and procedures resulted in unresolved issues for both residents. The staff interviews revealed a lack of awareness and proper training regarding the grievance process, leading to delays and inadequate responses to the residents' concerns. The Administrator, as the Grievance Official, did not ensure that grievances were addressed and resolved within the required timeframe, contributing to the deficiencies observed in the facility's handling of resident grievances.
Improper Labeling and Storage of Insulin Medications
Penalty
Summary
The facility failed to properly label and store insulin medications in accordance with the manufacturer's instructions. Specifically, the facility did not date opened multi-dose insulin pens, did not discard expired insulin pens and a multi-dose insulin vial, and did not store a multi-dose insulin vial in the refrigerator. These deficiencies were observed in two insulin medication carts: the Cherry Street cart and the [NAME] Hall cart. During an inspection, it was found that a Levemir insulin vial was opened and placed in the cart without being discarded after 42 days as required. Additionally, a Levemir insulin pen and a Glargine insulin pen were opened but not dated, and a Lispro insulin pen was past its 28-day expiration date. On the [NAME] Hall cart, a NovoLog insulin Flex pen had an illegible date, making it impossible to determine its discard date. Interviews with the nursing staff revealed that they were unaware of the expired and improperly labeled insulin pens. Nurse #4 admitted to not realizing the pens were not dated and had expired, and the Charge Nurse acknowledged the issue with the NovoLog Flex pen. The Director of Nursing (DON) confirmed that the nursing staff and medication technicians were expected to check the insulin carts daily and each shift, ensuring all insulin pens were labeled, stored correctly, and discarded after the appropriate time frame. Despite these expectations, the deficiencies were still present, indicating a lapse in adherence to proper medication management protocols.
Failure to Ensure Clean and Dry Dishes
Penalty
Summary
The facility failed to ensure that bowls, plates, metal bowls, serving pans, and baking sheets were dry before they were stacked, and to ensure dishes were clean. During an initial observation of the kitchen, surveyors found 12 wet plates stacked in a plate warmer, and several wet items including a large serving pan, baking sheets, and a metal bowl on a storage rack in the dishwashing area. Additionally, 12 small red saucer plates with white crumb-like particles and one small white saucer plate with a dried yellow substance were found on the clean dish rack. A second observation revealed 11 small white bowls stacked on the serving line were also wet. Interviews with the Dietary Manager (DM) and Dietary Aide #3 confirmed that the dishwashing area was humid, making it difficult for dishes to dry before being needed for the next meal service. Both staff members acknowledged that wet dishes should not be stacked and that dirty dishes should be rewashed. The DM and the Administrator both indicated that the facility used a low-temperature dishwasher, and dishes had to be placed on racks to dry. The DM stated that a fan had been ordered to help with the drying process. The Administrator confirmed that dietary staff should check dishes when removing them from the dishwasher to ensure they are clean and dry. The presence of dirty dishes on the clean dish rack was attributed to staff not checking them properly. The Administrator reiterated that wet dishes should not be stacked and that dirty dishes should be rewashed, highlighting a lapse in the facility's dishwashing and drying procedures.
Repeat Deficiencies in QA Program
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions following the recertification survey and complaint investigation completed on 10/19/2022. This failure resulted in repeat deficiencies in the areas of Notification of Changes (F580) and Respiratory Services (F695). Specifically, the facility did not notify the physician of low blood pressures requiring medication withholding for one resident and failed to notify the responsible party after a resident was transferred to the hospital. Additionally, the facility did not post precautionary and safety signs indicating the use of oxygen for two residents and failed to administer oxygen as prescribed for three residents. These deficiencies were also noted during the previous survey on 10/19/2022, indicating a pattern of non-compliance. The QAA committee also failed to maintain procedures and monitor interventions following the recertification survey and complaint investigation completed on 8/20/2021. This resulted in repeat deficiencies in the areas of Label/Store Drugs & Biologicals (F761) and Resident Allergies/Preferences/Substitutes (F806). The facility did not date opened multi-dose insulin pens, discard expired insulin pens and vials, or store a multi-dose insulin vial in the refrigerator. Additionally, the facility failed to honor food choices for two residents. These issues were also noted during the previous survey on 8/20/2021, further demonstrating the facility's inability to sustain an effective QA program. The Administrator, who has been in the position since December 2023, acknowledged these ongoing issues and expressed a commitment to improving the QA processes and follow-ups.
