NHC HEALTHCARE, HENDERSONVILLE
For profit - Corporation
122 Beds
NATIONAL HEALTHCARE CORPORATION
Data: November 2025
Trust Grade
65/100
#142 of 298 in TN
Last Inspection: June 2022
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
NHC Healthcare in Hendersonville holds a Trust Grade of C+, indicating it is slightly above average among nursing homes. It ranks #142 out of 298 facilities in Tennessee, placing it in the top half of state options, and #3 out of 6 in Sumner County, meaning there are only two better local choices. Unfortunately, the facility is experiencing a worsening trend, with the number of issues increasing from 6 in 2019 to 8 in 2022. Staffing is a relative strength, rated 3 out of 5 stars with a turnover rate of 34%, which is lower than the state average of 48%, suggesting staff stability. Notably, the facility has no fines on record, which is a positive sign. However, some specific concerns include instances where food was not served at the proper temperature, call lights were not within reach for some residents, and there was a lack of daily activity updates in a language understandable to a non-English speaking resident. While the facility has some strengths, these issues indicate areas needing improvement to enhance resident care.
- Trust Score
- C+
- In Tennessee
- #142/298
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 34% turnover. Near Tennessee's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Tennessee facilities.
- Skilled Nurses ○ Average
- Each resident gets 36 minutes of Registered Nurse (RN) attention daily — about average for Tennessee. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 17 deficiencies on record. Higher than average. Multiple issues found across inspections.
65/100
Top 47%
No red flags
6 → 8 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2019: 6 issues
2022: 8 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (34%)
14 points below Tennessee average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Tennessee average (2.8)
Meets federal standards, typical of most facilities
Staff Turnover: 34%
12pts below Tennessee avg (46%)
Typical for the industry
Chain: NATIONAL HEALTHCARE CORPORATION
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 17 deficiencies on record
Jun 2022
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to ensure call lights were within reach for 2 o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to ensure call lights were within reach for 2 of 31 sampled residents (Resident #55 and #67).
The findings include:
Review of the undated facility's policy titled, Patient Rights, revealed, .It is the policy of the management to provide a full complement of services as possible and attainable to meet the needs of all patients .
Review of the undated facility's policy titled, Call Lights, revealed, .Center will provide each patient with a functioning call light .Be sure the call light is always within easy reach of the patient .
Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Dementia, and Unspecified Fracture of Shaft of Humerus.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Resident required supervision to extensive assistance of one person physical assist with Activities of Daily Living (ADL)s.
Review of the current Care Plan for Resident #55 revealed, .Resident is at risk for falls .Keep personal items within reach .Orient resident to surroundings, call light, and location of personal items .Activities of Daily Living: Limited ability to perform self-care .Call light within reach when in room .
Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction.
Review of the Quarterly MDS assessment dated [DATE], revealed Resident #67 had a BIMS score of 6, which indicated severe cognitive impairment. Resident required supervision to extensive assistance of 2 person physical assist with ADLs.
Review of the current Care Plan for Resident #67 revealed, .Resident is a risk for falls .Keep personal items within reach .Orient resident to surroundings, call light, and location of personal items .Activities of Daily Living: Limited ability to perform self-care .Call light within reach when in room .
Observation and interview in resident's room on 6/6/2022 at 9:39 AM, revealed Resident #55 in bed with her call light between the wall and bed on the floor. Resident stated she did not know where her call light was. During an interview Certified Nursing Assistant (CNA) #2 confirmed the call light was not within reach of the resident.
Observation and interview in resident's room on 6/6/2022 at 11:07 AM, revealed Resident #67 in bed with his call light on the floor under his bed. During an interview the Administrator confirmed the call light was not within reach of the resident.
During an interview on 6/8/2022 at 3:36 PM, the Director of Nursing (DON) confirmed she expected the call light to be within reach of all residents while in their room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0574
(Tag F0574)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to provide a daily activ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to provide a daily activity update in an understandable language which affected 1 of 1 (Resident #33) non English speaking residents sampled.
The findings include:
Review of the facility's policy titled, Patient's Rights, revision date 2/2022 revealed, .at National Healthcare Corporation [NHC] we support the patient/resident's right to live in an environment which is individualized for them .strive to cultivate and sustain an excellent quality of life for each individual with person-centered care and services .
Review of the facility's admission packet policy titled, Patient's Rights, revision date 11/2017 revealed, .NHC .provides free language services to people whose primary language is not English, such as .information written in other languages .
Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic Heart Failure, Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region, and Myocardial Infarction.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment.
Review of Resident #33's face sheet revealed her preferred language as Castilian Spanish.
Review of the current Care Plan for Resident #33 revealed, .Communication .mostly speaks Spanish .
Observation and interview in Resident #33's room on 6/7/2022 at 10:04 AM, Certified Nurse Assistant (CNA) #6, who spoke Spanish, translated for me while doing Resident #33's interview.
