Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Cherokee Specialty Care during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and mobility issues suffered a second-degree burn after spilling hot coffee in their lap. The facility failed to secure the coffee with a lid and did not adequately supervise the resident, who was known to drink coffee at all hours. Additionally, the prescribed treatment for the burns was not documented or followed, leading to significant pain and delayed care. Interviews with staff confirmed these oversights, and the resident required frequent morphine for pain management before passing away.
A facility failed to provide a resident or their representative with a written notice of rights, rules, services, and charges upon admission. The admission paperwork was not completed with the POA on the day of admission, and discrepancies in e-signature dates were found. Interviews confirmed the facility's admission process was flawed, and the Document Manager process failed to time-stamp e-signatures correctly. The Resident Council Meeting Minutes indicated a lack of transparency in the admission process.
A resident reported being verbally and physically abused by a CNA, who allegedly backed them into a wall. Despite the allegations, the facility allowed the CNA to continue working with other residents, although not with the complainant. The facility's investigation did not substantiate the claims, and police involvement did not confirm the allegations. The resident expressed ongoing discomfort and dissatisfaction with the situation.
A facility failed to report alleged abuse and missing Fentanyl patches to the Department of Inspection and Appeals and Licensing (DIAL) within the required time frames. An incident involving a resident and a CNA was not reported within 2 hours, and missing Fentanyl patches for two residents were not reported within 24 hours. The facility did not adhere to its policies requiring immediate reporting of such incidents.
The facility failed to investigate missing Fentanyl patches for two residents, one with no impaired decision-making abilities and another with moderate impairment. Despite the discovery of missing patches during routine checks, no investigations were conducted, as confirmed by the DON. This oversight contravenes the facility's policy to protect residents from neglect and misappropriation of property.
A facility failed to follow a resident's plan of care by not checking the colostomy bag every 3 hours as required. The resident, dependent on staff for daily activities, reported discomfort due to the bag being full of air. Clinical records and staff interviews confirmed the deficiency, with a CNA admitting the bag was not burped as needed due to staffing issues. The DON acknowledged the absence of a specific policy for colostomy care.
The facility failed to provide sufficient nursing staff, resulting in delayed call light responses for residents. Interviews and records showed that call lights were not answered within the expected 15 minutes, with some residents waiting over 30 to 45 minutes. Staffing levels were below the recommended daily pattern, particularly during the second and third shifts, as confirmed by staff and the Director of Nursing.
The facility failed to serve food at appetizing temperatures to several residents with intact cognition, as meals were often cold when they should have been hot. Observations showed a significant drop in food temperature from the steam table to room service delivery. The Dietary Service Manager and Administrator expected food to be served at appropriate temperatures, consistent with the facility's policy.
The facility did not have the certified Infection Preventionist present at quarterly QAA meetings, as required by their QAPI policy. Instead, the DON attended these meetings without having completed the necessary certification test to serve in this role. This was confirmed through interviews with a certified RN and the DON.
A facility failed to update a care plan for a resident with moderate cognitive impairment and frequent bladder incontinence. Despite the resident's frequent incontinence since early 2023, no urinary toileting program was attempted, and the care plan inaccurately described the incontinence as occasional. The ADON confirmed the care plan should have reflected frequent incontinence.
A resident with moderate cognitive impairment and frequent bladder incontinence did not receive appropriate treatment to restore continence, as a urinary toileting program was not attempted. The care plan inaccurately reflected occasional incontinence, and staff acknowledged the need for a toileting plan. Observations showed the resident required assistance with toileting and had difficulty expressing needs.
A dietary cook in the facility was observed handling food without gloves or performing hand hygiene, violating professional standards. The cook repeatedly handled frozen hamburger patties and touched various kitchen items without washing hands. Interviews with the Dietary Service Manager and Administrator confirmed that staff were expected to wash hands appropriately, as outlined in the facility's policy on preventing foodborne illness.
A resident receiving antibiotic treatment via a PICC line was not provided with proper Enhanced Barrier Precautions (EBP) by an LPN, who failed to wear a gown during the procedure. The facility's policy and CDC guidelines require PPE during high-contact care activities, which was not followed in this instance.
