Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Life Care Center Of Red Bank during CMS and state inspections, most recent first.
The facility failed to properly store and sanitize food items and equipment, affecting 84 of 85 residents. Observations revealed dirty kitchen equipment and improperly stored, unlabeled food items in the kitchen and nourishment rooms. The CDM and ADON confirmed these issues, acknowledging non-compliance with facility policies.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with invasive devices, such as urinary catheters and feeding tubes. Observations showed a lack of EBP signage and PPE outside resident rooms. Staff interviews revealed a misunderstanding of EBP requirements, believing they were only necessary for active infections. The Regional Director confirmed the facility's non-compliance with EBP guidelines.
A resident's privacy was compromised when a sign indicating hospice care was visibly posted in their room without consent or documentation. The sign, visible to anyone entering, violated the resident's rights to dignity and confidentiality. The DON and LPN confirmed the sign's inappropriate placement, which was not requested by the resident or their representative.
The facility failed to notify the responsible parties of two residents about significant changes in their conditions. A resident with multiple diagnoses tested positive for COVID-19, but their family was not informed. Another resident with Alzheimer's and a history of falls experienced an unwitnessed fall resulting in an abrasion, yet their responsible party was not notified until four days later. The DON confirmed these notification delays.
The facility failed to accurately complete MDS assessments for four residents, leading to discrepancies in hospice care documentation and discharge status. A resident under hospice care was not coded for hospice services in the MDS, while another resident's discharge to home was inaccurately documented as a hospital discharge. Additionally, a resident requiring total meal assistance was incorrectly assessed as needing only setup or clean-up assistance.
The facility failed to resubmit a PASARR for two residents after new mental health diagnoses were identified. One resident was admitted with Depression and later diagnosed with Adjustment Disorder with Anxiety and Delusions, while another was admitted with multiple disorders and later diagnosed with Delusions. The DON confirmed that new PASARRs should have been completed for both residents.
A resident receiving enteral nutrition due to a stroke had their tube feeding bag and tubing reused for three days, contrary to the facility's policy of changing them every 24 hours. The oversight was confirmed by an LPN and acknowledged by the DON, indicating a failure to follow physician orders and professional standards.
The facility failed to store respiratory equipment properly for three residents, leaving nebulizer and CPAP masks exposed on bedside tables instead of in labeled bags as required by policy. Despite this, no respiratory illnesses were reported among the residents involved.
The facility did not maintain the garbage storage area in a sanitary condition, as observed during a survey. Trash, including paper, used exam gloves, and straws, was found on the ground, along with a partially decayed animal carcass behind a dumpster. The CDM confirmed the area was unclean.
A resident with diagnoses including Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness required total 2-person assistance with transfers. Despite the care plan specifying the use of a sit to stand lift and later a Hoyer lift, the resident experienced multiple falls due to improper transfer techniques. These falls resulted in injuries, including fractures requiring surgical intervention. Interviews with the DON and a CNA confirmed that the facility did not follow the care plan, leading to harm from falls. The failure to use the recommended mechanical lifts during transfers highlighted a significant deficiency in care delivery and staff compliance with established protocols.
A resident with Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness experienced multiple falls resulting in significant injuries, including a left hip fracture and an impacted humeral neck fracture. The resident required total, 2-person assistance with transfers but fell due to inadequate supervision and improper use of transfer devices. Staff interviews revealed that the resident was resistant to care and demanded specific transfer devices, sometimes refusing transfers if his preferred device was not used. The facility's failure to adhere to the care plan and implement proper transfer protocols led to repeated falls and injuries.
A facility's administration did not provide effective oversight or follow corporate notification protocols for falls with major injuries, resulting in harm to a resident with mobility impairments. The resident, who required total 2-person assistance for transfers, sustained multiple injuries due to improper transfer techniques. Staff inconsistently followed the care plan, and refusals to use specific transfer devices were not consistently documented. The former DON failed to notify corporate teams of these incidents, highlighting a lapse in administrative oversight and adherence to established protocols for resident safety.
The facility failed to maintain an accurate medical record for a resident who was resistant to transfers with the Hoyer lift. Despite multiple staff members being aware of and reporting the resident's refusals, these incidents were not documented in the medical record, resulting in an incomplete and inaccurate record.
