Cherrelyn Healthcare Center
Inspection Findings
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
medication in her mom's belongings from the previous facility and she left the medication with the nurse on duty. C. Record review Review of Resident #2's November CPO revealed the following physician's orders: -Xifaxan oral tablet (used to treat bacterial infections or hepatic encephalopathy). Give twice a day for hepatic encephalopathy, ordered on 11/6/25. -Midodrine oral tablet (used to treat low blood pressure). Give three times a day for hypotension, ordered 11/5/25. - Lotilaner ophthalmic solution (used to treat parasitic eye infections). One drop in both eyes two times a day, ordered on 11/5/25 and discontinued on 12/1/25.
Review of Resident #2's November 2025 medication administration record (MAR) revealed Resident #2 missed the evening dose of Xifaxan on 11/24/25 and 11/25/25. Review of the nursing progress notes on 11/24/25 and 11/25/25 documented the medication was not available in the facility and was on order from
the pharmacy. Review of the order history from the pharmacy, provided by the facility pharmacy consultant, revealed the Xifaxan prescription was filled by the facility on 11/6/25 for a 14-day supply. This medication would have lasted through 11/20/25. The prescription was filled again by the pharmacy on 11/26/25 for another 14-day supply. -The facility did not have Xifaxan from the pharmacy between 11/20/25 to 11/25/25 when the prescription ran out and had not yet been filled. Review of the December 2025 (12/1/25 to 12/3/25 and 12/12/25 to 12/30/25) MAR revealed she did not receive two of two doses of Xifaxan on 12/12/25 and 12/14/25. The MAR revealed she was not given Xifaxan for one of two administrations on 12/13/25. The nursing progress notes written on 12/13/25 and 12/14/25 documented the facility was waiting for the pharmacy to deliver the medication to the facility. Review of Resident #2's nursing progress notes revealed additional missed medications because the medication was documented as not available at the facility.
Review of the November 2025 MAR revealed Resident #2 was not administered lotilaner ophthalmic solution (an anti-parasitic eye drop medication) on 11/5/25, 11/6/25, 11/7/25, 11/15/25, 11/25/25, and 11/30/25, due to the medication not being delivered from the pharmacy. Review of the December 2025 MAR revealed Resident #2 was not administered midodrine (medication to prevent low blood pressure) on 12/12/25. D. Staff interviews The physician's assistant and registered nurse (RN) #1 were interviewed on 12/30/25 at 10:12 a.m. RN #1 said she remembered the resident's representative brought in a card of Xifaxan when Resident #2 was admitted and again on 11/5/25. RN #1 said there were 30 to 60 pills of the medication provided by the representative. RN #1 said the nursing staff would have administered the medication Resident #2's representative brought into the facility if the facility did not have the medication stocked. The physician's assistant said she also remembered Resident #2's representative brought in the medication. The physician's assistant said Xifaxan was a difficult medication to get insurance approval for because it was expensive. The physician's assistant said if the facility was out of a medication, the nursing staff was supposed to notify the provider on duty. The physician's assistant said there was no record of the provider group being notified when Resident #2 did not receive her Xifaxan on 11/24/25 and 11/25/25. The nursing home administrator (NHA) was interviewed on 12/30/25 at 1:25 p.m. The NHA said the facility had a 14-day supply of Xifaxan delivered on 11/6/25. The NHA said the prescription had been completed by 11/20/25, and the facility asked for a refill on 11/24/25. The NHA said the medication was then delivered on 11/26/25. The NHA said Resident #2's family brought in medication from home for the facility to use. The NHA said the nurses probably administered Resident #2's home medication during the time the facility did not have the medication from the pharmacy. The NHA said he did not know why the nursing staff had not provided the evening medication doses to the resident from the family provided medications on 11/24/25 and 11/25/26.
Event ID:
Facility ID:
If continuation sheet
CHERRELYN HEALTHCARE CENTER in LITTLETON, CO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LITTLETON, CO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CHERRELYN HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.