Observation and interview in Resident #33's room on 6/7/2022 at 4:40 PM, with the Business Office Manager revealed a daily activity note typed in English. During an interview the Business Office Manager who spoke Spanish and who visited Resident #33 daily confirmed the resident could not read the activity note which was typed in English.
During an interview on 6/8/2022 at 4:40 PM, the Recreation Director confirmed Resident #33 was not provided a daily activity note typed in Spanish.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to have quarterly care p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to have quarterly care plan conference meetings with resident/resident representative for 4 of 31 sampled residents (Residents #33, #42, #58, and #75).
The findings include:
Review of the facility's policy titled, Documentation Guidelines Section VII: Patient Care Plans updated 10/2021 revealed, .Routine Reviews and Updates: Care plans are updated as needed but are reviewed completely by the interdisciplinary team (IDT) on a quarterly basis within 7 days of the completion of the clinical MDS [minimum data set] assessment .
Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic Heart Failure, Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region, and Myocardial Infarction.
Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment.
Review of the Care Conference notes revealed Resident #33 had one Care Conference dated 9/10/2021.
Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis, Atherosclerotic Heart Disease (ASHD), and Chronic Systolic Heart Failure.
Review of the Quarterly MDS dated [DATE], revealed Resident #42 had a BIMS score of 6 which indicated severe cognitive impairment.
Review of the medical record revealed Resident #42 had one Care Conference dated 4/15/2021.
Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Simple Chronic Bronchitis, and Paroxysmal Atrial Fibrillation.
Review of the Care Conference notes revealed Resident #58 had one Care Conference dated 2/25/2022.
Review of the medical record revealed, Resident #75 was admitted to facility on 10/12/2020 with diagnoses which included Type 2 Diabetes Mellitus with Diabetic Neuropathy, Wedge Compression Fracture of First Lumbar Vertebra, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Polyneuropathy.
Review of the Minimum Data Set (MDS) assessments for Resident #75 revealed on 1/8/2022, and 2/24/2022, Significant Change in Status Assessments were completed. On 5/17/2022 a Quarterly MDS was completed revealed a BIMS score of 15 which indicated no cognitive impairment.
Review of Resident #75's Annual Care Plan on 10/27/2021, revealed care plan conference was held with Resident #75 and her representative was in attendance. Further review revealed the next Quarterly Care Plan meeting to convene 1/25/2022. No other Care Plan conference notes or documentation were found in the residents medical record.
Review of Resident #75's Care Plan Conference notes revealed a care plan conference was held on 10/27/2021 with Resident #75 and her representative in attendance. No other Care Plan Conference notes or documentation were found in the residents medical record.
Review of Resident #75's Nursing Progress notes revealed no documentation of Care Plan Conference meetings.
During an interview on 6/6/2022 at 3:44 PM, Resident #75's stated, Care Plan Meetings .unaware never been to one. My memory is not so good though.
During an interview on 6/7/2022 at 2:42 PM, the Social Worker (SW) confirmed the facility had not conducted IDT meetings since the pandemic started. Continued interview she stated the last Care Conference for Resident #33 was 9/10/2021, Resident #42's last Care Conference was 1/8/2021 and Resident #58's last Care Conference was 2/25/2022.
During an interview on 6/08/2022 at 3:38 PM, the SW confirmed that care plan meetings should be conducted 72 hours after admission and quarterly following completion of the MDS assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to perform oral care for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to perform oral care for 1 of 31 sampled residents (Resident #68).
The findings include:
Review of facility policy titled, Activities of Daily Living (ADLs), Supporting revised 3/2018 revealed .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) .If resident with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate .
Review of the medical record revealed Resident #68 was admitted to the facility with diagnoses which included Adult Failure to Thrive, Schizoaffective Disorder, and Bipolar Disorder.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. Continued review revealed Resident #68 had no issues with her teeth or gums.
Observation in Resident #68's room on 6/6/2022 at 9:56 AM and 3:44 PM, revealed Resident #68 with dried brown debris on her upper teeth.
During an interview on 6/6/2022 at 3:07 PM, the Certified Nurse Aide (CNA) #1 confirmed Resident #68's teeth were not clean. CNA #1 stated Resident #68 had refused oral care earlier when she attempted and did not report it to the nurse.
During an interview on 6/8/2022 at 3:07 PM, the Director of Nursing (DON) stated she expected oral care to be done morning and night and if the resident refused care she expected the CNA to tell the nurse. The refusal should be documented and care planned.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to administer oxygen (O2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to administer oxygen (O2) per physician order for 1 of 21 sampled residents (Resident #75).
The findings include:
Review of the facility policy titled, Nursing Services, Patient Care Policies revised 2/2022, revealed, .Medications, treatments, and diets are given as ordered and are documented in the medical record .
