Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Adamsplace, Llc during CMS and state inspections, most recent first.
Infection control practices were not followed when an RN performed a blood glucose check on a resident with DM, hyperglycemia, and long-term insulin use. The RN cleaned the glucometer with a germicidal wipe and used it immediately without allowing the required 2-minute wet contact time, then repeated the wipe after leaving the room. The facility also lacked documentation in its infection tracker and monthly/quarterly reports showing infections tracked by organism or room location, and the ICP/DON could not show how infections were being trended for outbreaks or cross contamination.
Failure to offer COVID-19 vaccination to newly hired staff. Review of the Infection Control Manual showed the facility’s infection prevention program included offering immunizations/vaccinations as appropriate. Review of the employee list showed 29 employees were hired after 2/2025, but the ICP/DON stated the facility did not offer the COVID vaccine this year and that the last in-facility offer to staff was in February 2025. The Administrator also stated, “Covid is a thing of the past, it will be here until we die.”
A facility failed to provide appropriate diagnoses for quetiapine use in two cognitively intact residents reviewed for unnecessary psychotropic medications. One resident received quetiapine 200 mg at bedtime and the chart lacked a clear diagnosis in progress notes, while the other received quetiapine 100 mg at bedtime and stated it was for sleep; the FNP said it was for insomnia and noted the resident had long-term use, anxiety, and major depression, but no psych provider was involved.
Failure to Notify Ombudsman of Emergency Transfers: The facility did not document or report emergency hospital transfers for three residents on the Ombudsman transfer list. One resident had severe cognitive impairment and was sent for ED evaluation after the daughter was notified; another was cognitively intact and had tachypnea, diaphoresis, hypotension, and low O2 sats with EMS called and an order to send him to the hospital; the third had moderate cognitive impairment and was leaving for a hospital bed after the wife and NP were notified. The HIM confirmed the residents should have been on the monthly list.
Failure to accurately capture antipsychotic use on the admission MDS for two residents. Both residents had depression and anxiety, were cognitively intact on BIMS, and had active quetiapine orders with MAR documentation showing the medication was administered, but the MDS did not document the antipsychotic use. The MDS Coordinator acknowledged the omission and stated it should have been documented.
A resident with glaucoma, cataract extraction, and macular degeneration had latanoprost eye drops ordered at bedtime, but a bottle was observed unattended and unsecured on the bedside table. The resident had a BIMS score of 12 and no medication self-administration assessment in the record. An LPN stated the drops should not be left at the bedside, and the DON stated that without a self-administration assessment, medications should not be left there.
Infection Control Failures During Glucometer Use and Infection Tracking
Penalty
Summary
Proper infection prevention and control practices were not followed during blood glucose monitoring when RN C performed a finger stick blood sugar check on a resident with diabetes, hyperglycemia, and long-term insulin use. During the observation, RN C removed the glucometer from the dresser, cleaned it with a germicidal wipe, and immediately inserted a test strip and obtained the resident’s blood glucose reading without allowing the device to dry for the required contact time. After leaving the room, RN C acknowledged not cleaning the machine for 2 minutes and then wiped the glucometer again, but still did not disinfect it for the full 2-minute contact time required by facility policy. The resident involved was admitted with diagnoses including Diabetes, Hyperglycemia, and Long-Term use of Insulin, and had physician orders for FSBS before meals and at bedtime. The facility policy for the glucometer required the meter to be cleaned and disinfected after each patient use, with the treated surface remaining wet for the recommended contact time of 2 minutes. The CDC guidance reviewed also stated that blood glucose meters can easily become contaminated during use and that germs and infections can spread if preventative measures are not in place. The facility also failed to establish and implement an effective infection control program to identify, report, investigate, and control infections and communicable diseases. Review of the Infection Tracker and Infection Control Monthly/Quarterly Reports for multiple months showed no documentation that infections were tracked by organism, and the facility could not provide documentation of tracking and trending by organism or room location to monitor for outbreaks or cross contamination. During interview, the ICP/DON stated that the report did not show what organisms were being monitored, exact room locations of infections, or whether residents with UTIs had the same staff providing care, and acknowledged that infections should be monitored by tracking and trending to prevent cross contamination.
Failure to Offer COVID-19 Vaccination to Newly Hired Staff
Penalty
Summary
The facility failed to educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member’s vaccination status. Review of the Infection Control Manual Volume 1 dated 10/2025 showed the infection prevention and control program was intended to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, with immunizations/vaccinations offered as appropriate to patients and partners to decrease the incidence of preventable infectious diseases. Review of the current employee list showed 29 employees were hired after 2/2025. During interview, the ICP/DON stated the facility did not offer the COVID vaccination this year and that several local clinics had it, and later stated the last time the vaccine was offered inside the facility to staff was February 2025. The Administrator stated, “Covid is a thing of the past, it will be here until we die.”