Improper Food Storage and Sanitation in Facility
Penalty
Summary
The facility failed to ensure proper storage and sanitation of food items and equipment, which had the potential to affect 84 of 85 residents. During a tour of the kitchen, surveyors observed dried food debris on a stainless steel pan, a stand mixer, and a divided plate, all of which were confirmed by the Certified Dietary Manager (CDM) to be dirty and available for use. Additionally, food storage issues were identified, including unlabeled and undated items such as a bag of red seasoning, a jug of teriyaki sauce, flour tortillas, diced ham, and maraschino cherries. These items were improperly stored in dry storage, reach-in, and walk-in refrigerators, contrary to the facility's policies on sanitation and food safety. Further observations in the nourishment rooms revealed items such as sundae syrup, a can of powdered protein supplement, peanut butter crackers, and cold cereal that were not labeled with resident names or dates, and were available for resident consumption. The CDM and the Assistant Director of Nursing (ADON) confirmed these findings, acknowledging that only resident food should be in the nourishment rooms. The Executive Director also confirmed that the food in the nourishment rooms should be stored according to policy and labeled appropriately, indicating a failure to adhere to the facility's food storage policies.
Failure to Implement Enhanced Barrier Precautions for Residents with Invasive Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for eight residents who were reviewed for invasive devices. These residents had various medical conditions requiring indwelling devices such as urinary catheters, feeding tubes, and central venous lines. Despite the facility's policy on EBP, which mandates additional precautions for residents with such devices, there was no signage or personal protective equipment (PPE) available outside the rooms of these residents. Observations revealed that residents with indwelling urinary catheters, such as those with neurogenic bladder or obstructive uropathy, did not have EBP signage posted, nor was PPE available for staff use. Interviews with staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), confirmed a lack of awareness and implementation of EBP. The staff believed that EBP was only necessary if a resident had an active infection, contrary to the facility's policy. The Regional Director of Clinical Services acknowledged the facility's non-compliance with EBP guidelines for residents with invasive devices, despite being aware of updated guidance. This oversight affected residents with various conditions, including those with feeding tubes and dialysis catheters, as no EBP measures were observed or enforced during the survey period.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the confidentiality and privacy of a resident's medical information, violating the resident's rights to dignity and respect. A sign was posted in the room of a resident with Alzheimer's Disease, Dementia, and other medical conditions, indicating that hospice supplies were to be used only for the hospice resident. This sign was visible to anyone entering the room, which compromised the resident's right to personal privacy and confidentiality of medical records as outlined in the facility's policies. The sign was not requested by the resident or their representative, nor was it documented in the resident's care plan. During interviews, both the LPN and the DON confirmed the visibility of the sign and acknowledged that it should not have been posted without a request from the resident or their representative. The DON was unaware of the sign's presence until it was brought to their attention and confirmed that the medical record did not contain any evidence of a request for such signage.
Failure to Notify Resident Representatives of Condition Changes
Penalty
Summary
The facility failed to notify the responsible parties of two residents about significant changes in their conditions, as required by their policies. Resident #14, who has diagnoses including Cerebral Palsy, Dementia, and Diabetes, tested positive for COVID-19. Despite the facility's policy mandating immediate notification of the resident's representative in such cases, there was no documentation that Resident #14's family was informed of the positive COVID status. This was confirmed during an interview with the Director of Nursing (DON) and the resident's responsible party. Similarly, Resident #46, who has Alzheimer's Disease and a history of falls, experienced an unwitnessed fall resulting in an abrasion to the left thigh. Although the facility's policy requires immediate notification of the resident's representative in the event of an accident, the responsible party was not informed until four days after the incident. The DON confirmed the delay in notification, acknowledging that the responsible party should have been notified at the time of the fall.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the documentation of their care. Resident #1, who was admitted with multiple diagnoses including Quadriplegic Cerebral Palsy and Dementia, was under hospice care since admission. However, the quarterly MDS assessment did not reflect this hospice service, as confirmed by the MDS Coordinator. Similarly, Resident #52, with Alzheimer's Disease and a terminal prognosis, was also receiving hospice care, but the quarterly MDS assessment inaccurately stated that hospice services were not provided. Resident #84, admitted with conditions such as Joint Replacement and Atrial Fibrillation, was planned to be discharged home. Despite this, the discharge MDS assessment inaccurately documented the discharge status as a short-term general hospital, rather than home, as confirmed by the MDS Coordinator. This discrepancy was noted despite the care plan and physician's orders indicating a discharge to home. Resident #45, diagnosed with Parkinson's Disease and requiring total assistance with meals, was inaccurately assessed in the significant change MDS assessment. The assessment indicated the resident required only setup or clean-up assistance with meals, contrary to the physician's order for total assistance. This inaccuracy was confirmed by the Clinical Reimbursement Specialist, highlighting a failure to accurately reflect the resident's needs in the MDS assessment.