A resident with no cognitive impairment experienced a fall while out with family, resulting in a fracture. Despite the resident's complaints of pain and visible swelling, the facility delayed notifying the physician and resident representative. The facility's policy required prompt notification, but staff were unaware of the need to report incidents occurring outside the facility.
A resident with no cognitive impairment and a history of diabetes and hypoglycemia reported a fall while out with family, resulting in pain and swelling in her right ankle. Despite the resident's complaints and visible swelling, the facility delayed notifying the physician and conducting a thorough assessment. This led to a missed diagnosis of an acute spiral fracture, which was only identified after an x-ray was performed days later.
The facility failed to ensure food was stored and prepared under sanitary conditions, with various items found without proper labeling and visible cleanliness issues in the kitchen. The Dietary Manager confirmed that staff are expected to label everything and keep the area clean, but the observed conditions indicated a failure to follow these expectations.
Failure to Secure Hot Coffee Leads to Resident Burn
Penalty
Summary
The facility failed to secure a hot cup of coffee and adequately supervise a resident known to drink hot coffee at all hours, resulting in a second-degree burn to the resident's groin area. The resident, who had moderate impaired decision-making abilities due to non-Alzheimer dementia, was frequently incontinent and used a wheelchair for mobility. Despite these conditions, the resident was allowed to have a hot cup of coffee without a lid, leading to an accidental spill that caused significant injury. The resident's care plan included interventions such as using sippy cups to prevent skin injuries and placing the resident in an area where frequent observation was possible. However, these interventions were not effectively implemented, as evidenced by the incident. The facility also failed to follow physician orders for wound treatment, as the prescribed Silvadene cream was not noted on the September Medication Administration Record (MAR) or Treatment Administration Record (TAR), delaying appropriate care for the burns. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Practical Nurse (LPN), confirmed the lack of directives to use a lid on the coffee mug and the failure to document and follow through with the prescribed treatment. The Dietary Manager also noted that coffee temperatures were not consistently recorded, which could have contributed to the severity of the burn. The resident experienced substantial pain from the burns, requiring frequent administration of morphine for pain management, and ultimately passed away later in the month.
Failure to Provide Written Notice of Rights and Charges
Penalty
Summary
The facility failed to provide a resident or their representative with a written notice of rights, rules, services, and charges upon admission. This deficiency was identified for one of the three residents reviewed, specifically Resident #4, who was admitted to the facility via family vehicle with their daughter. Despite the presence of the Durable Power of Attorney (DPOA) during the admission process, the facility did not provide the necessary written documentation to the resident or their representative. The admission paperwork was not completed with the Power of Attorney (POA) on the day of admission, and the POA later discovered discrepancies in the e-signature dates, indicating that they were not present when the documents were signed. Interviews with the Social Service Director and the Regional Director of Human Resources confirmed that the facility's admission process was flawed, as the admission paperwork was not properly provided to the resident or their representative. The facility's Document Manager process, which allows for electronic signatures, failed to automatically time-stamp the e-signatures as per normal routine. Additionally, the Resident Council Meeting Minutes revealed a request from a resident or representative to review the admission packet, indicating a lack of transparency in the admission process. The facility has since revised its admission process, but the deficiency highlights a failure to ensure that residents and their representatives are fully informed of their rights and responsibilities upon admission.
Resident Alleges Abuse by CNA, Facility Investigation Inconclusive
Penalty
Summary
The facility failed to provide a supportive and safe environment for a resident, identified as Resident #3, who reported an incident involving a Certified Nurse Aide (CNA). The resident alleged that the CNA backed them into a wall and verbally abused them. Despite the allegation, the facility allowed the CNA to continue working with other residents, although they were instructed not to assist Resident #3. The resident's Minimum Data Set (MDS) assessment indicated no impaired decision-making abilities and documented the need for partial assistance with certain activities of daily living. The facility's internal investigation did not substantiate the resident's claims, and the CNA was allowed to continue working. The resident's grievance was documented, and the police were involved, but the allegations were not confirmed. The resident expressed ongoing discomfort and reported physical pain related to the incident, although the facility's staff did not observe any functional impairments. The resident's behavior and interactions with the staff were monitored, and the resident was offered alternative living arrangements, which they considered but did not immediately accept. The facility's policies emphasize the right of residents to be free from abuse and neglect, and the resident's rights include being treated with dignity and respect. Despite these policies, the facility's response to the incident did not fully align with the resident's reported experience, as the CNA continued to work in the facility. The resident's ongoing dissatisfaction with the situation was noted in subsequent documentation, indicating unresolved concerns about the incident.