Review of the medical record revealed, Resident #75 was admitted to facility on 10/12/2020 with diagnoses which included Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #75 revealed, a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment.
Review of the Physician's Order Report dated 5/7/2022 to 6/7/2022, revealed, .Oxygen at 1-3 lpm (liters per minute) via NC (nasal cannula) as needed to keep SpO2 (Oxygen Saturation) at 88 % (percent) and above .
Review of the current care plan dated 1/20/2022, revealed, .O2 (Oxygen) at 2-3 L/min (liters per minute) via nasal cannula .
Observation in Resident #75's room on 6/6/2022 at 9:48 AM and 3:38 PM, revealed resident lying in bed, the call light within reach, and the O2 was humidified set at 4 L per NC.
Observation in Resident #75's room on 6/7/2022 at 8:37 AM, revealed resident lying in bed and the call light within reach, 02 per NC 4L.
During an interview on 6/7/2022 at 8:41 AM, with Licensed Practical Nurse (LPN) #1 at medication cart on 400 Hall LPN #1 reviewed oxygen orders for Resident #75 and confirmed the resident should be receiving O2 at 1-3 L per minute as needed (PRN) to keep her saturation above 88%.
During an interview on 6/7/2022 at 9:05 AM, with LPN #1 in Resident #75's room, she confirmed the residents O2 was set at 4L per minute. LPN #1 stated I didn't look at it today.
During an interview on 6/8/2022 at 4:51 PM, the Director of Nursing (DON) confirmed that nurses are expected to review the resident's physician orders for O2 and to verify the settings prior to going into the resident's room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to store medications prop...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to store medications properly for 1 of 31 sampled residents (Resident #1) and in room [ROOM NUMBER] and #312 ; the facility also failed to label Enteral feeding bag for 1 of 4 residents (Resident #42).
The Findings include:
Review of the facility's policy titled, Medication Storage In The Facility, dated 1/1/2019 revealed .Medications and biologicals are stored safely, securely, and properly .accessible only to licensed nursing personnel .authorized to administer medications .medication supplies are locked when not attended by persons with authorized access .Facility should assure that .labels include the Resident name .rate .date of preparation .initials of person administering .
Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes and Chronic Kidney Disease.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental status (BIMS) score of 15, which indicated no cognitive impairment.
Observation and interview in Resident #1's room on 6/6/2022 at 10:52 AM, revealed Resident #1 applying anti itch cream to her lower right leg. Resident #1 stated the nurses said it was okay for her to use the cream.
During an interview on 6/6/2022 at 11:44 AM, Licensed Practical Nurse (LPN) #2 confirmed Resident #1 did not have an order for an anti-itch cream, and had not been assessed for self administration of medication.
During an interview on 6/8/2022 at 2:54 PM, Director of Nursing (DON) stated she expected the nurses to look in the residents' rooms and be aware of items that family may have brought from home. Also, to retrieve the item and return to the family and get a physician's order for needed medication.
Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis, Atherosclerotic Heart Disease (ASHD), and Chronic Systolic Heart Failure.
Review of the Quarterly MDS assessment dated [DATE], revealed Resident #42 had a BIMS score of 6 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #42 had nutritional approaches for feeding tube in the last 7 days.
Observation in Resident #42's room on 6/6/2022 at 9:50 AM, revealed an enteral feeding bag with no name, date, or administration rate.
Observation and interview in Resident #42's room on 6/6/2022 at 10:00 AM, Director of Nursing (DON) confirmed the enteral feeding bag should be labeled with resident name, date and rate of administration.
Observation in the shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] on 6/6/2022 at 9:51 AM, revealed an unopened wound dressing and a medication cup of unidentified ointment on the back of the commode.
Observation and interview in the shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] on 6/6/2022 at 10:05 AM, Registered Nurse (RN) #1 confirmed the cup of unidentified medication was left unattended and should not have been left in the bathroom.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to store a BIPAP/CPAP (Bi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to store a BIPAP/CPAP (Bi-level Positive Airway/Continuous Positive Airway which help stimulate normal breathing) tubing and facemask for 1 of 5 residents (Resident #135); failed to don gloves while performing a blood glucose finger stick; failed to place a glucometer on a clean surface; and failed to don PPE (personal protective equipment) while in a Droplet Isolation Room for 1 of 7 rooms (room [ROOM NUMBER]) observed.
The findings include:
Review of the undated facility's policy titled, Transmission-Based Precautions/Isolation Rooms revealed .1. Review the isolation sign on the door for the specific information regarding isolation and instructions before entering the room. If there is no sign on the door, but your information indicates isolation or precautions, please check with Charge Nurse Before entering the room .
Review of the facility policy's titled, Blood Sampling-Capillary (Finger Sticks), revised 9/2014, revealed, .Always ensure that blood glucose meters intended for reuse are cleaned and disinfected .Don gloves .Place blood glucose monitoring device on clean field .
