Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Lewis Park Post Acute during CMS and state inspections, most recent first.
Failure to Stage Pressure Ulcers and Provide Ordered Wound Care: The facility did not stage pressure wounds when first identified, did not complete timely wound assessments, and missed ordered wound care for two residents. One resident with quadriplegia and multiple pressure wounds had a right buttock wound and a left leg wound left unstaged at discovery, while another resident with respiratory failure, HF, DM, and depression had ordered wound care missed after returning from the hospital and did not receive a wound evaluation until several days later, when multiple Stage 3 pressure ulcers were documented.
A resident with Cerebral Infarction, Malnutrition, Dysphagia, and Anxiety died with a trust fund balance of $70.08, but the facility did not refund the funds within 30 days or provide documentation that the estate had been reimbursed. The BOM confirmed the balance had not been returned to the resident’s estate.
MDS assessments for 7 of 18 sampled residents were signed for accuracy by an LPN instead of an RN. The residents had varied diagnoses including COPD, diabetes, PTSD, schizophrenia, dementia, and CKD, and their MDSs showed BIMS scores ranging from cognitively intact to severely impaired. The MDS Coordinator confirmed that all MDS assessments should be signed by an RN for accuracy.
A resident with cerebral infarction, DM, HTN, and severe cognitive impairment had an order for Losartan with a hold parameter for systolic BP below 110. MAR and vitals review showed no BP documentation during multiple administrations, and the DON confirmed BP should be checked and documented before giving an antihypertensive with hold parameters.
Failure to use hand hygiene and PPE during resident dining assistance. Staff assisted one resident with eating by handling food with bare hands without hand hygiene or gloves, and entered two residents' contact isolation rooms without gown or gloves while providing meal setup. Another staff member also handled food with bare hands for a resident who required eating assistance. The DON and ADON confirmed staff should not pick up residents' food with bare hands and should use appropriate PPE for contact isolation.
The facility failed to ensure a qualified Infection Preventionist was employed to oversee the IPCP. Facility policy stated the IPCP is coordinated and overseen by an infection prevention specialist, CMS guidance required an onsite part-time IP with specialized training, and review of the IP training certificate showed it had expired. During interview, the IP confirmed the certificate was expired.
The facility failed to maintain infection prevention practices for six residents and did not ensure proper PPE usage or signage for enhanced barrier precautions. Additionally, a CNA did not remove a urinal filled with urine from a resident's overbed table during dining, compromising the resident's dignity and safety.
The facility failed to inform five residents about their right to formulate an Advance Directive upon admission, as required by their policy. Despite varying cognitive statuses, none of these residents or their legal representatives were documented as having been provided with this information.
Failure to Stage Pressure Ulcers and Provide Ordered Wound Care
Penalty
Summary
The facility failed to ensure that residents received necessary treatment and services consistent with professional standards of practice for pressure ulcer care. The report states that the facility did not stage a pressure wound when it was first discovered, did not perform weekly wound assessments, and did not provide wound care treatments for 2 of 3 sampled residents reviewed for pressure ulcers. Resident #6 had multiple pressure wounds and diagnoses including quadriplegia, chronic pain syndrome, schizophrenia, abnormal weight loss, and open wounds. The record showed a facility-acquired pressure ulcer on the right buttock identified on 10/22/2024, but the wound assessment form left the pressure stage blank at discovery and again on later assessments on 10/28/2024 and 11/4/2024, even as the wound progressed and later was documented as a Stage 3 on 11/11/2024. The record also showed a facility-acquired wound behind the left knee identified on 8/11/2025 with 80% slough and the wound stage left as not applicable at that time. The DON confirmed that the right ischium wound and the left leg wound were not staged when identified and stated that when the wound care nurse was not present, the NP or any other RN could assess and stage wounds upon identification. Resident #79 was admitted with diagnoses including respiratory failure, pneumonia, heart failure, diabetes, and depression, and had 2 unstageable pressure ulcers present on admission. Physician orders required wound care to the right rear thigh and abdominal fold, but the treatment administration record showed wound care was not provided on 8/14/2025 and 8/15/2025. After the resident returned from the hospital, the Skin and Wound Evaluation was not completed until 8/18/2025, when the resident was documented to have three Stage 3 pressure ulcers involving the abdomen and right thigh. The DON confirmed that the resident returned to the facility on 8/14/2025, that the wound evaluation was not performed until 8/18/2025, that wound care was not performed on 8/14/2025 and 8/15/2025, and that wounds should be assessed and staged immediately when identified.