Failure to Report Alleged Abuse and Missing Fentanyl Patches
Penalty
Summary
The facility failed to report alleged violations involving mistreatment, neglect, or abuse of a resident to the Department of Inspection and Appeals and Licensing (DIAL) within the required time frame. Specifically, an incident involving a resident who accused a CNA of backing them against a wall was not reported within the mandated 2-hour window. The facility conducted an internal investigation and determined that the CNA was not capable of the alleged action, but did not notify DIAL as required. Additionally, the facility did not report missing Fentanyl patches for two residents to DIAL within the required 24-hour period. One resident, who was on a Fentanyl patch for chronic pain, was found without the patch during a scheduled check, and no investigation was initiated to determine the cause of the missing patch. Similarly, another resident's Fentanyl patch was not found during a scheduled change, and the facility again failed to report this to DIAL. The facility's policies require immediate reporting of all allegations of abuse, neglect, and misappropriation of resident property to DIAL. However, in these instances, the facility did not adhere to its own policies or regulatory requirements, resulting in a failure to report potential abuse and missing controlled substances in a timely manner.
Failure to Investigate Missing Fentanyl Patches
Penalty
Summary
The facility staff failed to investigate the missing Fentanyl patches for two residents, leading to a deficiency in handling opioid medications. Resident #3, who had no impaired decision-making abilities, was on a pain management plan involving Fentanyl patches due to chronic pain. On a scheduled medication administration, the nurse discovered that the Fentanyl patch was missing from the resident's body, and despite a thorough search and inquiry, the patch was not found. The Director of Nursing confirmed that no investigation was initiated regarding the missing patch, which is against the facility's expectations. Similarly, Resident #1, who had moderate impaired decision-making abilities, was also prescribed Fentanyl patches for pain management. During a routine check, the patch was found missing, and again, no investigation was conducted to determine the cause or whereabouts of the missing patch. The Director of Nursing acknowledged the failure to investigate the missing patch for this resident as well. The facility's policy mandates that all residents have the right to be free from abuse, neglect, and misappropriation of property, which includes ensuring the safe administration and monitoring of medications. The failure to investigate the missing Fentanyl patches for both residents indicates a lapse in adhering to these policies, potentially compromising the residents' safety and well-being.
Failure to Adhere to Colostomy Care Plan
Penalty
Summary
The facility failed to adhere to professional standards and the resident's plan of care by not checking a resident's colostomy bag every 3 hours as required. The resident, who has a colostomy and is dependent on staff for all activities of daily living, reported that the staff did not check the colostomy bag every 3 hours, leading to discomfort due to the bag being full of air. The clinical records corroborated the resident's statement, showing that the colostomy bag was not checked at the prescribed intervals. Observations and staff interviews confirmed the deficiency. A Certified Nursing Assistant admitted that the colostomy bag was not burped every 3 hours due to staffing issues, despite the plan of care's requirements. The Director of Nursing acknowledged the lack of a specific policy or procedure for colostomy care, stating that the facility follows state and federal guidelines. This lack of adherence to the plan of care and professional standards resulted in the identified deficiency.
Inadequate Staffing Leads to Delayed Call Light Response
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents, resulting in delayed response times to call lights. Interviews with residents and staff, as well as resident council minutes, revealed that call lights were not being answered within the expected 15-minute timeframe. Specifically, two residents reported waiting over 30 to 45 minutes for assistance. The facility's Director of Nursing confirmed the staffing shortages and acknowledged that the facility's guidelines for call light response times were not being met. The facility's assessment outlined a daily staffing pattern that was not adhered to, as evidenced by the two-week work schedule. On several days, the number of Certified Nursing Assistants (CNAs) scheduled was below the recommended levels, particularly during the second and third shifts. This staffing inadequacy was corroborated by staff interviews, where CNAs reported difficulties in responding to call lights promptly due to insufficient staffing, especially when assisting residents with mechanical lifts.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature to four residents, all of whom had intact cognition as indicated by their BIMS scores of 15. These residents reported that their meals were often served cold when they should have been hot. Specifically, Resident #1 mentioned that room trays were not delivered until after everyone in the dining room had been fed, resulting in cold food. Resident #5 and Resident #35 also reported that their meals were frequently cold, with Resident #35 noting that the food quality had been poor for the four years he had been at the facility. Resident #39 added that the food was often burnt and then served cold. Observations on a specific day revealed that the dining service was completed in the dining room before room trays were sent out, leading to a significant drop in food temperature. For instance, chicken and dumplings initially measured at 156 degrees dropped to 113.9 degrees by the time they were served to residents in their rooms. Similarly, green beans went from 146 degrees to 86.4 degrees. Interviews with the Dietary Service Manager and the Administrator confirmed that their expectations were for food to be served at appropriate temperatures, aligning with the facility's policy on food preparation and service, which mandates maintaining proper hot and cold temperatures during food service.