Failure to Notify Physician of Low Blood Pressures and Withheld Medication
Penalty
Summary
The facility failed to notify the physician of low blood pressures that required blood pressure medication to be withheld for a resident diagnosed with atrial fibrillation, hypertension, and congestive heart failure. The resident had an active physician order for Metoprolol Tartrate, but there were no heart rate or blood pressure parameters included with the order. The medication was documented as not administered multiple times due to low blood pressure, but there was no documentation of the physician being notified of these low blood pressures or the medication being withheld. Nurses used their own judgment to hold the medication based on their prior experience and other medication parameters, but did not notify the physician or document the low blood pressures in the resident's medical record. The Physician Assistant and Director of Nursing were unaware of the frequent withholding of the medication and stated that the physician should be notified if a blood pressure medication is held frequently. Interviews with the nursing staff revealed that they used blood pressure parameters of 110/60 to hold the Metoprolol Tartrate, based on their nursing knowledge and other medication parameters. The Physician Assistant stated that she would expect to be notified if a blood pressure medication needed to be held more than once or twice, and would have given orders for parameters if she had been informed. The Director of Nursing did not consider the withholding of the medication for four days in a row at the same time of day as a trend, and did not comment on whether this should have been reported to the physician. The Administrator confirmed that the physician should be notified of low blood pressures and involved in the decision to hold medication.
Failure to Apply Compression Stockings as Ordered
Penalty
Summary
The facility failed to follow a physician's order to apply compression stockings for a resident with diagnoses including cellulitis, localized edema, and lymphedema. The resident was admitted with weeping areas on her lower extremities and was at risk for further skin breakdown. Despite a physician's order dated 4/5/2024 to apply compression stockings daily, the resident was observed without them on 4/16/2024. The resident reported that staff had not put on her compression stockings and had told her they could not find them. An empty compression stocking wrapper was found on her nightstand, and her drawer did not contain the stockings. Nurse #2, who documented applying the stockings, admitted she had not done so and had asked a Nurse Aide to do it, but did not verify if it was done. The Director of Nursing confirmed that extra compression stockings were available in the facility and that the application should have been documented in the Electronic Medical Record. The Director of Nursing and the Administrator both stated that the compression stockings should have been applied as ordered. The Physician's Assistant confirmed the necessity of the compression stockings for managing the resident's swelling. The failure to apply the compression stockings as ordered was verified by multiple staff members and observed directly by the surveyor.
Failure to Assist Resident with Dressing
Penalty
Summary
The facility failed to provide assistance with dressing for Resident #367, who required partial to maximum assistance with activities of daily living (ADL) due to impaired mobility, muscle weakness, unsteadiness on feet, and chronic pain. Despite the resident's request to be dressed in regular clothes before lunch for a scheduled therapy session, Nurse Aide (NA) #7 did not assist, stating that the resident should have asked her morning sitter. Observations confirmed that Resident #367 remained in her nightgown throughout the day, and her clean clothes were available in her closet but not used. Interviews with the resident, the sitter, and staff revealed that the resident preferred to get dressed later in the morning, after breakfast, and before her therapy sessions. The Director of Nursing (DON) and the Administrator both expressed that it was the expectation for NA #7 to assist the resident with dressing regardless of the presence of a sitter. The Therapy Director confirmed that Resident #367 was making progress in therapy but was still unsafe to dress without assistance. The failure to assist the resident with dressing as requested led to the deficiency noted in the report.
Failure to Follow Physician Orders for Blood Glucose Monitoring
Penalty
Summary
The facility failed to follow physician orders to check a diabetic resident's blood sugar levels twice daily. Resident #27, who was admitted with a diagnosis of type 2 diabetes mellitus, had an active physician order dated 12/4/23 to check blood sugar at 6:00 AM and 4:30 PM daily. However, the electronic Medication Administration Record (MAR) for April 2024 did not show any blood glucose checks being completed. Interviews with the resident, staff, and Physician Assistant confirmed that the blood glucose checks were not performed. The resident stated she had not had her blood glucose checked since admission, and the nurse responsible for administering medications to the resident confirmed she did not check the resident's blood glucose levels. The Physician Assistant and Charge Nurse identified that the order was entered incorrectly into the electronic medical record, causing it not to appear on the MAR. The Charge Nurse admitted to entering the order incorrectly under a flow sheet that did not pull orders to the MAR. The Director of Nursing acknowledged the error and stated there was no process for a second nurse to check orders entered by another nurse. The Administrator also confirmed the issue and suggested that there should have been a follow-up or second check to ensure physician orders were followed correctly.