Failure to Resubmit PASARR After New Diagnoses
Penalty
Summary
The facility failed to resubmit a Pre-Admission Screening and Resident Review (PASARR) in a timely manner after new mental health diagnoses were identified for two residents. According to the facility's policy, any resident with a newly evident or possible serious mental disorder should be referred for a Level II resident review. However, this procedure was not followed for Resident #11 and Resident #39. Resident #11 was admitted with a diagnosis of Depression, and later received new diagnoses of Adjustment Disorder with Anxiety and Delusions. Despite these new diagnoses, a new PASARR was not submitted, as confirmed by the Director of Nursing (DON). Similarly, Resident #39 was admitted with diagnoses including Anxiety Disorder, Major Depressive Disorder, Primary Insomnia, and Visual Hallucinations. A new diagnosis of Delusions was added later, but the facility did not submit a new PASARR following this change. The DON confirmed that a new PASARR should have been completed after the new diagnosis was added. These oversights indicate a failure to adhere to the facility's policy regarding the coordination of assessments with the PASARR program.
Failure to Change Tube Feeding Bag and Tubing as Required
Penalty
Summary
The facility failed to adhere to its policy regarding the timely replacement of tube feeding bags and tubing for a resident receiving enteral nutrition. The policy, revised on 5/28/2024, mandates that feeding bags and tubing be changed every 24 hours in accordance with physician orders and professional standards of practice. Resident #587, who was admitted with conditions including Hemiplegia, Hemiparesis, and a Cognitive Communication Deficit, required nutritional support through a feeding tube due to a stroke. Physician's orders specifically instructed that the PEG syringe and feeding bags be changed every night shift. However, during an observation and interview, it was revealed that the feeding bag dated 7/12/2024 was reused for three days without being replaced, contrary to the 24-hour change requirement. The resident's representative reported witnessing a nurse refilling the old bag instead of replacing it. This was confirmed by LPN D, who acknowledged the oversight. The Director of Nursing (DON) also confirmed that the expectation was for daily changes of the tube feeding bag and tubing, highlighting a lapse in following the established protocol.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to appropriately store respiratory equipment for three residents, leading to a deficiency in providing safe and appropriate respiratory care. The facility's policy requires that respiratory supplies, such as nebulizer and CPAP masks, be stored in a bag labeled with the resident's name when not in use. However, observations revealed that the nebulizer masks for Residents #587 and #588, and the CPAP mask for Resident #589, were left exposed on their bedside tables instead of being stored properly. Resident #587, who has severe cognitive impairment and diagnoses including COPD and obstructive sleep apnea, was observed with a nebulizer mask lying uncovered on the bedside table. Similarly, Resident #588, who is cognitively intact and also diagnosed with COPD, had a nebulizer mask left exposed on the bedside table. Resident #589, with diagnoses of COPD and chronic respiratory failure, had a CPAP mask lying exposed on the bedside table. These observations were confirmed by the Assistant Director of Nursing (ADON) during interviews and walkthroughs. The Director of Nursing (DON) and the ADON both acknowledged that the respiratory equipment should have been stored in bags with the residents' names and dates after use, as per facility policy. Despite the improper storage, a Nurse Practitioner confirmed that none of the residents had experienced respiratory illnesses since admission, indicating that the deficiency had not yet resulted in adverse health effects for the residents.
Unsanitary Conditions in Garbage Storage Area
Penalty
Summary
The facility failed to maintain the garbage and refuse storage area in a sanitary condition, as required by their policy titled 'Disposal of Garbage and Refuse.' During an observation, it was noted that the dumpster area, which was surrounded on three sides by a fence, contained trash on the ground, including paper, used exam gloves, and straws. Additionally, a partially decayed animal carcass with exposed bones was found behind one of the dumpsters. The Certified Dietary Manager (CDM) confirmed during an interview that the dumpster area was generally unclean and had not been maintained in a sanitary condition.
Failure to Implement Comprehensive Care Plan Resulting in Resident Harm
Penalty
Summary
The facility failed to implement the comprehensive care plan for Resident #3, resulting in actual harm to the resident. Resident #3, admitted with diagnoses including Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness, required total 2-person assistance with transfers. Despite the care plan indicating the use of a sit to stand lift and later a Hoyer lift for transfers, Resident #3 experienced multiple falls due to improper transfer techniques. These falls led to injuries, including a left femur fracture and a left humeral fracture, requiring surgical intervention and emergency room visits. During interviews with the Director of Nursing and CNA #6, it was confirmed that the facility failed to follow Resident #3's comprehensive care plan related to fall interventions, leading to harm from the falls on 9/26/2022 and 5/1/2023. CNA #6 admitted to not using the recommended mechanical lifts for transfers as outlined in the care plan. The facility's failure to ensure proper transfer techniques and adherence to the care plan resulted in repeated incidents of harm to Resident #3, highlighting a significant deficiency in care delivery and staff compliance with established protocols. The facility's lack of adherence to the comprehensive care plan for Resident #3, specifically regarding the use of mechanical lifts for transfers, directly contributed to the harm experienced by the resident. Despite clear guidelines in the care plan and facility procedures, CNAs failed to utilize the appropriate equipment during transfers, leading to falls and subsequent injuries. The failure to monitor and implement the care plan interventions effectively resulted in repeated incidents of harm to Resident #3, underscoring the critical importance of proper care plan implementation and staff training in ensuring resident safety and well-being.
