Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Murfreesboro Rehab And Nursing, Inc during CMS and state inspections, most recent first.
Resident funds were not protected from exploitation when a cognitively intact resident’s $56,481 SSD check was opened, endorsed, and deposited into a facility account without permission and then used for facility business. The Administrator and MDS Coordinator gave inconsistent explanations, staff described a process of stamping and depositing resident checks into facility accounts, and the resident later reported depression and stress after learning the money had been taken. Surveyors also found missing cash in resident trust envelopes kept in a lockbox accessible to staff, and the Administrator admitted taking money from one resident’s envelope after death.
Mismanagement and Misappropriation of Resident Funds: The Administrator, who also served as the facility’s governing body representative, handled resident trust funds and facility monies without adequate documentation. Records showed transfers to the Administrator’s personal bank and credit card accounts, cash withdrawals, and a transfer from the resident fund account to the Administrator’s personal account. Resident ledgers lacked signatures and receipts for checks given to families, and the Administrator acknowledged a resident’s settlement check was deposited into a facility account and used for facility business, which she identified as misappropriation.
Lack of Governing Body Oversight: The facility failed to have a governing body in place to oversee the Administrator and facility operations. Records showed key program agreements signed by the Administrator as Owner/Administrator, and the Administrator provided a written statement identifying self as the sole governing body. The DON and an RN stated the Administrator handled all banking and monies.
Failure to Safeguard and Account for Resident Funds: The facility did not properly manage resident money for multiple residents. A cognitively intact resident’s $56,481 Social Security check was deposited into a facility-owned account, and the Administrator described repaying it in weekly installments while also claiming the resident owed the facility money without a matching ledger balance. Envelopes for three other residents showed inaccurate totals and missing funds, and an Administrator stated a deceased resident’s $47 was placed into the bingo fund after the family had left belongings behind.
Resident funds were not properly tracked or kept separate from facility funds. Staff kept resident money in envelopes in a lock box, but an LPN said several envelopes had inaccurate accounting, missing receipts, and unclear balances. Review of multiple residents’ envelopes showed mismatched totals, missing money, undated entries, and a gift card recorded without a clear final accounting. The Administrator also acknowledged that Medicaid dollars had been comingled with business funds and that checks could not be accounted for because of errors.
Failure to investigate allegations of resident financial abuse: one resident reported an SSD check was deposited into a facility account and another resident reported unauthorized debit card charges. The DON, RN, and Administrator acknowledged the incidents, but the record lacked witness statements, staff or resident interviews, financial documentation, and required reporting/investigation records.
A cognitively intact resident with spinal stenosis, insomnia, and depression had mail opened without permission, and an SSD check for $56,481 made payable to the resident in care of the facility was deposited into a facility account without the resident's knowledge or consent. An LPN reported the Administrator took about $56,000 and repaid $1,000, while the resident said the money issue was not in writing and the facility could not produce an accounting for the amount owed.
Failure to Report Misappropriation of Resident Funds: A resident with no cognitive impairment reported that an SSD check for $56,481 was deposited into the facility account and that the Administrator made partial repayments after saying it was a mistake. Staff and the resident reported the matter was not formally investigated or reported, and the Administrator acknowledged no reportable, interviews, financial review, or required 24-hour or 5-day reports were completed.
The facility failed to provide complete written transfer notices when several residents were sent to the hospital. For multiple residents with conditions including dementia, severe cognitive impairment, cerebral palsy, paraplegia, COPD, diabetes, and ESRD, the chart either lacked a transfer notice or the letter omitted required information about appeal rights, the appeal process, and how to contact the State LTC Ombudsman.
The facility did not properly credit monthly interest to the trust fund accounts of two residents, despite policy and bank statements indicating interest should be paid. Both residents had authorized the facility to manage their funds, but only a single interest payment was recorded, with no credits for subsequent months. The Administrator, acting as BOM, was unaware of the correct interest rate and did not follow federal regulations, while the DON and ADON had no involvement with the accounts.