Improper Reuse of Urinary Drainage Bags
Penalty
Summary
The facility failed to maintain infection control when staff reused urinary leg drainage bags, urinary bedside drainage bags, and connection tubing, causing an increased risk of infection. This deficiency was observed in the care of a resident who was readmitted to the facility with diagnoses including obstructive uropathy with urinary retention. The resident's care plan included specific instructions for catheter care, which were not followed correctly by the staff. Observations revealed that the resident's urinary drainage bags were reused and improperly stored, with old urine visible in the bags and no caps on the tubing tips. Staff interviews confirmed that the bags were reused for several days and stored inappropriately, sometimes on top of the toilet or in a bathroom cabinet without proper sanitation measures. The staff also admitted to using baby wipes instead of alcohol wipes to clean the tubing connection tips before reattaching them to the catheter. The staff development coordinator and the director of nursing both stated that urinary drainage bags should not be reused and that a new bag should be used each time the catheter was disconnected. However, the staff had not received specific training on this process, leading to inconsistent and improper practices. The physician assistant and the administrator also confirmed that reusing urinary drainage bags could introduce bacteria and cause infections, and they were unaware that this practice was occurring in the facility.
Failure to Post Oxygen Use Signage
Penalty
Summary
The facility failed to post precautionary and safety signs indicating the use of oxygen for two residents. Resident #117, who was admitted with diagnoses including unspecified diastolic heart failure, shortness of breath, and acute respiratory failure with hypoxia, had a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. Observations on multiple dates revealed that Resident #117 was receiving oxygen therapy without any precautionary or safety signs posted in her room or environment. Interviews with nursing assistants and a nurse confirmed the absence of such signage, and the Director of Nursing and Administrator stated that the facility's policy was to post oxygen use signage only at the main entrance, as the facility was non-smoking since 2016. Similarly, Resident #5, who was admitted with chronic respiratory failure and chronic obstructive pulmonary disease, had a physician's order for continuous oxygen at 3 liters per minute via nasal cannula. Observations on multiple dates showed that Resident #5 was receiving oxygen therapy without any cautionary or safety signage in her room or environment. Interviews with the Director of Nursing and the Administrator reiterated that the facility's policy was to post oxygen use signage at the main entrance, covering the entire facility, due to its non-smoking status.
Failure to Provide Correct Dysphagia Mechanical Consistency Meal
Penalty
Summary
The facility failed to provide a dysphagia mechanical consistency meal as ordered by the nurse practitioner for a resident with a history of traumatic brain injury, gastro-esophageal reflux disease, type 2 diabetes mellitus, and diaphragmatic hernia. The resident was observed receiving incorrect meal consistencies on two separate occasions during a single meal service. Initially, the resident received a whole pork chop instead of the prescribed ground kielbasa sausage with pureed sides. The nursing assistant detected the error and returned the meal to the kitchen. However, the replacement meal also contained non-pureed items, which were again returned by the nursing assistant before the correct meal was finally provided. Interviews with dietary staff revealed a breakdown in the meal preparation and verification process. Dietary Aide #3 admitted to delivering the wrong replacement meal without double-checking the dietary ticket. Dietary Aide #1 was responsible for calling out the diet to the cook and placing condiments on the tray, while Dietary Aide #2 was supposed to verify the meal before it left the kitchen. The cook confirmed that the wrong meal was prepared due to a mix-up with another resident's ticket. Despite the established process, the dietary aides failed to ensure the correct meal was delivered to the resident. The dietary manager and district dietary manager both acknowledged that the correct meal should have been provided initially and that the verification process was not followed properly. The registered dietician confirmed that all other residents on pureed diets received the correct meals on the same day, indicating that the issue was isolated to this particular resident. The director of nursing and the administrator both emphasized the importance of verifying meal trays before delivery, highlighting that the nursing assistant's vigilance prevented the resident from consuming the incorrect meals.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food choices for two residents, leading to deficiencies in accommodating their dietary preferences. Resident #38, who was cognitively intact, repeatedly received scrambled eggs and hard toast, which she disliked and had communicated to the dietary staff over a year ago. Despite her complaints, her food preferences were not updated in the meal tracker system, and she continued to receive the same disliked items. The Dietary Manager, who had been in the role for about a year, was unaware of the need to update food preferences in the system until recently and had not completed the necessary updates for Resident #38. Similarly, Resident #27, who was also cognitively intact and on a mechanically altered therapeutic diet, frequently received grits and powdered eggs, which she disliked. She had communicated her preferences to someone in the kitchen, but her dislikes were not reflected in the meal tracker system. The Dietary Manager admitted to not being aware of the need to update food preferences in the system until two months ago and had not completed the updates for Resident #27 either. Interviews with the DON, RD, and Dietary Manager revealed a lack of proper training and awareness regarding the documentation and updating of residents' food preferences. The meal tracker system was not being used effectively to ensure that residents' dislikes were noted and avoided in their meal plans. This led to repeated instances where residents received food items they had explicitly stated they did not like, indicating a systemic issue in the facility's dietary management process.
