Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Accura Healthcare Of Cherokee, Llc during CMS and state inspections, most recent first.
A facility failed to ensure room trays were served at proper hot-food temperatures. Two residents reported meals delivered to their rooms were cold or only warm, and an observation showed room trays were plated in the kitchen, covered, and immediately delivered, with measured temperatures of 110°F for apple pork chop, 116°F for squash, and 115°F for mixed vegetables, below the facility’s 135°F standard.
Failure to respect residents during meal assistance. A CNA was observed standing over three residents while helping them eat breakfast, and another CNA was later observed standing over a resident during breakfast as well. The facility’s Dining Experience policy stated staff should sit next to a person when assisting with eating rather than standing over them. The DON/Administrator acknowledged the observations and stated she had already spoken to staff about the issue.
Failure to perform hand hygiene between assisting residents with breakfast was cited after a CNA alternated help between three residents, using each resident’s utensils and handling drinking cups without cleaning hands in between. The facility’s hand hygiene policy required staff to complete hand hygiene after handling contaminated items and before handling food. The Administrator confirmed observing the CNA assist residents in the dining room without hand hygiene and stated hand sanitizer was provided.
Staff failed to interact with two residents with moderate cognitive impairment in a dignified and respectful manner, including telling a resident to urinate in bed and removing call lights, as well as displaying rude or gruff behavior. Multiple staff and family interviews confirmed these actions, and complaints were reported to management without resulting in disciplinary action.
A resident with impaired cognition eloped from a facility due to a propped open door, while other residents experienced unsafe transfers due to improper use of mechanical lifts and incorrect sling sizes. Staff failed to follow protocols requiring two-person assistance for transfers, leading to a resident falling from a lift. Additionally, incorrect sling sizes were used, causing improper positioning during transfers.
The facility did not implement a legionella water program as required by their infection control policy. The Maintenance Director admitted to not conducting any testing or monitoring, only checking water temperatures weekly. The policy required flushing toilets and running faucets in vacant rooms monthly, but the Administrator confirmed this was not being followed.
The facility failed to refer two residents for a Level II PASRR evaluation despite serious mental disorders. One resident had anxiety, major depressive, and delusional disorders with severe cognitive impairment, but the PASRR was not updated. Another resident with major depressive disorder, dementia, and prescribed Seroquel for behavioral disturbances also lacked an updated PASRR. Both residents were not referred for necessary evaluations.
A resident with lymphedema, cellulitis, and obesity did not receive physician-ordered ace wraps for leg edema due to unavailability. Despite the order being in place, the facility failed to provide the necessary wraps from the pharmacy, leading the resident to manage swelling by elevating his legs.
Food Served to Room Residents at Improper Temperatures
Penalty
Summary
The facility failed to ensure proper temperatures for foods served to residents. Two residents reported that meals delivered to their rooms were not hot, with one stating the food was "half-ass warm" and another stating the food was always cold when it arrived. During an observation of room tray service, the Dietary Manager dished the room trays in the kitchen, covered the plates, and staff immediately delivered them to residents' rooms. After the last tray was served, temperatures were taken and the Apple Pork Chop measured 110 degrees Fahrenheit, the Squash 116 degrees Fahrenheit, and the Mixed Vegetables 115 degrees Fahrenheit. The facility policy required hot food items to be held and served at at least 135 degrees Fahrenheit, and the Dietary Manager acknowledged it was hard to keep room tray food hot but it should be hot. The Administrator stated the food should be served at the proper temperatures.