The facility failed to use an acceptable accounting system for resident trust funds, resulting in commingling of resident money with operational and payroll accounts, lack of individual ledgers for several residents, and failure to provide required quarterly statements. Some residents and their representatives did not receive documentation of their funds, and significant discrepancies were found between trust fund account balances and resident ledgers.
The facility did not notify two residents with severe cognitive impairment, both Medicaid recipients, of their account activities and balances at least quarterly. Despite having significant balances, the residents or their representatives were not informed unless they requested the information, as stated by the administrator.
The facility did not notify two residents or their representatives when their account balances were within $200 of the Medicaid cash asset limit. Both residents had severe cognitive impairments, and their balances exceeded the threshold, risking Medicaid payment rejections.
The facility failed to accurately complete MDS assessments for two residents, leading to deficiencies in their care plans. One resident's MDS inaccurately recorded an antiplatelet medication as an anticoagulant, while another resident's assessment did not reflect their serious mental illness and/or intellectual disability as determined by the state PASRR process. These inaccuracies were confirmed by the MDS Coordinator and the DON.
A facility failed to ensure proper infection control during medication administration, wound care, and enteral feeding. An LPN did not perform hand hygiene or change gloves between tasks, potentially contaminating medications and enteral feedings. Another LPN conducted wound care without changing gloves or sanitizing hands, placing supplies on the floor. The DON confirmed the lack of training and adherence to infection control policies.
A resident's personal and medical information was compromised when an LPN left a laptop unattended with the information visible on the screen. The resident was cognitively intact, and the incident was confirmed by the LPN and acknowledged by the DON as a violation of HIPAA. Facility policy requires that electronic health records be kept confidential and screens hidden when staff are away from the nurses' station.
An LPN left a medication cart unlocked and unattended, which was observed by a surveyor. The LPN later admitted the cart should have been locked to prevent unauthorized access. The DON confirmed the requirement for nurses to lock the cart and hide the screen when unattended, as per facility policy.
Resident Funds Misappropriation and Failure to Protect Resident Property
Penalty
Summary
The facility failed to protect residents from exploitation and failed to protect resident funds from misappropriation for four residents reviewed for resident fund handling. The deficiency was cited at F483.12 with Immediate Jeopardy, beginning when facility staff opened and deposited a check belonging to a cognitively intact resident into a facility bank account without the resident’s knowledge or permission and used the funds for facility purposes. The report states the Administrator and DON were notified of the IJ, but an acceptable plan of removal had not been provided and the facility remained in IJ status. For one resident, the record showed a BIMS score of 15 and that the resident was cognitively intact, with diagnoses including lumbar spinal canal narrowing with pain, weakness in the legs, incomplete cervical spinal cord injury, and adjustment disorder. A U.S. Treasury check payable to the resident in care of the facility, in the amount of $56,481.00, was received and endorsed for deposit into a facility account. The facility bank statement showed the deposit, and the Administrator later acknowledged the check was deposited into a facility account on 07/30/2025 and that the funds were utilized for facility business. The Administrator stated the facility did not have the funds to return the money and continued to use the funds for the benefit of the facility. The resident stated the money had gone missing, that the resident had repeatedly asked about the expected check, and later learned the facility had received and cashed it. The resident also reported feeling depressed and stressed, and the record showed increased antidepressant dosing and notes of isolation, sadness, and depressed mood. The Administrator and other staff gave inconsistent explanations about the check and the handling of resident funds. The Administrator stated she thought the check was for insurance or back payment, said there was a verbal repayment arrangement, and later acknowledged the arrangement was not signed by the resident. Staff described a process in which checks received for residents were stamped and deposited into facility accounts, and the MDS Coordinator confirmed she was instructed by the Administrator to stamp and deposit the resident’s check into a facility account. The Administrator also stated staff should not open a resident’s mail unless permission was given. The report also identified problems with resident trust funds for three other residents. During observation of envelopes kept in a lockbox in the medication room, the Activities Director and surveyor found discrepancies between the totals written on the envelopes and the actual cash present. Resident envelopes showed updated totals that did not match the amounts counted, and the Activities Director had no knowledge of where the missing money was. LPNs stated nursing staff had access to the medication room and lockbox, and one LPN reported that money had gone missing from residents’ envelopes. The Administrator stated she took $47.00 from an envelope after a resident’s death, and the family later reported only $14.00 remained in the envelope. Facility policy required resident funds to be safeguarded, individually accounted for, and accessed only by authorized personnel, but the report documented that resident funds were handled in a way that resulted in missing money and unauthorized use.