Infection Preventionist Absence at QAA Meetings
Penalty
Summary
The facility failed to have the Infection Preventionist present at the quarterly Quality Assessment and Assurance (QAA) meetings, as required by their Quality Assurance and Performance Improvement (QAPI) Program policy. The Director of Nursing (DON) attended the meetings on behalf of the Infection Preventionist on three specific dates. However, the DON had not completed the necessary certification test to officially serve as the Infection Preventionist. This oversight was confirmed during interviews with both a Registered Nurse, who had obtained certification as an Infection Preventionist but did not attend the meetings, and the DON, who acknowledged the incomplete certification process.
Failure to Revise Care Plan for Frequent Incontinence
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for one resident, who was identified as having moderate cognitive impairment and frequent bladder incontinence. The Minimum Data Set (MDS) assessment indicated that the resident had been frequently incontinent since February 2023, yet no urinary toileting program had been attempted. The care plan, last revised in June 2022, inaccurately described the resident's incontinence as occasional and included interventions such as assisting the resident to the bathroom or commode as needed. The Assistant Director of Nursing acknowledged that the care plan should have reflected the resident's frequent incontinence, not occasional incontinence.
Failure to Implement Urinary Toileting Program for Incontinent Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with bladder incontinence, as required to restore continence to the extent possible. The resident, who had a moderate cognitive impairment, was frequently incontinent of bladder, yet a urinary toileting program had not been attempted. The resident's care plan, which was revised over a year prior, inaccurately identified the resident as having occasional bladder incontinence, and interventions included assisting the resident to the bathroom or commode as needed. Observations and staff interviews revealed that the resident had been frequently incontinent, and the care plan did not reflect this accurately. The Assistant Director of Nursing acknowledged that the resident's care plan should have indicated frequent incontinence and that a toileting plan had not been tried. Additionally, a Certified Nursing Assistant noted that the resident sometimes took herself to the bathroom but required assistance, and had difficulty verbally expressing her needs. The facility's policy on urinary continence and incontinence management required staff to screen and manage individuals with urinary incontinence, and to initiate a toileting plan if the resident remained incontinent despite treating transient causes.
Failure to Maintain Hand Hygiene in Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards in the preparation, serving, and distribution of food, as observed during a survey. A dietary cook, identified as Staff B, was seen handling food without wearing gloves or performing hand hygiene. Specifically, Staff B opened a freezer, retrieved a box of frozen hamburger patties, and used a spatula to cook them, all without washing hands. This process was repeated three times, and Staff B also touched various kitchen items, such as lids, cabinet handles, spatulas, and freezer door handles, without completing hand hygiene. Interviews with the Dietary Service Manager and the Administrator confirmed that the expectation was for staff to wash hands at appropriate times while in the kitchen. The facility's policy on preventing foodborne illness, dated October 2017, requires employees to wash their hands before contacting food surfaces, after handling raw meat, and after handling soiled equipment or utensils.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to universal infection control measures and Enhanced Barrier Precautions (EBP) during the care of a resident with a peripherally inserted central catheter (PICC) line. The resident, identified as having intact cognition, was receiving antibiotic treatment for a urinary tract infection and had a history of methicillin-resistant Staphylococcus aureus (MRSA). During an observation, a Licensed Practical Nurse (LPN) performed hand hygiene and donned gloves before cleansing the PICC line port and administering medication. However, the LPN did not wear a gown, which is required under EBP for residents with indwelling medical devices. Interviews with the LPN and the Director of Nursing (DON) confirmed the expectation that staff should wear gloves, gowns, and appropriate personal protective equipment (PPE) for residents on EBP. The facility's policy on Enhanced Barrier Precautions, as well as guidelines from the Centers for Disease Control and Prevention, emphasize the necessity of PPE during high-contact care activities, such as device care. The failure to wear a gown during the procedure was a deviation from these established protocols, contributing to the deficiency noted in the report.