Failure to Respect Residents During Meal Assistance
Penalty
Summary
The facility failed to treat residents in a kind and respectful manner and failed to honor residents’ rights for 4 of 8 residents reviewed (#3, #8, #10, and #12). During breakfast observations, Staff A, a CNA, was seen standing over Residents #8, #10, and #12 while assisting them to eat on 1/7/26 at 8:20 AM. On 1/8/26 at 8:03 AM, Staff B, a CNA, was observed standing over Resident #3 while assisting that resident to eat breakfast. The facility’s Dining Experience policy dated 2021 stated that staff will sit next to a person when assisting them with eating rather than standing over them. In an interview on 1/8/26 at 8:24 AM, the Administrator stated that the CNA stood over the residents while helping them eat and reported giving verbal education to staff. The Administrator also stated that Staff B stood over Resident #3 that morning despite having already spoken to staff about the issue.
Failure to Perform Hand Hygiene Between Assisting Residents
Penalty
Summary
Provide and implement an infection prevention and control program was cited after staff failed to use universal infection control practices during breakfast service for three residents. On 1/7/26 at 8:20 AM, Staff A, a CNA, assisted Resident #8, Resident #10, and Resident #12 with breakfast and alternated assistance between the residents while using each resident’s utensils and handling drinking cups without performing hand hygiene between residents. The facility’s Hand Hygiene policy, last updated 11/13/24, states staff should always complete hand hygiene after handling contaminated items and equipment, after hands become physically soiled, and before eating, drinking, or handling food. During an interview on 1/8/25 at 8:24 AM, the Administrator reported observing Staff A assist residents in the dining room during breakfast on 1/7/26 without performing hand hygiene and stated she expected hand hygiene to occur; she also indicated she provided Staff A with a bottle of hand sanitizer.
Failure to Maintain Resident Dignity and Respect During Care
Penalty
Summary
Facility staff failed to interact with residents in a kind and considerate manner, resulting in a lack of dignity and respect for at least two residents with moderate cognitive impairment. Interviews and clinical record reviews revealed that one resident reported being told by staff to urinate in bed and that staff would clean her up afterward. Another resident stated that an LPN did not treat him with dignity and respect, and staff interviews corroborated that complaints had been made about staff being gruff, rude, or not listening to residents. There were also reports that staff had withheld or removed call lights from residents, limiting their ability to request assistance. Multiple staff members, including CNAs and LPNs, confirmed hearing about or witnessing inappropriate comments and actions, such as instructing residents to be incontinent and delaying responses to call lights. Staff also reported that grievances and complaints about these behaviors had been brought to management, but no disciplinary actions were found in the personnel files of the staff involved. Documentation from staff meetings and performance evaluations indicated ongoing concerns about staff attitudes and interactions with residents. The Director of Nursing and Administrator acknowledged receiving complaints about staff behavior, including rough bedside manners and not providing call lights to residents. Despite these reports, investigations were unable to determine the specific staff responsible in some cases, and the issues persisted over time. Facility policy requires all staff to promote and maintain resident dignity, but the documented actions and inactions of staff failed to uphold this standard for the residents involved.
Elopement and Unsafe Transfers in LTC Facility
Penalty
Summary
The facility failed to prevent a resident with impaired cognition from eloping, resulting in the resident leaving the facility without staff knowledge. The resident, diagnosed with Alzheimer's Disease, psychotic disorder, and Schizophrenia, was found outside the facility by a staff member in the parking lot. The resident was dressed appropriately for the weather and did not sustain any injuries. However, the facility was unsure how the resident managed to exit the building, as the doors and alarms were reportedly functioning properly. Staff statements revealed that the door to the memory care unit had been propped open during the night, which may have facilitated the resident's elopement. Additionally, the facility failed to ensure safe and appropriate transfers for residents requiring mechanical lifts. One incident involved a CNA transferring a resident alone using a Hoyer lift, resulting in the resident falling to the floor when a sling loop became unhooked. The facility's policy requires two staff members to assist with such transfers to prevent injuries. Another observation noted staff failing to lock the wheelchair brakes during a transfer, causing the wheelchair to roll back as the resident was lowered into it. This improper handling of equipment posed a risk of injury to the residents involved. Furthermore, the facility did not ensure the correct size of slings was used during transfers, leading to improper positioning of residents. In one case, a resident was transferred using an extra-large sling, which was too big for the resident's weight, causing difficulty in positioning the resident correctly in the wheelchair. Staff admitted to not knowing the correct sling size and cited a lack of available sizes, especially after laundry staff left. These deficiencies highlight a lack of adherence to safety protocols and proper training in the use of mechanical lifts and slings, compromising resident safety.