Review of the medical record revealed Resident #135 was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure with Hypoxia.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #135 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. Continued review revealed Resident #12 had shortness of breath during exertion and while lying down.
Review of the current Care Plan revealed .Respiratory Complications: At Risk For, Will not exhibit complications r/t [related to] aspiration for 120 days from update/last review AND/OR Will not experience any respiratory complications for 120 days from update/last review. BIPAP at hs [bedtime] .
Review of the current Physician Orders dated 5/23/2022, revealed .Physician Orders: BIPAP Auto Ipap [inspiratory positive airway] 14 Epap [expiratory positive airway] 9 PER HOME SETTINGS at HS At Bedtime .
Observation in Resident #135's room on 6/6/2022 at 9:42 AM, 11:39 AM, and 3:39 PM, revealed a BIPAP machine placed on top of the bedside drawer with the tubing and face mask not covered.
During an interview on 6/6/2022 at 3:39 PM, Resident #135 stated he had not been given a bag to place the tubing and mask in when the BIPAP machine were not in use.
During an interview on 6/6/2022 at 4:02 PM, Licensed Practical Nurse (LPN) #2 confirmed the tubing and mask were to be in a bag when not in use.
During an interview on 6/8/2022 at 2:54 PM, the Director of Nursing expected the BIPAP machine tubing and face mask to be covered when not in use.
Observation and interview on 6/6/2022 at 11:17 AM, revealed Registered Nurse (RN) #1 went in Resident #27's room to perform a blood glucose fingerstick. RN #1 did not wear gloves during the procedure; laid the glucometer on the bedside table without a barrier; punctured the resident's finger with needle; and aspirated blood to apply on test strip. Continued observation revealed she washed her hands after the fingerstick then picked up the uncleaned glucometer and carried it back to the medication cart. Further observation revealed she put gloves on; cleaned the glucometer with a bleach wipe; and then laid it back down on the cart without a barrier to dry. RN #1 confirmed she should have worn gloves during the fingerstick procedure and should have placed the glucometer on a clean barrier during the procedure and after cleaning the glucometer.
Observation in room [ROOM NUMBER] on 6/6/2022 at 10:22 AM, revealed a Housekeeper not wearing PPE such as a gown and face mask while cleaning a Droplet Isolation room.
During an interview on 6/6/2022 at 10:48 AM, the Housekeeper confirmed she was to wear PPE while in an isolation room. She stated she did not wear PPE because there was not a box of PPE supplies outside of the door.
During an interview on 6/8/2022 at 4:40 PM, the Infection Preventionist confirmed she required the staff to wear a face shield and mask while in a Droplet Isolation room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation, medical record review, observations, and interview, the facility failed to ensure a clean, sani...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation, medical record review, observations, and interview, the facility failed to ensure a clean, sanitary environment for 1 of 4 sampled residents (Resident #27) who required enteral feedings.
The findings include:
Review of the undated facility's document titled, Noncritical Patient Care Equipment-Cleaning Procedure Summary, revealed, .Consistent with cleaning frequency for patient area and as needed .
Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses which included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Dependence on Renal Dialysis, and Dysphagia, Oropharyngeal Phase.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Continued review revealed Resident #27 required a feeding tube.
Review of the Comprehensive Care Plan for Resident #27 revealed care plans which included Nutrition/Hydration/Dental, Need for Enteral Support.
Review of the Physician Order Report dated 6/7/2022-6/7/2022, for Resident #27 revealed, .5/6/2022 .Tube feeding formula .Nepro [brand of enteral formula] 1.8 @ (at) 55 ML/HR (milliliter/hour) .
Observation and interview in Resident # 27's room on 6/6/2022 at 2:10 PM, revealed a feeding pump had dried beige debris on the top and face of the pump. During an interview the Unit Manager/Licensed Practical Nurse (LPN) #5 confirmed the feeding pump had not been cleaned of the dried debris.
During an interview on 6/8/2022 at 3:38 PM, the Director of Nursing (DON) confirmed she expected all feeding pumps to be cleaned daily and as needed.
Jul 2019
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to complete a Quarterly Minimum Data Set (MDS) for 1 (#1) of 38...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to complete a Quarterly Minimum Data Set (MDS) for 1 (#1) of 38 residents reviewed.
The findings include:
Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, Long Term Use of Insulin, Kidney Transplant Status and Atrial Fibrillation.
Medical record review revealed Resident #1 had a Quarterly MDS completed on 3/19/19. Further medical record review revealed no Quarterly MDS was completed in June 2019.