Mismanagement and Misappropriation of Resident Funds
Penalty
Summary
The facility administration failed to effectively and efficiently manage resident funds and facility resources, including resident trust funds and other monies handled by the Administrator. Records showed the Administrator was the registered agent, President, and Owner/Administrator of the facility, and the facility assessment identified the Administrator as the Governing Body Representative. The Administrator’s job description assigned responsibility for administrative functions, resident rights, and management of resident funds, including maintaining accounting records and ensuring funds were handled in accordance with regulations. Review of the facility’s general ledger showed transfers from the A/R Officer line item to the Administrator’s personal banking account, payments to the Administrator’s personal credit card, handwritten notes indicating monies paid to another person from prepaid items bought by her, and cash withdrawals from a beauty and barber expense line item. The ledger also reflected bank service charges, including overdraft and returned item fees. A bank statement for the Resident Fund Account showed a transfer of $500.00 out of the account to an account identified by the Administrator as her personal account. During interview, the Administrator stated the facility managed funds for two residents in an interest-bearing resident fund account, did not have a trust account, and that she was the only person who handled resident trust funds. Record review showed resident ledger accounts with limited documentation of how resident funds were handled. The Administrator stated that when resident funds were received, the facility gave residents $40.00 and that families came to pick up the checks, but there was no documentation of family signatures or receipts for purchases made with resident funds. Ledgers for several residents reflected deposits, interest, and $40.00 allowances, but no supporting documentation was attached showing who received the checks or what was purchased. One resident’s ledger showed a $500.00 payment to the resident’s daughter with no receipts attached. The Administrator also acknowledged that a resident’s settlement check was deposited into a facility account and used for facility business, and stated the facility did not have the funds to return the resident’s money and continued to use the funds for the benefit of the facility, identifying this as misappropriation of the resident’s money.
Lack of Governing Body Oversight
Penalty
Summary
The facility failed to have a governing body in place to oversee the Administrator and the operations of the facility, affecting all residents residing within. Record review showed documents related to participation in Arkansas Medicaid, the Arkansas Nursing Home Program, and a Health Insurance Benefit Agreement, all signed by the Administrator as Owner/Administrator. During an interview, the Administrator provided a written statement identifying the Administrator as the sole governing body of the facility. In interviews, the DON stated the Administrator handled all banking and everything, and RN #2 stated the Administrator handled all monies and was the owner and Administrator.
