Below 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 Berrien Oaks Nursing And Rehab Center during CMS and state inspections, most recent first.
Pureed meals were prepared without standardized recipes or measured ingredients for eight of eight residents on a pureed diet. A cook blended chicken salad with unmeasured water, bouillon seasoning, and thickener, then added more water while checking consistency by sight. The cook stated she had never used a recipe in eight years at the facility, and the Dietary Manager confirmed recipes were not used for puree meal preparation.
Unlabeled and undated food items were found in the walk-in refrigerator and freezer, along with expired cornmeal and flour in dry storage. The Dietary Manager confirmed the findings and stated he was responsible for ensuring food was labeled with open or expiration dates.
A resident with severe cognitive impairment, Alzheimer's disease, and dementia-related behavioral disturbance was not given adequate supervision or a specific wandering/elopement care plan. The record showed no elopement risk assessments, no alarm devices, and no documentation of wandering concerns in care plan meetings. Staff later had to search for the resident after she could not be located, and she was found in a bathroom in a bathtub; other notes also described her outside near the building and wandering at a hospital in a wheelchair.
Medication Error Rate Exceeded Allowed Threshold: The facility failed to keep the medication error rate below the required level after an observed med pass showed 6 errors in 30 opportunities. A DON administered scheduled meds for a resident but omitted several ordered meds, including OTC meds and ciprofloxacin otic solution; she later stated she could not locate the ear drops and needed another nurse to show her where the OTC meds were stored in the med cart.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with multiple resident rooms exhibiting gouged walls, broken sheetrock, damaged air filters, and bathroom doors in disrepair. The kitchen was observed to have dirty floors, rusted equipment, holes in walls, and leaking oil from a fryer, with these issues confirmed by staff and the Administrator.
Staff did not provide full visual privacy for two residents during personal care activities. One resident was left exposed during a bed bath without the privacy curtain or window blinds being closed, while another had a catheter dignity bag positioned so that urine was visible from the doorway. Both incidents involved lapses in staff adherence to privacy protocols.
A resident with a physician order for a Foley catheter did not have a corresponding care plan developed, as required by facility policy. Staff confirmed that the omission was not corrected until several days after the deficiency was identified, despite the importance of care plans in guiding resident care.
Three residents receiving oxygen therapy experienced deficiencies, including crimped tubing preventing oxygen delivery, dirty concentrator filters, and oxygen flow rates set higher than physician orders. Nursing staff and the DON confirmed these issues, and required oxygen-in-use signage was missing from resident rooms. The facility also lacked a specific Oxygen Safety Policy despite referencing it in procedures.
Pureed Meals Prepared Without Standardized Recipes
Penalty
Summary
Pureed meals were not consistently prepared according to standardized recipes or measured ingredients for eight of eight residents receiving a pureed diet. During observation of puree preparation, a cook placed chicken salad in a blender, added an unmeasured amount of water, added chicken bouillon seasoning from a small Styrofoam cup, blended the mixture, then added thickener from another small Styrofoam cup and more water without measuring anything during the process. The cook stated she had worked at the facility for eight years and had never used a recipe, explaining that she went by consistency and knew what it should look like. The Dietary Manager also confirmed that recipes were not used when preparing puree meals.
Unlabeled and Expired Food Items in Kitchen Storage
Penalty
Summary
The facility failed to ensure that food was properly labeled, dated, and maintained in sanitary conditions in accordance with its policy titled Food Storage: Cold Food Items. During a kitchen tour with the Dietary Manager, surveyors observed in the walk-in refrigerator a bag of finely diced cabbage with carrots, a package of cooked ham, a piece of open ham, an open pack of sliced turkey, and a block of cheese, all without labels or dates. In the walk-in freezer, surveyors observed a bag of zucchini, a bag of grilled cheese, and a package of green vegetables, also without labels or dates. In dry storage, expired cornmeal and flour were found in large containers. The Dietary Manager confirmed the concerns during the tour and stated he was responsible for ensuring food was labeled with open or expiration dates to support resident safety.
Failure to Monitor Resident at Risk for Wandering and Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for a resident with severe cognitive impairment related to wandering and elopement. The resident, admitted with diagnoses including Alzheimer's disease and unspecified dementia with behavioral disturbance, had a BIMS score of 3 on the 04/20/2025 MDS, indicating severe cognitive impairment. The record showed no physical or electronic alarm devices used to monitor the resident's movement, and there was no specific care plan in place for wandering or elopement despite documentation of confusion, impaired decision making, memory problems, disorganized thinking, and wandering in the care plan. The resident's record also showed no assessments completed for risk of elopement and unsafe wandering since admission. The facility policy titled Elopement and Wandering Policy required assessment for elopement and unsafe wandering upon admission and throughout the resident's stay, along with adequate supervision and a systematic approach to monitoring residents at risk. However, the care plan meeting documentation from 2025 did not include concerns related to wandering or elopement, and the medical record did not show documentation of a wandering/elopement-specific assessment. The deficiency was reflected in multiple events involving the resident leaving or being found outside the expected area. One progress note documented that staff could not locate the resident during the night, prompting a search by nursing staff, CNAs, hospital security, and police before the resident was found in a bathroom lying in a bathtub with a burned-out light. Another note documented the resident outside near the building and returning on a wheelchair ramp, and a separate note described the resident wandering at a hospital in a wheelchair with a cervical collar in her lap before being returned to the facility. The record also stated that no FRI was completed for the 10/05/2025 elopement event.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent. During observation, staff interview, record review, and review of the facility’s Medication Administration Policy- General, a total of 30 medication administration opportunities were observed and six errors were identified, resulting in a 16.6 percent error rate for one resident and one of three nurses. The policy required staff to verify that the medication name and dose matched the medication order on the MAR. For one resident, the physician’s orders and October 2025 MAR included ciprofloxacin HCL otic solution, cetirizine HCL, fluticasone propionate, magnesium oxide, docusate sodium, and Refresh ophthalmic solution, all scheduled for 8:00 a.m. During the medication pass, the DON administered prepackaged 8:00 a.m. medications including sertraline, omeprazole, nortriptyline, Eliquis, baclofen, and gabapentin, but did not administer the ordered cetirizine, fluticasone, magnesium oxide, docusate sodium, Refresh ophthalmic solution, or ciprofloxacin otic solution. In interview, the DON stated she could not locate the ciprofloxacin drops, said the pharmacy told her they had been delivered the prior evening, and later had another nurse show her where the omitted over-the-counter medications were located in the top drawer of the medication cart. The DON stated it was the first time she had to work on the medication cart, and the Administrator stated he would have told her to assign the cart to another nurse if he had known she was working it.