Interview on 7/9/19 with Registered Nurse (RN) #1, MDS Coordinator at 4:43 PM in her office revealed Resident #1 had not had a Quarterly MDS completed since March 2019. When asked when the MDS assessment was due for Resident #1 the MDS Coordinator confirmed, The Quarterly MDS was due on June 19, 2019 and I missed it.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review observation and interview, the facility failed to revise/update care plan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review observation and interview, the facility failed to revise/update care plans for 2 (#55 and #237) of 38 residents reviewed.
The findings include:
Review of the facility policy, Care Plan Development, revised 7/3/08 revealed .Care Plans are updated as needed, but are reviewed completely by the interdisciplinary team on a quarterly basis within 7 days of completion .New problems are handled as they arise, and are to be added to the current care plan even if the change in condition is not considered significant enough for a complete revision .
Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Kidney Disease Stage 2, Urinary Incontinence and Urinary Tract Infection.
Medical record review of the Discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #55 was always incontinent of bladder and bowel.
Medical record review of the admission Observation dated 7/2/19 revealed Resident #55 was admitted with an indwelling catheter.
Observation on 7/8/19, 7/9/19, and 7/10/19 in Resident #55's room revealed the resident's catheter bag was in a dignity bag on the side of the bed.
Interview with Registered Nurse #5 (RN) on 7/10/19 at 11:50 AM at the nurse station revealed the staff nurses, MDS coordinator and Unit Managers could update the care plans. Continued interview revealed when asked what the date on the care plan was RN #5 responded .7/10/19 . Continued interview revealed when asked when it would be appropriate to update the care plan she replied .If I see a new care order I would update the care plan .
Interview with the Director of Nursing (DON) on 7/10/19 at 6:10 PM in the conference room revealed care plans are completed on admission. Continued interview revealed the MDS coordinator completed the comprehensive care plan after the 1st Resident Assessment Instrument (RAI) assessment.
Interview with the MDS Coordinator on 7/10/19 at 6:23 PM in her office revealed the care plan was not updated until after an assessment. Continued interview revealed nurses were responsible for updating the care plan when a resident was admitted to the facility.
Interview with LPN #6 also known as the Unit Manager on 7/10/19 at 6:30 PM in the conference room confirmed .Normally it [catheter] should be put on admission. I don't know why it was missed .
Interview with the DON on 7/10/19 at 6:44 PM in the hall by the conference room when asked to review Resident #55's care plan she confirmed .I will be honest with you, if it's [catheter] not there we forgot to do it .
Medical record review revealed Resident #237 was admitted to the facility on [DATE] with diagnoses which included Subsequent Encounter Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris and Type 2 Diabetes without Complications.
Medical record review of Resident #237's admission MDS dated [DATE] revealed the resident had no venous or arterial ulcers.
Medical record review of Resident #237's 14 day MDS dated [DATE] revealed the resident had 1 venous and arterial ulcer present.
Medical record review of the Physician Orders for Resident #237 revealed .5/1/19 .Right LAT.[Lateral] ANKLE - (SCAB REMOVAL FROM ABRASION) .CLEANSE WITH WOUND WASH &[And] PAT DRY .APPLY SKIN PREP COVER WITH MEDIUM ALLEVYN-DAILY .5/6/19 RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .CLEANSE WITH WOUND WASH & PAT DRY .APPLY SKIN PREP TO PERI-WOUND .APPLY SANTYL TO WOUND BED .COVER WITH MEDIUM ALLEVYN .CHANGE DRESSING EVERY MON [Monday]/WED [Wednesday]/FRI [Friday] .5/10/19 RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .CLEANSE WITH WOUND WASH & PAT DRY .APPLY SKIN PREP TO PERI-WOUND .APPLY BIOSTEP TO WOUND BED .COVER WITH MEDIUM ALLEVYN .CHANGE DRESSING DAILY .RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .PRN [As needed] .CLEANSE WITH WOUND WASH & PAT DRY. APPLY SKIN PREP TO PERI-WOUND .APPLY SANTYL TO WOUND BED .COVER WITH MEDIUM ALLEVYN .CHANGE DRESSING AS NEEDED DUE TO ACCIDENTAL REMOVAL/LOOSE/SOILED .6/18/19 RIGHT LATERAL ANKLE - (ARTERIAL ULCER) .CLEANSE WITH WOUND WASH & PAT DRY .APPLY SKIN PREP TO PERI-WOUND .APPLY ZINC OINTMENT TO PERI-WOUND .APPLY THICK LAYER OF SANTYL TO WOUND BED .LARGE MEPILEX .CHANGE DRESSING - EACH SHIFT .Day 7:00 AM .Night 7:00 PM .FLOAT ANKLES/HEELS .
Medical Record Review of Resident #237's comprehensive care plan dated 3/29/2019 - 7/10/2019 revealed .alteration in/potential for alteration in skin integrity R/T [related to] CVA [cerebral vascular accident] with right sided weakness . Continued review revealed the resident had no wounds to the right lateral ankle.