Failure to Notify Physician and Representative of Resident's Fall
Penalty
Summary
The facility failed to immediately notify the physician and resident representative of a fall with an injury for a resident. The resident, who had no cognitive impairment and was diagnosed with diabetes and hypoglycemia, experienced an unwitnessed fall in the dining room and later reported a fall while out with family. Despite the resident's complaints of pain and visible swelling and bruising on the right ankle, the facility did not notify the physician until two days after the resident reported the fall, and the resident representative was not informed until the following day. The resident was administered pain medication multiple times due to increasing pain in the right ankle, which was later diagnosed as an acute spiral fracture of the distal fibula. The facility's policy required prompt notification of the physician and resident representative in the event of an accident or incident, but this was not adhered to in this case. The Assistant Director of Nursing acknowledged that staff were unaware of the need to report incidents occurring outside the facility, leading to a delay in completing the incident report and notifying the necessary parties.
Failure to Timely Assess and Notify Physician of Resident's Injury
Penalty
Summary
The facility failed to provide adequate assessment and timely intervention for a resident who experienced a change in condition. The resident, who had no cognitive impairment and was diagnosed with diabetes and hypoglycemia, reported a fall while out with family, which resulted in pain and swelling in her right ankle. Despite the resident's complaints of pain and the visible swelling and bruising, the facility did not notify the physician or conduct a thorough assessment until two days later. The resident initially reported pain in her right leg and ankle, receiving Hydrocodone and Acetaminophen for relief. However, the pain persisted, and the resident's condition worsened, with increased swelling and bruising noted by staff. Despite these observations, the facility delayed notifying the physician and failed to conduct an x-ray until several days after the resident first reported the fall and pain. The delay in assessment and notification resulted in a missed diagnosis of an acute spiral fracture of the distal fibula, which was only identified after the resident was sent for an x-ray. The facility's policy required prompt notification of the physician in the event of a change in a resident's condition, but this protocol was not followed, leading to inadequate care for the resident.
Failure to Maintain Sanitary Food Storage and Preparation Conditions
Penalty
Summary
The facility failed to ensure food was stored and prepared under sanitary conditions, as observed during an initial kitchen tour. Various items in the kitchen fridge, freezer, drink refrigerator, and dry storage area were found without proper labeling, including open containers of chicken, cottage cheese, deli ham, tuna salad, smoked chicken salad, potato salad, coleslaw, and various beverages. Additionally, several items in the freezer and dry storage lacked received dates, and some items were past their use-by dates. The kitchen also had visible cleanliness issues, such as dried food and white streaked areas on the front of refrigerators, freezers, ovens, and cabinets, as well as food crumbs, dried food items, and other debris on the floor. The facility's policies on food receiving, storage, and sanitation were not adhered to, as evidenced by the observations made during the tour. Further observations revealed unsanitary conditions, such as a red substance on a cabinet shelf, excess peanut butter around a container with an uncovered knife, and a knife with margarine left on top of a margarine container. The Dietary Manager confirmed that staff are expected to label everything in the kitchen, keep the area clean, and discard expired items. However, the observed conditions indicated a failure to follow these expectations, leading to the identified deficiencies in food storage and preparation practices.
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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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Illustrative
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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) |
|---|---|---|---|---|
| Careage Hills Rehabilitation And Healthcare | 0.5 mi | ★★★★★ | 9 | 0 |
| Accura Healthcare Of Cherokee, Llc | 0.6 mi | ★★★★★ | 6 | 0 |
| Accura Healthcare Of Aurelia, Llc | 6.2 mi | ★★★★★ | 10 | 0 |
| Heartland Care Center | 13.7 mi | ★★★★★ | 8 | 0 |
| Aspire Of Sutherland | 14.7 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.