Failure to Refund Resident Trust Funds After Death
Penalty
Summary
The facility failed to refund a resident’s trust fund balance within 30 days of death or discharge. Review of the facility’s Resident Trust Fund policy showed that upon death or discharge, the resident’s funds and a final accounting are to be conveyed within 30 days to the individual or probate jurisdiction administering the resident’s estate. Resident #78 was admitted with diagnoses including Cerebral Infarction, Malnutrition, Dysphagia, and Anxiety. The resident’s trust fund statement showed an account balance of $70.08, and a nurse’s note documented pronouncement of death at 6:10 AM. The facility did not provide documentation that the resident’s estate had been reimbursed within 30 days of death, and the Business Office Manager confirmed during interview that the account balance had not been refunded to the individual or the resident’s estate.
MDS assessments were not signed by an RN
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were signed by a Registered Nurse for 7 of 18 sampled residents, including Resident #1, #6, #13, #23, #31, #40, and #73. Review of the Resident Assessment Instrument (RAI) User’s Manual dated 2023 identified the RNAC as an individual licensed as a registered nurse who is responsible for coordinating and certifying completion of the resident assessment instrument. However, the MDS section Z0500 for each of the cited assessments was electronically signed for accuracy by LPN B instead of a Registered Nurse. The affected residents had a range of diagnoses and cognitive statuses documented in their records. Resident #1 had COPD, diabetes, anxiety, and depression and had a quarterly MDS with a BIMS score of 15. Resident #6 had quadriplegia, PTSD, and schizophrenia, with quarterly and annual MDS assessments showing BIMS scores of 15. Resident #13 had depressive disorder, hypertension, and anxiety, with a quarterly MDS BIMS score of 9. Resident #23 had a femur fracture, diabetes, anxiety, and UTI, with an admission MDS BIMS score of 15. Resident #31 had cerebral infraction, diabetes, and hypertension, with a quarterly MDS BIMS score of 00. Resident #40 had Alzheimer’s disease, anxiety, depression, and dementia, with admission and quarterly MDS BIMS scores of 00. Resident #73 had anxiety, depression, and chronic kidney disease, with an admission MDS BIMS score of 14. During interview, the MDS Coordinator confirmed that all MDS assessments should be signed by a Registered Nurse for accuracy.
Missing BP Monitoring for Antihypertensive Administration
Penalty
Summary
The facility failed to ensure monitoring was completed according to the physician’s order for Resident #31, who was admitted with diagnoses including cerebral infarction, diabetes, and hypertension and was assessed as severely cognitively impaired on the quarterly MDS. The physician’s order dated 2/24/2025 directed Losartan Potassium 50 mg by mouth daily and to hold the medication when systolic BP was less than 110. Review of the MAR and Weights and Vitals Summary sheet showed no BP results documented during multiple periods when Losartan was administered, including 7/29/2025 to 7/31/2025, 8/1/2025 to 8/4/2025, 8/6/2025 to 8/8/2025, 8/10/2025 to 8/16/2025, and 8/18/2025. During interview on 8/19/2025 at 3:43 PM, the DON confirmed that BP should be checked and documented before giving an antihypertensive medication when there are ordered hold parameters.
Failure to Use Hand Hygiene and PPE During Resident Dining Assistance
Penalty
Summary
The facility failed to ensure prevention and spread of infection when staff did not follow hand hygiene and transmission-based precaution requirements during resident dining assistance. The facility policy stated hand hygiene is the primary means to prevent the spread of healthcare-associated infections and is indicated before touching a resident, after touching a resident, and after touching the resident's environment. The transmission-based precautions policy stated that contact precautions require staff and visitors to wear clean gloves when entering the room and to wear a disposable gown upon entering the room. Resident #6 was admitted with diagnoses including quadriplegia, PTSD, chronic pain syndrome, a pressure ulcer of the right buttocks, schizophrenia, and dysphagia. The resident's annual MDS showed a BIMS score of 15, indicating cognitive intactness, and the resident was dependent on staff for eating. During dining observation, CNA E assisted the resident with the meal by cutting up a pulled chicken sandwich and repeatedly picking up pieces of the sandwich with bare hands and placing them into the resident's mouth. CNA E did not perform hand hygiene and did not apply gloves while assisting with the meal and before handling the food with bare hands. Resident #25 had diagnoses including COPD, anxiety, and hypertension, and the admission MDS showed a BIMS score of 15. The resident had a physician order for contact precautions related to VRE. During dining observation in the resident's room, CNA C entered without donning a gown or gloves and provided setup assistance with the meal tray. Resident #33 had diagnoses including bacteremia and sepsis, and the physician ordered contact isolation due to E. coli and ESBL in urine; the admission MDS showed a BIMS score of 11. During dining observation in the resident's room, CNA C again entered without PPE and provided setup assistance with the meal tray. Resident #40 had diagnoses including Alzheimer's disease, anxiety, claustrophobia, and depression, and the quarterly MDS indicated severe cognitive impairment with supervision assistance needed for eating. During dining observation, CNA F cut up the resident's pulled chicken sandwich, picked up a piece with bare hands, and handed it to the resident without performing hand hygiene and/or applying gloves. The DON and ADON confirmed staff should not pick up residents' food with bare hands and should use appropriate PPE when entering a contact isolation room.