Interview with the DON on 7/11/19 at 11:51 AM in the conference room when asked to look at the care plans for Resident #237, she stated There's nothing in here that addresses the ankle. Continued interview with the DON confirmed Resident #237's care plan was not updated, she stated any nurse receiving orders should update the care plan with what the orders reflect and [named resident] was not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to obtain physician orders timely for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to obtain physician orders timely for placement of an indwelling catheter for 1 (#55) of 38 residents reviewed.
The findings include:
Review of the facility policy, Medication Orders, dated 6/2016 revealed .Medications are administered only upon an order from a person lawfully authorized to prescribe .
Medical record review revealed Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Kidney Disease Stage 2, Urinary Incontinence and Urinary Tract Infection.
Medical record review of the History of Present Illness dated 6/28/19 revealed .had evidence of a acute kidney injury .was found to have acute urinary retention by bladder scan .Foley catheter was placed with 1200 ml [milliter] of urine returned .
Medical record review of the Physician Orders for Resident #55 dated 7/5/19 revealed .Change Indwelling Catheter every 30 days once a day on the 1st month .Catheter Care Once per shift and document .
Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #55 required an indwelling catheter.
Interview with Licensed Practical Nurse #6 also known as the Unit Manager on 7/11/19 at 11:55 AM in his office revealed .normally the staff nurses would put the orders in on admission .
Interview with the Director of Nursing on 7/11/19 at 12:32 PM in the conference room revealed it was a night shift admission and the information did not get relayed appropriately. Continued interview confirmed .any of the nurses could have gotten an order and put it in. It should have been in place .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to label and date oxygen ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to label and date oxygen and nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) tubing and humidified canisters for 1 (#71) of 20 residents reviewed receiving respiratory treatments.
The findings include:
Facility policy review, Supplemental Oxygen, dated 1/2005, revealed .the purpose of delivering oxygen by nasal cannula is to: correct hypoxia [low oxygen] by increasing available alveolar oxygen .Diminish the myocardial [heart] work load by correcting hypoxemia [low level of oxygen in the blood] .decrease in breathing efforts to maintain adequate oxygenation .infection can occur if equipment is not changed and cleaned properly .change tubing and cannula every 7 days .label each tubing with date, and your initial .change humidifier when empty or at least weekly and date .
Facility policy review, Aerosol Therapy, revised 7/2014, revealed .intermittent Aerosol with Medication Administration with medication is used to deliver fine particles of liquid and medication in the tracheobronchial tree .this means of medication administration is quick and has few systemic side effects .Intermittent aerosol with medication administration is indicated for Chronic Lung disease such as asthma or COPD .be sure nebulizer and tubing are labeled with the date and initial .nebulizer can become contaminated resulting in an infection .change nebulizer and tubing every 7 days .
Medical record review revealed Resident #71 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Anemia and Dependence on Supplementary Oxygen.
Medical record review of Resident #71's Significant Change Minimum Data Set (MDS) dated [DATE] revealed the resident received oxygen therapy.
Medical record review of Resident #71's physician orders dated 5/27/19 revealed .oxygen [02] 2 liters per minute via nasal cannula continuous .6/14/19 ipratropium albuterol [a medication used to open the airway] solution for nebulization 0.5 milligram [mg] - 3 mg (2.5 mg base)/3 milliliter [ml] 1 inhalation every 6 hours [hr] as needed .Chronic Obstructive Pulmonary Disease (COPD) .
Medical record review of Resident #71's comprehensive care plan dated 6/26/19 revealed .Respiratory complications: at risk for R/T [related to] COPD 02 dependent .Administer 02 at bipap [positive air pressure machine to treat sleep apnea] at hour of sleep as ordered neb [nebulizer] treatments as ordered 02 as ordered .administer bronchodilators .
Observation on 07/08/19 at 10:56 AM and at 4:22 PM in Resident #71's room revealed the resident receiving 02 via [by] nasal cannula at 2 liters per minute. Continued observation revealed a nebulizer machine [a machine used to deliver aerosol treatments] on the resident's bedside table not in use. Continued observation revealed the oxygen tubing, humidified water bottle and the nebulizer tubing were dated 6/27/19.
Interview with the Central Supply Nursing Assistant on 7/8/19 at 4:38 PM in her office revealed she was responsible for changing the residents' oxygen tubing, humidified water bottles and nebulizer tubing. Continued interview revealed oxygen tubing, nebulizer tubing and humidified water were changed weekly.
Observation and interview with the Central Supply Nursing Assistant on 7/8/19 at 4:40 PM in Resident #71's room when asked to look at the resident's tubings and humidified water bottle she confirmed the tubings and bottle were dated 6/27/19. Continued interview she stated I thought I changed these Friday [July 5 2019]; I did not do [named resident], [named resident] was the last one, [named resident] was in the shower; I meant to go back and change them and I did not.