Falls and Injuries Due to Inadequate Supervision and Improper Transfer Techniques
Penalty
Summary
The report details a series of incidents involving Resident #3 at a nursing home facility, where the resident experienced multiple falls resulting in significant injuries. Resident #3 was admitted to the facility with diagnoses including Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness. Despite being assessed as requiring total, 2-person assistance with transfers, Resident #3 experienced falls due to inadequate supervision and improper transfer techniques. The facility's policy on Fall Management emphasized the importance of evaluating hazards, implementing interventions, and monitoring their effectiveness to prevent accidents. The first fall occurred when Resident #3 attempted to transfer himself to the toilet without assistance, resulting in a fall from the wheelchair. Subsequent falls involved staff using inappropriate transfer devices, such as a slide board instead of the recommended sit to stand lift. These incidents led to Resident #3 sustaining a left hip fracture and later an impacted humeral neck fracture. Interviews with staff revealed that Resident #3 was resistant to care and would demand the use of specific transfer devices, sometimes refusing transfers if his preferred device was not used. The facility's failure to adhere to the care plan and implement proper transfer protocols, despite Resident #3's specific needs and care requirements, resulted in repeated falls and injuries. Staff members, including CNAs and nurses, acknowledged instances where correct transfer devices were not used, leading to harm to the resident. These events highlight a critical lapse in supervision and adherence to care plans, ultimately resulting in Resident #3 experiencing preventable accidents with major injuries.
Oversight and Protocol Failures in Fall Management
Penalty
Summary
The facility's Administration failed to provide effective oversight and follow the facility's corporate notification protocol for falls with major injury, resulting in actual harm to Resident #3. Resident #3, admitted with diagnoses including Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness, sustained a left hip fracture on 9/26/2022 due to a fall during a transfer from bed to wheelchair. Despite being care planned for specific transfer devices, Resident #3 experienced repeated fall occurrences and a transfer injury on 5/1/2023, resulting in a left humerus fracture. The facility's policy identified falls resulting in serious injury as Never Events, requiring immediate notification to corporate teams for review and intervention. Documentation revealed that Resident #3 required total 2-person assistance with transfers and was at risk for falls due to impaired mobility and balance issues. However, staff did not consistently follow the care plan, leading to multiple incidents of improper transfers and subsequent injuries. Interviews with nursing staff confirmed that Resident #3 had been resistant to transfers using specific devices, but these refusals were not consistently documented in the medical record. The Regional Director of Clinical Services highlighted the failure of the former Director of Nursing to notify corporate teams of Resident #3's falls with major injuries, indicating a lack of effective administration oversight that could potentially impact all residents in the facility. The facility's policies emphasized the importance of continuous quality improvement, monitoring adverse events, and implementing corrective actions to prevent future incidents. Despite these policies, the facility's Administration did not adhere to the corporate notification protocol for Never Events, leading to inadequate oversight and intervention in response to Resident #3's repeated falls with major injuries. The deficiency spanned from 9/26/2022 to 8/28/2023, highlighting a significant period of non-compliance with established protocols and care plans for resident safety.
Failure to Document Resident's Refusal of Care
Penalty
Summary
The facility failed to maintain an accurate medical record for Resident #3, who was admitted with diagnoses including Hemiplegia, Hemiparesis, Lack of Coordination, and Muscle Weakness. Despite the facility's policies requiring documentation of care refusals, there was no record of Resident #3's resistance to transfers with the Hoyer lift. Multiple staff members, including CNAs and nurses, confirmed that the resident had been resistant to care and mechanical lift usage, preferring the sit-to-stand lift over the Hoyer lift. However, these refusals and resistances were not documented in the medical record as required by the facility's policies on Authentication of All Record Entries and Refusal of Care or Treatment. Interviews with various staff members, including the Restorative CNA, multiple CNAs, an RN, and an LPN, revealed that they were aware of Resident #3's resistance to the Hoyer lift and had reported these incidents to the assigned nurse. Despite this, both the RN and LPN admitted to not documenting these refusals in the medical record. The Director of Nursing confirmed that it was her expectation for nurses to document any refusals of care, transfers, or behaviors in the medical record, and acknowledged that the medical record for Resident #3 was incomplete and inaccurate due to the lack of documentation of these incidents.
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What surveyors actually found near you
We read the 58 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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 Chattanooga
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ascension Living Alexian Village Tennessee | 2.7 mi | ★★★★★ | 10 | 0 |
| Siskin Subacute West | 4.5 mi | ★★★★★ | 1 | 0 |
| Nhc Healthcare, Chattanooga | 5.7 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Hixson | 6.2 mi | ★★★★★ | 4 | 1 |
| Nhc Healthcare Rossville | 9.7 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.