Failure to Safeguard and Account for Resident Funds
Penalty
Summary
The facility failed to act as a fiduciary for resident funds by not safeguarding and properly managing Medicaid resident money for five residents. The report states that Resident #5 was cognitively intact with a BIMS score of 15 and had diagnoses including narrowing of the lumbar spinal canal with pain, weakness in the legs, incomplete spinal cord injury at C7, and adjustment disorder. A Social Security hearing reminder and a U.S. Treasury check payable to Resident #5 in the amount of $56,481.00 were found in the record, and the back of the check showed it had been endorsed for deposit only into a facility bank account. During interview, Resident #5 stated the check had been mistakenly deposited into a facility-owned account in July 2025 and that the Administrator said the facility would repay the money in weekly installments, which Resident #5 described as creating an interest-free loan for the facility. The Administrator later stated Resident #5 owed the facility around $39,000.00, but the ledger provided did not show bed charges or an outstanding balance of that amount, and the Administrator said there had not been any discussion with Resident #5 about a past due balance. The Administrator also stated the facility’s electronic accounting system was never correct and that accounting was done on paper. In a later interview, the Administrator stated only two residents had Resident Trust Accounts, while other residents had checks sent to the facility and family members came to get their $40.00, with no signatures required when picking up residents’ checks. The report also identified problems with resident envelopes for Resident #8, Resident #9, and Resident #10. These residents had varying cognitive and functional status, including moderate cognitive impairment for Resident #8 and Resident #10, and cognitive intactness with dementia listed for Resident #9. During observation, their envelopes showed totals on the outside with updated amounts written below, but no entries documenting fund removal. When Activities counted the money, the amounts in the envelopes did not match the written totals, and Activities had no knowledge of where the missing money was. LPN #1 stated that resident funds were kept in a locked metal box, that totals were written on envelopes when money was deposited or removed, and that receipts and change should be returned and added back, but also stated several envelopes in the box did not have an accurate accounting of the funds. For Resident #13, the report states the resident died while on hospice and had $47.00 in $1 bills. The Administrator said the family had left many belongings behind and, after a long time had passed, she took the $47.00 and told the Activity Director to put it into the bingo fund. The Administrator later said a relative came and picked up an envelope for Resident #13 that contained $12.00, indicating the resident had more than one envelope. The facility policy required resident trust funds to be managed, documented, safeguarded, and audited, and the resident rights policy stated residents had the right to manage personal affairs or receive an accounting upon request.
Resident Funds Were Not Properly Accounted For or Kept Separate
Penalty
Summary
The facility failed to ensure a complete and separate accounting of residents’ personal funds that were deposited with the nursing home, and failed to prevent commingling of resident funds with facility funds or with funds belonging to other residents. Staff described a lock box in the medication room where envelopes containing resident-owned bingo money and money left by families were kept. An LPN stated that resident funds, including monthly $40.00 amounts and bingo winnings, were stored in envelopes with totals written on the outside, but also acknowledged that several envelopes did not have an accurate accounting of the funds and that receipts and change were not consistently documented. Record review showed accounting errors and missing balances for multiple residents. Resident #10’s envelope showed cash and change that did not match the written balance, with a missing amount and no receipts present. Resident #8’s envelope contained numerous undated additions and balance changes, including a gift card entry, with inconsistent totals and no clear final accounting. Resident #9’s envelope also showed a mismatch between the written total and the cash and change present, with missing funds and no receipts available. In addition, the MDS Coordinator stated that when the Administrator was away, resident checks were deposited into whichever account the Administrator indicated, and the Administrator acknowledged that Medicaid dollars had been comingled with business funds and that checks could not be accounted for because errors were made.
Failure to Investigate Allegations of Resident Financial Abuse
Penalty
Summary
The facility failed to immediately and thoroughly investigate allegations of misappropriation of resident property for two residents. One resident with spinal stenosis, insomnia, and depression, and a BIMS score of 15, reported that an SSD check for $56,481.00 dated July 25, 2025 had been endorsed for deposit into a facility account. The resident stated the Administrator told them the deposit was a mistake and that four $1,000 payments had been made back to the resident. An LPN reported the resident had been upset, sad, and self-isolating, and the resident stated no interview had been completed as part of any investigation and was unaware of any investigation. The Administrator confirmed the payments and mistaken deposit, but the record contained no evidence of an immediate investigation, witness statements, staff interviews, financial record review, or required 24-hour or 5-day reports. A second resident with bipolar disorder, diabetes II, and CHF, and a BIMS score of 15, reported unauthorized debit card purchases after giving debit card information to a family member of another resident to purchase a bed for $50.00. The DON and MDS consultant acknowledged the incident had been reported but there were no witness statements or investigation documentation. RN #2 stated no witness statements, interviews, or investigations were completed because the individuals did not stay at the facility long. The Administrator confirmed the resident reported unauthorized charges of $700.00 to $900.00 and stated the facility had 24 hours to report and 5 days to investigate, but could not provide bank statements, witness statements, or investigation notes. An OLTC incident report documented unauthorized charges and cancellation of the debit card, but no thorough investigation was shown.
