Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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What surveyors actually found near you
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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 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 |
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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 August 2026) and official state health department websites.