Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Heritage Place Care & Rehabilitation Llc during CMS and state inspections, most recent first.
Failure to Monitor Antibiotic Use and Track Infections: The facility did not implement an effective Antibiotic Stewardship Program to track antibiotic starts, monitor infections, or identify and report outbreaks for all residents. Infection Control surveillance logs showed residents receiving antibiotics for multiple symptoms and infections, including an Influenza outbreak, but the logs lacked room numbers and trending data, and there was no log for one month. The DON stated there was no IP nurse, an LPN was handling infection control, antibiotics were not being tracked when ordered, and the Influenza outbreak was not reported to the State.
The facility failed to designate a qualified Infection Preventionist with specialized IPC training. The policy and job description identified the IP role as responsible for oversight of the infection prevention program, surveillance, isolation, documentation, and reporting, but the employee list showed no staff in that role. The DON stated the prior IP had left months earlier, one LPN had been handling infection control without training, and another LPN had just been told to take over but had not started CDC training; the DON confirmed no nurse at the facility had the required IP training.
Lack of Ongoing Activities in ACU: The facility failed to provide an ongoing activity program in the ACU to meet residents' needs and interests. Although the calendar listed manicures, 1:1 visits, arts and crafts, sensory activities, games, and other events, observations showed residents sitting at empty tables, wandering the halls, and no activities, sensory items, or leisure supplies being offered. Staff confirmed activities were limited and often not occurring on the unit.
Medication refrigerator temperatures were not monitored and documented as required, and opened TB ppd vials were found improperly labeled and kept past the 30-day discard timeframe in two medication rooms. Surveyors observed blank temperature logs, out-of-range refrigerator temperatures, and opened multi-dose vials available for resident use; an LPN and the DON confirmed the vials were past the required open-date limit and should have been discarded.
Expired foods were found in the personal refrigerators of three residents, including unopened milk cartons and an unopened dessert item past their use-by or best-if-used-by dates. An LPN confirmed the items were expired and still available for resident use. The DON stated nursing staff were responsible for weekly checks of resident refrigerators and confirmed the outdated items had not been discarded.
Failure to Monitor Antibiotic Use and Track Infections
Penalty
Summary
The facility failed to implement an effective Antibiotic Stewardship Program to identify specific or potential infectious outbreaks and to identify, report, and track antibiotic usage for 75 of 75 residents. Review of the facility’s Infection Prevention and Control Program policy stated that surveillance is used for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases, and the Antibiotic Stewardship Program policy stated that the program is intended to optimize infection treatment while reducing adverse events associated with antibiotic use and to track antibiotic starts, monitor adherence to evidence-based criteria, and review antibiotic-resistant patterns. Review of the Infection Control monthly surveillance logs for 1/2026 and 2/2026 showed several residents received antibiotics for multiple types of symptoms and/or infections, including 6 residents with Influenza in 1/2026. The logs contained no room numbers, and the facility map was blank with no data indicating tracking or trending of infections. The DON stated the prior IP left at the end of 12/2025 or beginning of 1/2026, that there was no IP nurse at the time, and that an LPN had been doing infection control since 1/2026. The LPN stated antibiotics had not been tracked when ordered, the antibiotic report was printed from the EHR at the beginning of each month for the prior month, and there was no Infection Control monthly surveillance log for 3/2026. The DON also confirmed the facility was not aware of Tennessee reportable diseases, the Influenza outbreak in 1/2026 was not reported to the State, antibiotics had not been monitored proactively, infection tracking and trending had not been completed, and there was no Infection Control monthly surveillance log for 3/2026.
No Qualified Infection Preventionist Designated
Penalty
Summary
The facility failed to designate an individual as the Infection Preventionist with completion of specialized training in Infection Prevention and Control. Review of the facility policy titled, Infection Prevention and Control Program, showed the designated Infection Preventionist was responsible for oversight of the program, infectious diseases, implementing isolation, leading surveillance activities, maintaining documentation, and reporting surveillance findings. Review of the job description titled, Infection Control, showed the role was responsible for the Infection Prevention Program and required completion of training on infection prevention. Review of the current employee listing showed no employee listed as Infection Control or Infection Preventionist. During interviews, the DON stated the previous Infection Preventionist left the facility at the end of 12/2025 or beginning of 1/2026 and that there was not an IP nurse at the facility at the time of the interview. The DON stated an LPN had been doing the infection control work since 1/2026. That LPN stated she had not received Infection Control training and was not an Infection Preventionist. Another LPN stated she had just been told she would start doing Infection Control, had not received any training, and had not enrolled in or started the CDC training program. The DON later confirmed there were no nurses at the facility with the required Infection Preventionist training and that the facility had not had an Infection Preventionist for the last 3 months.