Expired Infection Preventionist Training Certificate
Penalty
Summary
The facility failed to ensure employment of a qualified Infection Control Preventionist to monitor and maintain its Infection Prevention and Control Program. Review of the facility policy titled, Infection Prevention and Control Program, dated 12/2023, showed that the IPCP is established and maintained to provide a safe, sanitary, and comfortable environment and is coordinated and overseen by an infection prevention specialist. Review of CMS guidance titled, Updated Guidance for Nursing Home Resident Health and Safety, showed that facilities are required to have a part-time Infection Preventionist who physically works onsite and cannot be an off-site consultant or work at a separate location, and that specialized training is required. Review of the Infection Prevention Control Officer Training certificate showed an expiration date of [DATE], and during an interview on [DATE] at 2:52 PM, the IP confirmed that the training certificate had expired.
Infection Control and Resident Dignity Deficiencies
Penalty
Summary
The facility failed to ensure practices to prevent the potential spread of infection were maintained for six sampled residents and one Certified Nursing Assistant (CNA). The facility's policy on Transmission Based Precautions required enhanced barrier precautions for residents with conditions such as pressure ulcers, indwelling medical devices, and feeding tubes. However, observations revealed that staff did not follow these guidelines. For instance, an LPN failed to wear PPE while administering medications via a gastrostomy tube to a resident, and there was no enhanced barrier precaution signage on the resident's door. Similar lapses were observed for other residents with conditions requiring enhanced barrier precautions, such as wounds and tracheostomies, but no signage or proper PPE usage was noted during care activities. Additionally, the facility's policy on Resident Rights and Resident Responsibilities emphasized the right to a safe, clean, and comfortable environment. However, a CNA failed to remove a urinal filled with urine from a resident's overbed table during dining. The resident requested the CNA to empty the urinal, but the CNA informed the resident that they would have to wait until all residents were served lunch. The CNA then placed the resident's plate of food on the overbed table next to the urinal containing urine, which remained there while the resident ate. Interviews with the Director of Nursing (DON) confirmed that the facility did not have enhanced barrier precaution signage for the affected residents and that staff should wear gloves and gowns when providing wound and trach care. The DON also confirmed that staff should place the plate in a clean location, empty the urinal, and perform hand hygiene when a resident requests them to empty a urinal during dining. These deficiencies indicate a failure to adhere to infection prevention and control protocols, compromising the safety and dignity of the residents.
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to provide information regarding residents' right to formulate an Advance Directive for five of the twenty-four sampled residents. The facility's policy on Advance Directives, revised on January 8, 2024, mandates that residents be informed and provided with written information about their right to formulate an Advance Directive upon admission. However, medical record reviews revealed that Residents #1, #15, #22, #34, and #39 were not informed, offered, or provided with written information regarding their right to formulate an Advance Directive upon admission. This was confirmed during an interview with the Social Services Director (SSD), who acknowledged the lack of documentation for these residents. Resident #1, admitted with diagnoses including Calculus of Kidney, Diabetes, Gastrostomy Status, and Heart Failure, had a BIMS score indicating severe cognitive impairment. Resident #15, with diagnoses such as Cerebral Infarction and Hypertension, had a BIMS score indicating moderate cognitive impairment. Resident #22, diagnosed with conditions like Hemiplegia and Paranoid Schizophrenia, was cognitively intact. Resident #34, with diagnoses including Aphasia and Hemiplegia, was severely cognitively impaired. Resident #39, admitted with diagnoses such as Surgical Amputation and End Stage Renal Disease, was cognitively intact. Despite their varying cognitive statuses, none of these residents or their legal representatives were documented as having been informed about their right to formulate an Advance Directive upon admission.
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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 Hohenwald
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mt Pleasant Healthcare And Rehabilitation | 7.7 mi | ★★★★★ | 0 | 0 |
| Nhc-maury Regional Transitional Care Center | 14.2 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Columbia | 15.2 mi | ★★★★★ | 0 | 0 |
| Magnolia Healthcare And Rehabilitation Center | 15.5 mi | ★★★★★ | 15 | 0 |
| Life Care Center Of Centerville | 15.7 mi | ★★★★★ | 0 | 0 |
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