Inspection Reports for NHC HealthCare, Tullahoma
1321 Cedar Lane, Tullahoma, TN, 37388
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% better than Tennessee average
Tennessee average: 4.4 deficiencies/year
Deficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 8
Date: Jun 11, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident assessments, care planning, medication storage, infection control, food safety, waste management, hospice services, and respiratory care.
Findings
The facility was found deficient in multiple areas including failure to complete quarterly resident assessments timely, failure to revise care plans after changes, improper medication storage, inadequate respiratory care equipment storage, failure to maintain sanitary conditions in the dumpster area, failure to ensure dietary staff wore proper hair coverings, lack of coordinated hospice care plans in medical records, failure to implement proper infection control practices including PPE use and hand hygiene assistance prior to meals.
Deficiencies (8)
Failed to complete quarterly assessments within regulatory time frames for 7 of 28 residents reviewed.
Failed to revise the care plan for 1 resident to reflect discontinuation of indwelling urinary catheter.
Failed to ensure medications were stored and secured properly for 2 residents.
Failed to ensure nebulizer mask was stored appropriately for 1 resident.
Failed to ensure dietary workers wore protective hair coverings during food preparation.
Failed to ensure garbage and refuse were properly contained and dumpster area maintained in sanitary condition.
Failed to ensure a coordinated plan of care with the hospice provider was available in the medical record for 1 resident.
Failed to ensure appropriate PPE was donned for 2 residents on Enhanced Barrier Precautions and failed to offer hand hygiene assistance prior to meals to 3 residents.
Report Facts
Residents reviewed for MDS assessment: 28
Residents reviewed for care plans: 18
Residents observed for medication storage: 90
Residents observed on nebulized medications: 3
Residents reviewed for hospice services: 4
Residents observed on Enhanced Barrier Precautions: 6
Residents observed for hand hygiene assistance: 3
Residents affected by hair covering deficiency: 89
Broken items found in dumpster area: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator J | MDS Coordinator | Confirmed late completion of quarterly assessments |
| Registered Nurse I | RN | Administered medication and left inhaler at bedside |
| Medical Director | Commented on medication toxicity and safety | |
| Pharmacy Consultant | Commented on medication toxicity and safety | |
| Licensed Practical Nurse H | LPN | Confirmed medications left unsecured at bedside |
| Director of Nursing | DON | Confirmed care plan deficiencies and medication storage issues |
| Assistant Dietary Manager | ADM | Observed with hair uncovered during food preparation |
| Food and Nutrition Director | FND | Confirmed dietary hair covering deficiencies and dumpster area condition |
| Infection Preventionist | IP | Confirmed nebulizer mask storage and PPE requirements |
| Certified Nursing Assistant B | CNA | Failed to wear gown and gloves for EBP resident care |
| Licensed Practical Nurse C | LPN | Failed to wear gown for EBP resident care |
| Licensed Practical Nurse E | LPN | Forgot gown when managing PICC line |
| Certified Nursing Assistant A | CNA | Failed to wear gown and gloves for EBP resident care and failed to offer hand hygiene assistance |
| Certified Nursing Assistant D | CNA | Failed to wear gown and gloves for EBP resident care |
| Certified Nursing Assistant F | CNA | Failed to offer hand hygiene assistance prior to meals |
| Certified Nursing Assistant G | CNA | Failed to offer hand hygiene assistance prior to meals |
| Licensed Practical Nurse Unit Manager M | LPN Unit Manager | Confirmed hospice documentation missing from medical record |
| Registered Nurse L | RN | Unaware how to locate hospice plan of care |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 13, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, infection prevention, and wound care practices at Nhc Healthcare, Tullahoma.
Findings
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident, failed to revise comprehensive care plans to include new fall prevention interventions for two residents, and failed to ensure proper hand hygiene during wound care for one resident. These deficiencies were identified through record reviews, observations, and interviews.
Deficiencies (3)
Failed to accurately complete a Minimum Data Set (MDS) assessment for Resident #47, including inaccurate documentation of pressure ulcers.
Failed to revise comprehensive care plans to include new fall prevention interventions after falls for Residents #5 and #27.
Failed to ensure proper hand hygiene during wound care by the Wound Care Nurse for Resident #6.
Report Facts
Residents reviewed: 18
Stage 3 pressure ulcer size: 3
Stage 3 pressure ulcer size: 2
Stage 3 pressure ulcer size: 0.6
BIMS score: 15
BIMS score: 13
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed inaccuracies in MDS assessment and care plan revisions; confirmed failure of hand hygiene during wound care |
| MDS Coordinator #1 | MDS Coordinator | Confirmed the MDS completed on 2/22/2024 showing inaccurate stage 2 pressure ulcer |
| Wound Care Nurse | Wound Care Nurse | Observed failing to perform hand hygiene during wound care for Resident #6 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 31, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to protect a resident from abuse by another resident and failure to follow a physician's order for wound care.
Complaint Details
The complaint investigation revealed that Resident #2, who had advanced dementia and behavioral issues, struck Resident #1 multiple times causing no physical injury but constituting abuse. Resident #2 was aggressive towards staff and was transferred to a geriatric psychiatric hospital. The facility conducted interviews with staff, residents, and reviewed medical records confirming the abuse. Resident #3's physician's order to remove staples was not followed, and staples remained in place 12 days beyond the ordered removal date.
Findings
The facility failed to protect Resident #1 from abuse by Resident #2, who exhibited aggressive behaviors and struck Resident #1. Resident #2 was transferred to a psychiatric hospital following the incident. Additionally, the facility failed to follow a physician's order to remove staples from Resident #3's surgical wound, resulting in delayed staple removal.
Deficiencies (2)
Failed to protect Resident #1 from abuse by Resident #2 who struck Resident #1 multiple times.
Failed to follow physician's order to remove staples from Resident #3's mid-chest surgical incision.
Report Facts
Residents reviewed for abuse: 5
Staples present on Resident #3's wound: 22
Days staples remained after ordered removal date: 12
Date of survey completed: Jan 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #1 | Nurse Practitioner | Recalled incident between Residents #1 and #2 and confirmed Resident #2 was sent for psychiatric evaluation. |
| Director of Nursing | Director of Nursing | Interviewed regarding incident and confirmed expectations for following physician's orders. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Witnessed aftermath of altercation between Residents #1 and #2 and provided statements about the incident. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Provided statements about Resident #2's behavior and incident awareness. |
| Medical Doctor #1 | Medical Doctor | Confirmed expectation that physician's orders were followed. |
| Administrator | Administrator | Interviewed regarding incident and facility expectations. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 12, 2020
Visit Reason
The inspection was conducted as a routine annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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