Failure to Maintain Safe and Clean Environment in Resident Rooms and Kitchen
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to maintain a safe, clean, and homelike environment in several resident rooms, the kitchen, and the laundry area. Observations over several days revealed gouged and scraped walls, broken sheetrock, and damaged air filters in resident rooms. In one room, a bathroom door hinge was broken, causing the door to lean and making it difficult to open and close, and there were also broken tiles in the shower. These issues were confirmed by both staff and the facility Administrator during walking rounds, with some residents and their family members also noting the need for repairs. In the kitchen, surveyors observed dirty floor tiles with built-up dirt and grease, debris, and dirty walls, particularly under the three-compartment sink and drying rack. The dishwasher door was coated with rust, and the chemical storage area had a dirty floor, large holes in the wall, and dark brown spots on the ceiling. The kitchen exit door did not close securely, and the deep fryer had grease buildup, rust, and a small hole that caused oil to leak onto the floor. Additional issues included peeling aluminum on the air conditioner duct and missing seals on door frames and wall corners. These conditions were confirmed by the Dietary Manager, Maintenance Supervisor, and Administrator. The facility's policy requires a safe, homelike environment free from physical hazards, with repairs prioritized and addressed as needed. However, the repeated observations of unaddressed maintenance issues in resident rooms and the kitchen indicate that the facility did not ensure timely repairs or adequate cleanliness, resulting in an environment that did not meet regulatory standards for safety and comfort.
Failure to Maintain Resident Dignity and Privacy During Personal Care
Penalty
Summary
Staff failed to maintain resident dignity and privacy during personal care for two residents. In one instance, a resident with chronic kidney disease, diabetes, and an amputation was assisted with a bed bath in a shared room without the privacy curtain being fully drawn or the window blinds closed. The resident was left exposed, and both the CNA and the resident confirmed that full visual privacy was not provided during the bathing process. The CNA also reported not receiving training on the proper use of privacy curtains. In another case, a resident with chronic kidney disease and a Foley catheter was observed multiple times with the dignity bag for the catheter drainage bag positioned incorrectly, allowing urine to be visible from the doorway. The RN confirmed that CNA staff failed to ensure the dignity bag was properly placed to prevent exposure. The DON stated that CNAs were expected to pull privacy curtains and use dignity bags for residents with catheters, but was unaware that these lapses were occurring.
Failure to Develop Care Plan for Foley Catheter
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with a physician order for a Foley catheter. Review of the resident's Minimum Data Set (MDS) assessment and physician orders confirmed the presence of a Foley catheter and the need for oxygen therapy. However, the resident's care plan did not include any plan of care for the Foley catheter. Staff interviews with the MDS Coordinator and DON confirmed that a care plan for the Foley catheter was not created until the fourth day of the survey, despite the facility's policy requiring comprehensive care plans to address all resident needs. The MDS Coordinator and DON acknowledged that any nurse could have created the care plan and emphasized the importance of care plans in guiding resident care.
Failure to Properly Administer and Monitor Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who were receiving oxygen therapy. For one resident with COPD and oxygen dependence, surveyors observed that the oxygen tubing was crimped, preventing oxygen from reaching the resident, and the concentrator filter was caked with dust over several days. The humidifier bottle was not changed as ordered, and there was no specific signage indicating oxygen use in the room. The Director of Nursing (DON) and Administrator confirmed the dirty filter and acknowledged that the filter should have been cleaned and that the tubing should not have been crimped. Another resident with COPD was observed multiple times receiving oxygen at a flow rate of 3.5 liters per minute, despite a physician's order for 2 liters per minute. The DON confirmed that the oxygen should have been set at 2 liters per minute and that only a physician could authorize a change in flow rate. The DON also stated that nurses were expected to check oxygen settings at the beginning of each shift, but the incorrect flow rate persisted across several observations. A third resident with Alzheimer's disease and COPD was found receiving oxygen at higher flow rates than ordered, with the oxygen concentrator set at 4 liters per minute and later at 3 liters per minute, despite an order for 2 liters per minute as needed for shortness of breath or low oxygen saturation. Nursing staff confirmed the incorrect settings and adjusted the flow rate during the survey. Additionally, there was no signage on the resident's doorway to indicate oxygen therapy was in use, as required by facility policy. The facility also lacked a specific Oxygen Safety Policy, despite referencing it in their procedures.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 44 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Nashville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southwell Health And Rehabilitation | 12.9 mi | ★★★★★ | 5 | 0 |
| Sgmc Health Villa | 14.4 mi | ★★★★★ | 0 | 0 |
| Harborview Tifton | 23 mi | ★★★★★ | 22 | 0 |
| Pruitthealth - Lakehaven, Llc | 23.3 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Valdosta, Llc | 23.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Berrien Oaks Nursing And Rehab Center.
100% money-back within 48 hours.
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.