Resident Mail Opened and SSD Check Deposited Into Facility Account Without Consent
Penalty
Summary
The facility failed to ensure a cognitively intact resident was protected from misappropriation of property and had privacy of mail. Resident #5 had diagnoses including spinal stenosis, insomnia, and depression, and a quarterly MDS with a BIMS score of 15, indicating the resident was cognitively intact. During interviews, an LPN reported that the Administrator had taken about $56,000 from the resident and repaid $1,000, and the resident stated a Social Security Disability check had been mistakenly deposited into a facility bank account in July 2025 without the resident's knowledge or consent. The resident also reported not having anything in writing regarding the missing money and showed a copy of the cancelled check made payable to the resident in care of the facility, with the back stamped for deposit only to the facility and deposited into the facility's Medicaid account. The MDS Coordinator stated that while covering for the Administrator, they opened Resident #5's mail without the resident's knowledge or permission, then called the Administrator and was told to stamp a check included in the mail and deposit it into a facility checking account. The MDS Coordinator confirmed the check for $56,481 was made out to Resident #5 in care of the facility and was sent to the bank for deposit into a facility account. The Administrator stated the resident with a BIMS of 15 was entitled to know that the SSD check had been received by mail at the facility, and also stated the facility should only open resident mail if family had given permission. The Administrator provided a letter stating $56,481 was mistakenly deposited into a facility account and that the facility would pay $1,000 per week until paid in full, but the facility could not produce an accounting for the amount stated as owed.
Failure to Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to immediately report allegations of misappropriation of resident property involving a resident with diagnoses of spinal stenosis, insomnia, and depression, whose BIMS score was 15 and who was independent in meeting emotional, intellectual, physician, and social needs. The resident disclosed that a Social Security Disability check for $56,481.00 had been endorsed for deposit into a facility account, and reported that the Administrator had told the resident the deposit was a mistake and had made four $1,000 payments. The resident also stated the matter had not been formally investigated and that staff and other residents had been told about the incident. During interviews, an LPN reported the resident had said the Administrator had stolen close to $60,000.00 and repaid $1,000, and the resident expressed sadness and disappointment. The Administrator confirmed the check had been mistakenly deposited into the facility account and acknowledged there was no reportable submitted to OLTC, no immediate investigation, no witness statements, no staff interviews, no review of financial records, and no required 24-hour or 5-day reports. The Administrator later stated the repayment arrangement was only verbal and there was nothing in writing showing the resident agreed to receive $1,000 a week for 56 weeks.
Missing Required Transfer Notifications
Penalty
Summary
The facility failed to ensure written notification was provided to residents and/or their representatives when residents were transferred or discharged to the hospital, and the notices that were sent did not include required information about appeal rights, the appeal process, or how to contact the Office of the State Long-Term Care Ombudsman. Surveyors reviewed records for five residents and found that the facility’s transfer notices were either missing from the chart or, when present, did not contain the required content. Resident #2 had diagnoses including non-Alzheimer’s dementia, UTI, and diabetes mellitus, with a BIMS score of 4 indicating severe cognitive impairment. Records showed hospitalizations for UTI and acute encephalopathy, but the medical record did not contain a notice of transfer for the hospital transfers. Resident #5 had end stage renal disease, diabetes mellitus, and fractures, with a BIMS score of 5 indicating severe cognitive impairment; the record also lacked a notice of transfer for the hospital transfer after a fall with fractures. Resident #28 had cerebral palsy, paraplegia, and abnormal albumin, with a SAMS score of 3 indicating severe cognitive impairment, and was hospitalized for PEG tube dislodgement and surgical replacement; no notice of transfer was found. Resident #36 had cerebral palsy, paraplegia, diabetes mellitus, and a BIMS score of 14 indicating cognitive intactness, and was hospitalized twice for neurologic changes and possible aspiration; no transfer notices were found. Resident #32 had diabetes mellitus, COPD, bipolar disorder, and anxiety disorder, with a BIMS score of 15 indicating cognitive intactness, and the record did not contain a notice of transfer for the hospitalization related to vomiting yellow-tinged liquid. The MDS Coordinator and Administrator confirmed the transfer letters that were sent did not include appeal rights or Ombudsman contact information, and the facility policy on notification of family when a resident is sent to the hospital did not address those required elements.