Observation and interview with the Director of Nursing on 7/8/19 at 4:58 PM in the Resident #71's room confirmed the resident's oxygen tubing, nebulizer tubing and humidified water bottle were dated 6/27/19. Continued interview she stated the bottle and tubings were to be changed weekly by the Central Supply Nursing Assistant.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0711
(Tag F0711)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to ensure the attending physician visi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to ensure the attending physician visit included an evaluation of the resident's total program of care including medications, treatments and a decision about continued appropriateness for current medical regimen for 1 (#237) of 12 residents reviewed.
The findings include:
Facility policy review, Medical Services, revised 2/2018, revealed .The physician delegated option does not relieve the physician of the obligation to visit a patient when the patient's medical condition makes that visit necessary or from performing services or procedures prohibited under state law from being delegated .reviews medications, patient program of care, and diagnoses, at regular intervals .supports efforts to assure that patients have indicated laboratory and X-ray or other procedures .
Medical record review revealed Resident #237 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Presence of Aortocoronary Bypass Graft, Atherosclerotic Heart Disease of Native Coronary Artery, Personal History of Pulmonary Embolism, Long term (current) use of Insulin and Type 2 Diabetes Mellitus without Complications.
Medical record review of the Resident #237's physician visit note dated 4/1/19 revealed, .No Ulcer/Rash/Petechia/Purpura/Masses/or other Lesions .
Medical record review of Resident #237 Resident Progress Notes by the NP (Nurse Practitioner) dated 4/4/19 revealed, .Ext [Extremities]: No edema .
Medical record review of Resident #237's Resident Progress Notes by the NP dated 4/11/19 revealed, .Skin: No rashes, lesions or ulcers .
Medical record review of Resident#237's Reesident Progress Notes by the NP dated 4/18/19 revealed, .Ext: No edema .
Medical record review of Resident #237's Resident Progress Notes by the NP dated 4/25/19 revealed, .Skin: see nursing notes .
Medical record review of Resident #237's Resident Progress Notes by the PA (Physician's Assistant) dated 4/30/19 revealed, .Skin: warm and dry .
Medical record review of Resident #237's physician visit note dated 5/27/19 revealed skin assessment not performed.
Medical record review of Resident #237's Resident Progress Notes by the NP dated 6/13/19 revealed, .wound care following skin break down on penis .skin: see wound care notes .
Medical record review of Resident #237's Resident Progress Notes by the PA dated 6/21/19 revealed, .Skin: No rashes, lesions or ulcers .
Interview with the Medical director, also Resident #237's attending physician on 7/9/19 at 5:29 PM in the conference room revealed the resident did not have a diagnosis of vascular disease. Continued interview he stated the resident was at risk for progression with any problem. Continued interview when asked if Resident's #237's right below the knee amputation could have been prevented he stated, It's hard to tell; possibly if the resident had a Doppler done of the extremity [named resident] could have went to a vascular surgeon for an angioplasty. Further interview when asked if he had assessed Resident #237's wound he confirmed, I never saw the resident.
Interview with the Administrator with the Director of Nursing present on 7/10/19 at 7:20 PM in the conference room revealed when asked if Resident #237's attending physician assessed Resident #237's wound during his visit he stated, He signed the orders, I leave the assessments to the nursing department and the Director of Nursing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Medical record review, facility policy review and interview the facility failed to ensure timely physician visits were ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Medical record review, facility policy review and interview the facility failed to ensure timely physician visits were performed for 1 (#237) of 12 residents reviewed.
The findings include:
Facility policy review, Medical Services, revised 2/2018, revealed .The physician delegated option does not relieve the physician of the obligation to visit a patient when the patient's medical condition makes that visit necessary or from performing services or procedures prohibited under state law from being delegated .reviews medications, patient program of care, and diagnoses, at regular intervals .supports efforts to assure that patients have indicated laboratory and X-ray or other procedures .
Medical record review revealed Resident #237 was admitted to the facility on [DATE] with diagnoses which included Subsequent Encounter Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris and Type 2 Diabetes without Complications.
Medical record review of Resident #237's physician visit notes dated 4/1/19 revealed the resident was seen by the physician.
Medical record review of Resident #237's physician visit notes dated 5/27/19 revealed the resident was seen by the physician.
Interview with the Medical director, also Resident #237's attending physician on 7/9/19 at 5:29 PM in the conference room revealed when asked if he had assessed Resident #237 he confirmed, I never saw the resident.
Jul 2018
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to replace and repair the baseboards for 1 of 14 rooms (room [ROOM NUMBE...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to replace and repair the baseboards for 1 of 14 rooms (room [ROOM NUMBER]) on the 400 hall reviewed.
