Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Nhc Healthcare, Hendersonville during CMS and state inspections, most recent first.
Staff failed to follow the individualized transfer care plan for a resident with significant mobility limitations and a history of falls, resulting in two separate incidents where the resident was manually transferred without the required mechanical lift. These actions led to the resident sustaining a right tibia fracture and a right lower femur fracture requiring surgery. The failure to adhere to the care plan and facility policies placed the resident and others at risk for serious harm.
The facility did not update care plans to include specific transfer methods for several residents, despite therapy assessments and internal documentation indicating the need for mechanical lifts or two-person assistance. Staff interviews and observations confirmed that the care provided did not match the written care plans, and the DON acknowledged the care plans were not revised to reflect current transfer needs.
Failure to Follow Transfer Care Plan Results in Resident Injuries
Penalty
Summary
Staff failed to follow the resident-specific care plan for transfers, resulting in two separate incidents where a resident with significant mobility limitations and a history of falls was not transferred using the required mechanical lift. In the first incident, a single staff member transferred the resident without a lift, despite the care plan indicating the need for a Hoyer lift or sit-to-stand lift, leading to the resident being lowered to the floor and sustaining a right tibia fracture. Documentation and interviews revealed that the staff member was unaware of the resident's transfer requirements due to the absence of a sling and lack of familiarity with the resident. In the second incident, two staff members attempted a stand/pivot transfer from a shower chair to a wheelchair without using the Hoyer lift, as the sling was not properly positioned under the resident. Both CNAs decided to manually lift the resident, resulting in the resident being lowered to the floor and sustaining a right lower femur fracture that required surgical intervention. Interviews with the involved staff confirmed their knowledge of the care plan requirement for a Hoyer lift but indicated they proceeded with a manual transfer due to perceived urgency and inability to reposition the sling. The resident involved had a medical history including spinal stenosis, cervical spine fusion, a history of falls, and lumbosacral disc disorder, and was dependent on staff for all transfers. The care plan and facility policies required the use of mechanical lifts for transfers, and documentation showed inconsistencies and confusion regarding the correct transfer method. The facility's failure to ensure staff followed the individualized care plan for transfers resulted in serious injuries and constituted Immediate Jeopardy, placing the resident and others requiring similar assistance at risk.
Removal Plan
- Resident #1's care plan was updated on the use of a shower bed (instead of a shower chair).
- The facility identified residents who require a Hoyer lift, and care planned these residents to use the shower bed (instead of a shower chair) on shower days.
- Staff in-services and education: a. How to safely place Hoyer slings from various positions, sitting and lying. b. How to reduce injury with an interrupted fall. c. How to lower a patient to the floor and body positioning. d. Timely assessments at time of fall. e. Timely notifications with family communication.
- New Hire orientation to include fall safety and transfer training.
- Complete competencies with all new hires and transfer training with therapy.
- Current employees will complete annual competency checks with return demonstration.
Failure to Update Care Plans with Resident-Specific Transfer Methods
Penalty
Summary
The facility failed to revise and update resident care plans to include resident-specific transfer methods, as required by facility policy and clinical documentation. For four residents reviewed for transfers, the care plans did not reflect the current transfer needs and methods, such as the use of mechanical lifts or the required number of staff for safe transfers. This deficiency was identified through policy review, medical record review, observations, and staff interviews. For example, one resident with a history of falls and total dependence for transfers was documented in therapy notes and on the Can-Do Information Sheet as requiring a Hoyer lift with two-person assistance. However, the care plan did not specify the use of a Hoyer lift for transfers. Another resident, who required a sit-to-stand mechanical lift and two-person assistance according to the Can-Do Information Sheet, also had a care plan that lacked this specific intervention. In both cases, staff interviews confirmed that the actual transfer methods used were not reflected in the care plans. Additional residents with significant mobility limitations, including those with severe cognitive impairment or a history of stroke, were also found to have care plans that did not match the documented transfer methods or staff assistance levels indicated in therapy assessments and Can-Do Information Sheets. The Director of Nursing confirmed that the care plans for these residents had not been revised to include the appropriate transfer methods, resulting in inconsistencies between the care plans and the actual care provided.
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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 Hendersonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Old Hickory Village | 4.8 mi | ★★★★★ | 2 | 0 |
| Alta Heights Post Acute | 5.5 mi | ★★★★★ | 0 | 0 |
| Nhc Place Sumner | 6.4 mi | ★★★★★ | 3 | 0 |
| Creekside Center For Rehabilitation And Healing | 6.5 mi | ★★★★★ | 0 | 0 |
| The Mckendree Post Acute & Rehabilitation | 8 mi | ★★★★★ | 1 | 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.