Inappropriate Use of Quetiapine Without Clear Supporting Diagnoses
Penalty
Summary
The facility failed to provide appropriate diagnoses for the use of antipsychotic medications for two residents reviewed for unnecessary medications. A Mayo Clinic article cited in the report stated that quetiapine is an antipsychotic used for conditions such as bipolar disorder and schizophrenia and should not be used to treat behavioral problems in older adult patients with dementia or Alzheimer disease. The report identified that both residents were cognitively intact on admission MDS assessments, with BIMS scores of 13 and 15, and neither MDS was coded to show antipsychotic use. For one resident, the medical record showed quetiapine 200 mg at bedtime, and the pharmacist requested a diagnosis for the medication in November 2025. The physician entered agitation, insomnia, and anxiety, but progress notes did not show a diagnosis for quetiapine. The resident stated she took it for anxiety and sleep, and the DON confirmed the physician response to the pharmacy recommendation. For the second resident, the record showed quetiapine 100 mg at bedtime, and the resident stated she took it to sleep. The FNP stated the medication was for insomnia, explained the resident had been on Seroquel for years at the 100 mg dose, and noted the resident had anxiety on arrival and major depression, but no psychiatric provider was involved.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the Ombudsman of emergency transfers for 3 of 3 sampled residents reviewed for discharges. Review of the Ombudsman Emergency Transfers from Facility forms for August, September, October, and November 2025 showed the facility was to send the form to the Office of the State Ombudsman each month, but the records for the sampled residents did not include documentation that they were transferred to the hospital. Resident #41 was admitted with diagnoses including a displaced bimalleolar fracture of the right lower leg, disruption of an external surgical wound, and osteomyelitis. Her admission MDS showed a BIMS score of 2, indicating severe cognitive impairment. Progress notes on 11/6/2025 documented that the daughter was informed of the resident's clinical status and the MD's recommendation for ED evaluation, and the daughter stated she would meet the resident in the ER. The Ombudsman Emergency Transfers from Facility document for 11/2025 did not document that Resident #41 was transferred. Resident #42 was admitted with diagnoses including surgical aftercare following digestive system surgery, neutropenia due to infection, immunodeficiency, and multiple myeloma; his admission MDS showed a BIMS score of 15, indicating cognitive intactness. Progress notes on 9/20/2025 documented tachypnea, diaphoresis, hypotension, low O2 saturations, EMS notification, and a physician order to send the patient to the hospital for further evaluation, but the 9/2025 Ombudsman form did not document the transfer. Resident #43 was admitted with diagnoses including orthopedic aftercare following surgical amputation, peripheral vascular disease, sepsis due to MRSA, Pseudomonas infection, hypertension, and anxiety; his admission MDS showed a BIMS score of 12, indicating moderate cognitive impairment. Progress notes on 10/31/2025 documented that the wife reported the hospital had a bed available and that the resident would be leaving there, with the NP and unit manager notified, but the 10/2025 Ombudsman form did not document the transfer. During interview, the HIM stated she was responsible for generating and sending the Ombudsman list and confirmed that Residents #41, #42, and #43 should have been on the list.
Failure to Accurately Capture Antipsychotic Use on Admission MDS
Penalty
Summary
The facility failed to ensure accurate assessment of antipsychotic medication use for two residents reviewed for unnecessary medication use. The facility policy on RAI/MDS 3.0 completion states residents are assessed using a comprehensive assessment process and notes the importance of antipsychotic medication use and management in relation to residents receiving these medications. Resident #6 was admitted with diagnoses including depression, anxiety, and agitation. A physician order dated 11/21/2025 ordered quetiapine 200 mg daily at 8:00 PM, and the November 2025 MAR showed the resident received the medication from 11/22/2025 through 11/30/2025. The admission MDS showed a BIMS score of 13, indicating cognitive intactness, but the antipsychotic medication use was not captured. Resident #45 was admitted with diagnoses including depression and anxiety. Physician orders dated 11/21/2025 and 12/3/2025 ordered quetiapine at 8:00 PM and then 9:00 PM daily, and the December MAR showed quetiapine 100 mg was administered from 12/3/2025 through 12/16/2025. The admission MDS showed a BIMS score of 15, indicating cognitive intactness, but the antipsychotic medication use was also not captured. During interview, the MDS Coordinator stated the admission MDS for both residents did not document quetiapine and that it definitely should have been.
Unsecured Eye Drops Left at Bedside
Penalty
Summary
The facility failed to ensure medications were properly stored when a bottle of latanoprost eye drops was found unattended and unsecured at the bedside of one resident. The facility policy titled, Medication Storage In The Facility, stated that medication supplies are accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications, and that medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. The resident involved was admitted with diagnoses including glaucoma, cataract extraction, and macular degeneration. The resident's admission MDS showed a BIMS score of 12, indicating moderate cognitive impairment. Physician orders included latanoprost 0.005% ophthalmic drops, 1 drop into the affected eye at bedtime. During observation, one bottle of latanoprost was seen on the resident's bedside table, and the medical record did not show a medication self-administration assessment. An LPN stated prescription eye drops should not be left at the bedside unsecured and unattended, and the DON stated that if the resident does not have a self-administration evaluation or assessment, then there should not be any left at bedside.
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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) |
|---|---|---|---|---|
| Stone River Post Acute | 0.4 mi | ★★★★★ | 4 | 0 |
| Stones River Manor, Inc | 0.9 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Murfreesboro | 2 mi | ★★★★★ | 5 | 0 |
| Tennessee Veterans Home | 2.3 mi | ★★★★★ | 2 | 0 |
| Community Care Of Rutherford | 7.7 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.