Removal Plan
- The facility floor nurse checked all facility windows and doors in the chronic confusion or dementing illness unit and all were intact and working properly.
- Frequent checks were initiated on Resident #1.
- Administrator conducted a door alarm check, and all doors and alarms were working properly.
- Administrator reviewed elopement binder was current.
- Administrator completed education on the facility elopement policy.
- Administrator changed all facility door codes for exits and CCDI unit.
- Administrator initiated a sign off sheet for facility floor nurses to conduct door alarm checks at shift change.
Failure to Implement Legionella Water Program
Penalty
Summary
The facility failed to implement a legionella water program, as required by their infection control policy. During an interview, the Maintenance Director, identified as Staff A, admitted to not conducting any testing or monitoring of the legionella program, only checking water temperatures weekly. The facility's policy on legionella, which was undated, stated that sound clinical and infection control practices should be used to identify and treat potential Legionnaires' related illnesses, and that preventive maintenance and housekeeping practices should minimize exposure risks. The policy included specific actions such as flushing toilets and running faucets for a minimum of 30 seconds in vacant resident rooms and other rooms with plumbing fixtures monthly. However, the Administrator confirmed that the facility was not following this policy.
Failure to Refer Residents for Level II PASRR Evaluation
Penalty
Summary
The facility failed to refer two residents for a Level II PreAdmission Screening and Resident Review (PASRR) evaluation despite the presence of serious mental disorders. Resident #6 had diagnoses of anxiety disorder, major depressive disorder, and delusional disorders, with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The clinical record did not include an updated PASRR reflecting the delusional or psychotic disorder. Staff B, a Registered Nurse, acknowledged that the delusional disorder should have been included in the PASRR. Resident #14 had diagnoses of major depressive disorder, dementia, and had been prescribed Seroquel for tearfulness and paranoia related to dementia with behavioral disturbances. The clinical record lacked an updated PASRR to include these diagnoses and the use of Seroquel. Both residents were not referred to the appropriate state-designated authority for a Level II PASRR evaluation, which is required when there is a newly evident or possible serious mental disorder.
Failure to Provide Physician-Ordered Leg Wraps for Edema
Penalty
Summary
The facility failed to provide physician-ordered leg wraps for a resident diagnosed with lymphedema, cellulitis, and obesity. The resident, who had no cognitive impairment, reported not receiving the prescribed ace wraps for his legs to manage swelling. Instead, an alternative edema treatment was applied, which was too tight and caused discomfort by pushing the edema up into the knee area. The resident attempted to manage the swelling by elevating his legs while seated. The physician's order, dated October 4, 2024, specified the application of ace wraps from toes to knees daily, to be removed as needed or at bedtime. However, progress notes and the Treatment Administration Record (TAR) indicated that the ace wraps were consistently unavailable from October 5 to October 9, 2024. Despite the order being received, the facility did not have the wraps on hand, and they were noted to be on order from the pharmacy. A registered nurse confirmed that the wraps should have been applied as per the order, but they were not available until the day of the interview.
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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 Cherokee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cherokee Specialty Care | 0.6 mi | ★★★★★ | 0 | 0 |
| Careage Hills Rehabilitation And Healthcare | 0.8 mi | ★★★★★ | 9 | 0 |
| Accura Healthcare Of Aurelia, Llc | 5.7 mi | ★★★★★ | 10 | 0 |
| Heartland Care Center | 14.3 mi | ★★★★★ | 8 | 0 |
| Aspire Of Sutherland | 14.9 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.