Lack of Ongoing Activities in ACU
Penalty
Summary
The facility failed to ensure an ongoing program of activities was implemented in the Alzheimer's Care Unit (ACU) to meet the needs and interests of the residents, affecting 20 of 20 residents in the unit. The facility policy stated that specialized activities would be developed for residents with Alzheimer's Disease and/or other dementia-related conditions, with the Activity Director responsible for ensuring supplies were available. However, review of the ACU activity calendar for 4/2026 showed scheduled activities such as manicures, 1:1 visits, movie time, arts and crafts, balloon volley, patio time, music, sit and be fit table, sensory activities, table top games, and snack social. During observations on 4/6/2026 through 4/8/2026, the scheduled activities did not occur. Residents were repeatedly observed sitting at empty tables in the dining room with the TV on low or turned off, while others wandered the hallways and entered other residents' rooms. No activities, sensory stimulation, or independent leisure supplies were available or offered during the observed periods. Staff interviews confirmed that activities had not been on the unit for several days, that activity staff were limited because one person had been out of work and another had just returned, and that nursing and CNA staff were trying to do what they could while also performing their other duties. The Activities Director also confirmed the residents in the ACU had limited activities.
Medication Refrigerator Temperature Monitoring and Labeling Failures
Penalty
Summary
Drugs and biologicals in the facility were not consistently labeled and stored according to policy and manufacturer guidance in 2 of 3 medication rooms reviewed. The facility policy required refrigerated medications and biologicals to be kept between 36 and 46 degrees Fahrenheit and for refrigerator temperatures to be monitored daily and documented on a temperature log. Manufacturer guidance for TUBERSOL and FLUAD also required refrigeration between 36 and 46 degrees Fahrenheit, and both products were to be discarded after 30 days once opened. During observation and interview in the ACU medication room, surveyors found an opened 30 ml vial of TB ppd that was 3/4 full and labeled with an open date of 10/4/2025; an LPN confirmed it was available for resident use and stated it was about 6 months past the open date and should have been discarded after 30 days. The ACU refrigerator temperature log was blank for 3 of 7 days and recorded 32 degrees Fahrenheit on 4 of 7 days, which was outside the required range, with no documented corrective action. In the B-Wing medication room, surveyors found another opened 30 ml vial of TB ppd that was 1/2 full and not labeled with an open date; the DON confirmed it was available for resident use and stated it was about 7 months past the open date and should have been discarded after 30 days. The B-Wing refrigerator temperature log was blank for 4 day shifts and 4 night shifts, and the DON confirmed both medication room refrigerator temperatures were not documented daily and the ACU refrigerator temperatures containing TB ppd and influenza vaccines were out of range.
Expired Foods Found in Resident Personal Refrigerators
Penalty
Summary
The facility failed to ensure expired foods were not available for resident use in the personal refrigerators of 3 residents. The facility policy titled, Resident Refrigerators, dated 4/1/2026, stated staff were to ensure safe and sanitary use of resident-owned refrigerators, discard foods that were out of compliance, and discard foods with use-by dates accordingly. During observations and interviews, expired milk and dessert items were found in the refrigerators of Residents #9, #65, and #8, and LPN D confirmed the items were expired and available for resident use. Resident #9 had diagnoses including Vascular Dementia, Morbid Obesity, and Functional Quadriplegia, and a quarterly MDS showed a BIMS score of 12, indicating moderate cognitive impairment. Resident #65 had diagnoses including COPD, unspecified dementia, essential hypertension, and hyperlipidemia, and a quarterly MDS showed a BIMS score of 13, indicating cognitive intactness. Resident #8 had diagnoses including COPD, vascular dementia, and primary osteoarthritis, and a quarterly MDS showed a BIMS score of 14, indicating cognitive intactness. The refrigerators contained unopened milk cartons and, for Resident #8, an unopened No Bake Blueberry Cheesecake Parfait, all past their use-by or best-if-used-by dates. The DON stated nursing staff were responsible for checking resident personal refrigerators at the beginning of each week and confirmed the outdated items had not been discarded and were available for resident use.
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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 Winchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southern Tenn Medical Center Snf | 0.5 mi | ★★★★★ | 0 | 0 |
| Elk River Health & Nursing Center Of Winchester | 0.7 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Monteagle Rehab & Wellness | 15 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Tullahoma | 15.8 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Tullahoma | 16 mi | ★★★★★ | 5 | 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.