Failure to Properly Credit Interest on Resident Trust Funds
Penalty
Summary
The facility failed to properly manage resident trust fund interest payments for two residents who had authorized the facility to handle their personal funds. Both residents had signed authorizations, either by themselves or through their Power of Attorney, allowing the facility to hold and disburse their funds. A review of the facility's policy indicated that resident trust accounts should be maintained in interest-bearing accounts, with interest credited accordingly. However, the resident ledgers for both individuals showed only a single, undated interest payment for June balances, with no interest credited for the following months. The facility's pooled trust account bank statement confirmed that interest was paid monthly, but this was not reflected in the residents' individual ledgers for July and August. Interviews with the DON and ADON revealed that neither had any involvement or access to the resident fund ledgers or bank accounts. The Administrator, who also served as the Business Office Manager, admitted to not knowing the actual interest rate on the resident trust fund account and stated she used a calculation method provided by her accountant, rather than following federal regulations or the facility's own policy. This lack of proper oversight and failure to credit interest as required resulted in the deficiency.
Failure to Properly Manage and Account for Resident Trust Funds
Penalty
Summary
The facility failed to properly manage and account for residents' personal funds deposited with the nursing home, as required by regulation and facility policy. The facility did not utilize a generally acceptable accounting system for the resident trust fund, resulting in the commingling of residents' trust fund money with the facility's operational and payroll accounts. The Administrator routinely transferred resident funds from the trust fund account into the facility's operational and payroll accounts, and wrote checks for resident allowances and other disbursements from these facility accounts rather than from a dedicated trust fund account. There was no written consent from residents or their representatives to allow this commingling of funds. The facility also failed to maintain accurate and complete records for all residents whose funds were managed. For several residents, there were no individual ledger pages to track deposits, withdrawals, and balances, and in some cases, there was no signed authorization for the facility to manage personal funds. Errors were found in the accounting of at least one resident's ledger, and the combined balances in the trust fund account did not match the total of the residents' personal ledgers, with significant amounts missing from the account at the beginning of each month reviewed. The Administrator acknowledged that only two residents had ledgers maintained, and that checks for allowances were written from the operational account without documentation of the disposition of funds for other residents. Additionally, the facility did not issue required quarterly statements to residents or their representatives regarding the status of their trust fund accounts. Interviews with residents and their representatives confirmed that they did not receive any statements or documentation about their funds. The Administrator admitted to not being familiar with the federal regulations governing resident trust funds and confirmed that no quarterly statements were provided. The Director of Nursing and Assistant Director of Nursing stated they had no role or access to the resident ledgers or bank accounts.
Failure to Notify Residents of Account Activities
Penalty
Summary
The facility failed to notify two residents, both Medicaid recipients with severe cognitive impairment, of their account activities and balances at least quarterly. Resident #5 had a balance of $2,176.51, and Resident #14 had a balance of $2,004.20, as per their respective Participant Ledger Account Cash Journals. Both residents scored 03 on the Brief Interview of Mental Status (BIMS), indicating severe cognitive impairment, according to their Minimum Data Set (MDS) assessments. The facility's administrator stated that statements are only provided to residents or their representatives upon request, which led to the deficiency in notifying the residents or their representatives about their account activities and balances.