Inaccurate Documentation of Compression Stockings Application
Penalty
Summary
The facility failed to ensure accurate medical records for a resident's compression stockings. Resident #220, who was cognitively intact, had a physician's order to apply compression stockings to both lower extremities upon rising and to remove them at night. However, on two separate occasions, staff documented that the compression stockings were applied when they were not. On 4/15/2024, Medication Aide #1 documented the application of the stockings, but Resident #220 reported and was observed to not have them on. Similarly, on 4/16/2024, Nurse #2 documented the application of the stockings, but Resident #220 again reported and was observed to not have them on. Nurse #2 admitted to documenting the task without verifying its completion by a Nurse Aide, whose name she could not recall. Interviews with the Director of Nursing (DON), the Administrator, and the Physician's Assistant (PA) revealed that they were unaware of the inaccurate documentation. The DON stated that tasks documented as completed were expected to have been done, and the PA echoed this expectation. The Administrator was also not aware of the false documentation. The deficiency was identified through observations, record reviews, and interviews with the resident and staff, highlighting a failure in maintaining accurate medical records and ensuring the application of prescribed compression stockings.
Incorrect Nurse Staffing Information Posting
Penalty
Summary
The facility failed to post the correct Skilled Nursing Facility census, the actual staff working hours, and change the staff posting each shift to reflect changes in actual working hours for 36 of 49 days reviewed. The posted nurse staffing information often included combined data for both the Skilled Nursing and Assisted Living units, leading to inaccuracies. For example, the census was consistently reported as 117 on computer-generated postings, which was incorrect for the Skilled Nursing unit that only had 70 beds. Handwritten postings, which were more accurate, were only used sporadically and not consistently updated to reflect actual working hours. The Director of Nursing (DON) and the Scheduler were interviewed and revealed that the Scheduler was responsible for updating the posted nurse staffing information every morning, except on weekends when the Charge Nurse took over. The Scheduler admitted to printing the staffing information for the weekends on Fridays and leaving it for the Charge Nurse, without reprinting to reflect actual working hours. Both the DON and the Scheduler were unaware that the computer system was combining census and staffing data for both units, leading to the erroneous postings. The Administrator was informed of the issue by the DON and acknowledged that the posted nurse staffing information had been incorrect. The Administrator confirmed that the posted nurse staffing should be updated daily and whenever changes occur. The failure to correctly post and update the nurse staffing information led to significant discrepancies in the reported census and actual staff working hours, affecting the accuracy of the facility's records.
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Illustrative
What surveyors actually found near you
We read the 91 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cherryville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carolina Care Health And Rehabilitation | 2.5 mi | ★★★★★ | 0 | 0 |
| The Greens At Lincolnton | 7.8 mi | ★★★★★ | 8 | 0 |
| Cardinal Healthcare And Rehabilitation | 8.3 mi | ★★★★★ | 1 | 0 |
| Lincolnton Rehabilitation Center | 8.8 mi | ★★★★★ | 0 | 0 |
| White Oak Manor-kings Mountain | 9.9 mi | ★★★★★ | 13 | 1 |
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