Findings include:
Observation on 7/16/18 at 9:30 AM, 7/17/18 at 10:36 AM, and 7/18/18 at 8:08 AM, in room [ROOM NUMBER] on the 400 hall revealed the baseboard on the left side entrance to the bathroom was missing. Further observation revealed the baseboard adjacent to the bathroom on the left side was separated from the wall.
Observation on 7/18/18 at 5:09 PM, with the Director of Nursing (DON), in room [ROOM NUMBER] revealed the baseboard on the left side entrance to the bathroom was missing. Further observation revealed the baseboard adjacent to the bathroom on the left side was separated from the wall.
Interview with the DON on 7/18/18 at 5:44 PM in room [ROOM NUMBER] confirmed the facility failed to replace and repair the baseboards in room [ROOM NUMBER].
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 34 reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 34 residents (Resident #294) reviewed, had clean and groomed finger nails.
Findings include:
Review of facility policy Fingernails, Cleaning and Trimming, undated, revealed .Designated partner will care for patients nails daily and PRN [as needed] .clean around and under the nails .
Medical record review revealed Resident #294 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Respiratory Failure, Chronic Obstructive Pulmonary Disease, Dysphagia, Other Lack of Coordination, and Muscle Weakness.
Medical record review of Resident #294's comprehensive care plan dated 7/12/18 revealed the resident required assistance with activities of daily living. Continued review of the care plan revealed .Check, clean, and trim nails as needed and to keep nails short .
Observations of Resident #294 on 7/16/18 at 11:16 AM, 12:47 PM, and 4:41 PM in the residents room revealed the resident's fingernails were long, chipped, and had brown debris under the nails on both hands.
Interview with the Director of Nursing (DON) on 7/16/18 at 4:41 PM in Resident #294's room confirmed the resident's nails were uncleaned and ungroomed. The DON looked at Resident #294's nails and stated You're in need of a trim. Further interview with DON revealed resident nail care was to be performed during showers and as needed.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility dietary department failed to maintain and serve hot food at or greater than 135 degrees Fahrenheit (F) for 1 of 6 meal services observed.
Findings incl...
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Based on observation and interview, the facility dietary department failed to maintain and serve hot food at or greater than 135 degrees Fahrenheit (F) for 1 of 6 meal services observed.
Findings included:
Observation on 7/16/18 at 11:48 AM in the dietary department, with the Registered Dietitian (RD) present, revealed the resident mid-day meal trayline service was in progress. Further observation revealed residents in the main dining room and the 300 hall had been served their meal. Observation of the dietary department trayline revealed the dietary server obtaining food temperatures. Further observation revealed the broccoli was 115 degrees F and the baked pureed fish was 126 degrees F. Further observation revealed the server continued to serve the broccoli after the temperatures were obtained.
Interview with the dietary server and the RD on 7/18/18 at 11:55 AM in the dietary department at the trayline confirmed the facility failed to maintain and serve hot food at or greater than 135 degrees F.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Tennessee facilities.
- • 34% turnover. Below Tennessee's 48% average. Good staff retention means consistent care.
Concerns
- • 17 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.
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About This Facility
What is Nhc Healthcare, Hendersonville's CMS Rating?
CMS assigns NHC HEALTHCARE, HENDERSONVILLE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Tennessee, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Nhc Healthcare, Hendersonville Staffed?
CMS rates NHC HEALTHCARE, HENDERSONVILLE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 34%, compared to the Tennessee average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Nhc Healthcare, Hendersonville?
State health inspectors documented 17 deficiencies at NHC HEALTHCARE, HENDERSONVILLE during 2018 to 2022. These included: 17 with potential for harm.
Who Owns and Operates Nhc Healthcare, Hendersonville?
NHC HEALTHCARE, HENDERSONVILLE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by NATIONAL HEALTHCARE CORPORATION, a chain that manages multiple nursing homes. With 122 certified beds and approximately 101 residents (about 83% occupancy), it is a mid-sized facility located in HENDERSONVILLE, Tennessee.
How Does Nhc Healthcare, Hendersonville Compare to Other Tennessee Nursing Homes?
Compared to the 100 nursing homes in Tennessee, NHC HEALTHCARE, HENDERSONVILLE's overall rating (3 stars) is above the state average of 2.8, staff turnover (34%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Nhc Healthcare, Hendersonville?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Nhc Healthcare, Hendersonville Safe?
Based on CMS inspection data, NHC HEALTHCARE, HENDERSONVILLE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Tennessee. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Nhc Healthcare, Hendersonville Stick Around?
NHC HEALTHCARE, HENDERSONVILLE has a staff turnover rate of 34%, which is about average for Tennessee nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Nhc Healthcare, Hendersonville Ever Fined?
NHC HEALTHCARE, HENDERSONVILLE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Nhc Healthcare, Hendersonville on Any Federal Watch List?
NHC HEALTHCARE, HENDERSONVILLE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.