Failure to Notify Residents of Excessive Account Balances
Penalty
Summary
The facility failed to notify residents and/or their representatives when their account balances were within $200 of the maximum cash asset limit allowed for Medicaid recipients. This deficiency was identified for two residents, both of whom were Medicaid recipients and had severe cognitive impairments as indicated by their Brief Interview of Mental Status (BIMS) scores. Resident #5 had an account balance of $2,176.51, and Resident #14 had a balance of $2,004.20. The facility's administrator confirmed that neither the residents nor their representatives were informed of the account balances nearing the Medicaid limit, which could result in Medicaid payment rejections.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care plans. For Resident #3, the quarterly MDS assessment inaccurately recorded the use of an anticoagulant medication, Clopidogrel, which is actually an antiplatelet medication. This error was identified during a review of the resident's Order Summary Report and Medication Administration Record, which showed no order or administration of an anticoagulant. The MDS Coordinator admitted to incorrectly coding the medication, emphasizing the importance of accurate MDS coding as it directly impacts the resident's care plan. For Resident #16, the MDS assessment failed to reflect the resident's serious mental illness and/or intellectual disability as determined by the state level II Preadmission Screening and Resident Review (PASRR) process. Despite the resident being on psychotropic medications for bipolar schizoaffective disorder, the comprehensive assessment did not include this critical information. Both the MDS Coordinator and the Director of Nursing confirmed the oversight, acknowledging that the resident's care could have been affected by the inaccurate assessment.
Infection Control Deficiencies in Medication, Wound Care, and Enteral Feeding
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration, wound care, and enteral feedings. An LPN was observed administering medication to five residents without performing hand hygiene before or after the process. The LPN also wiped sweat from her face and nose with her hands without sanitizing them afterward and handled medication cups improperly by placing her fingers inside them. Additionally, the LPN touched various surfaces with gloves used for checking blood glucose, further compromising infection control. In another instance, the same LPN was observed performing enteral feeding for a resident with severe mental impairment and multiple diagnoses, including cerebral palsy and dysphagia. The LPN coughed toward an open nutritional supplement and continued to pour it into the resident's PEG tube without changing gloves or sanitizing hands. The LPN also wiped sweat from her forehead with a gloved hand and continued handling the PEG tube, potentially contaminating the feeding process. The DON confirmed the importance of hand hygiene and acknowledged the LPN's failure to maintain a clean environment. Additionally, another LPN was observed performing wound care for a resident with a diabetic ulcer and a history of MRSA. The LPN did not change gloves or sanitize hands during the procedure and placed wound care supplies on the bare floor. The LPN admitted to not receiving training on wound care, and the DON confirmed that no in-service training on handwashing or wound care had been provided. The facility's policy on infection control and standard precautions was not followed, as gloves were not changed between tasks involving potential microorganism contact.
Resident Privacy Breach Due to Unattended Laptop
Penalty
Summary
The facility failed to protect the personal and health information of a resident, identified as Resident #16, who was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. On two separate occasions, a Licensed Practical Nurse (LPN) left a laptop unattended with Resident #16's personal and medical information visible on the screen. The first incident was observed by a surveyor, and the LPN later confirmed that the laptop was left open. The Director of Nursing (DON) acknowledged that the nurse should have closed the laptop screen to protect the resident's information, as leaving it open posed a risk to privacy and violated the Health Insurance Portability and Accountability Act (HIPAA). The facility's policy on electronic health records mandates that all screens must be hidden when staff are away from the nurses' station.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure the secure storage of medications in an unattended medication cart. On August 20, 2024, at 12:00 PM, a surveyor observed an LPN leaving a medication cart unlocked, unattended, and out of view while in a resident's room. Later, at 1:46 PM, the LPN acknowledged that the medication cart should be locked before leaving it unattended, as someone could access it and obtain medications. On August 22, 2024, the DON confirmed that nurses are required to lock the medication cart and hide the screen before walking away. The facility's policy on medication storage specifies using the cart's locking mechanism to restrict access to authorized personnel only.
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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 Murfreesboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Springs Of Mine Creek | 11.8 mi | ★★★★★ | 1 | 0 |
| The Blossoms At Nashville Rehab And Nursing Center | 12.5 mi | ★★★★★ | 1 | 0 |
| Dierks Health And Rehab Of Dierks | 19.1 mi | ★★★★★ | 0 | 0 |
| Nightingale At Glenwood | 20 mi | ★★★★★ | 3 | 0 |
| The Springs Of Hillcrest | 25.4 mi | ★★★★★ | 8 | 0 |
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