Above 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, Murfreesboro during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls was found to be restrained in bed using chairs, contrary to facility policy. Despite conflicting reports on who placed the chairs, staff and family interviews confirmed their use as restraints. The facility administrator was unaware of the situation until shown photographic evidence.
A resident with severe cognitive impairment and exit-seeking behavior was unsafely transferred to a facility lacking necessary security measures. The discharge summary was completed after the transfer, failing to inform the receiving facility of the resident's needs. Miscommunication led to the resident being placed in an unsecured environment, necessitating another transfer.
A facility failed to develop a comprehensive discharge plan for a resident with severe cognitive impairment and multiple diagnoses, including Dementia and Depression. Despite discussions and agreements for transfer to a memory care unit, the discharge plan was not documented in the care plan. This deficiency was confirmed through medical record reviews and staff interviews.
A resident with severe cognitive impairment and a history of falls experienced multiple unwitnessed falls resulting in injuries due to inadequate supervision and failure to adhere to care plans requiring mechanical lift and two-person assistance. Alarms were often found unattached, and the resident was placed in isolation far from the nurse's station, contributing to the lack of timely assistance.
Failure to Maintain a Restraint-Free Environment
Penalty
Summary
The facility failed to provide an environment free from physical restraints for a resident, identified as Resident #3, who was reviewed for restraints. Resident #3 had a history of severe cognitive impairment, multiple falls, and required extensive assistance for daily activities. Despite the facility's policy against the use of physical restraints unless medically necessary, it was observed that chairs were placed against the resident's bed, effectively restraining her. This was corroborated by interviews with staff and family members, who reported that chairs were used to prevent the resident from getting out of bed, which constitutes a physical restraint. The resident had a history of 39 documented falls, including two major injuries requiring hospital transfer. Interviews with staff and family members revealed conflicting accounts of who was responsible for placing the chairs, with some staff claiming the family staged it, while others, including an anonymous RN, confirmed finding the chairs in place when the family was not present. The facility's administrator was unaware of the situation until shown a photograph of the resident's bed with chairs placed against it, confirming the use of restraints. No in-service or educational measures were provided to staff or family regarding the inappropriate use of restraints.
Improper Discharge Summary Leads to Unsafe Resident Transfer
Penalty
Summary
The facility failed to ensure a proper discharge summary was completed for a resident, leading to an unsafe transfer. The resident, who had severe cognitive impairment and exhibited behaviors such as wandering, exit-seeking, and intrusive actions, was transferred to a facility that did not have the necessary security measures in place. The discharge summary, which should have included critical information about the resident's behaviors and needs, was completed two days after the transfer, indicating it was not provided to the receiving facility in a timely manner. The resident had a history of dementia, anxiety, and other psychiatric conditions, which contributed to her wandering and exit-seeking behaviors. Despite these known issues, the facility did not document these behaviors in the referral to the receiving facility. The receiving facility was not informed of the resident's need for a secured unit, which was crucial for her safety given her tendency to wander and seek exits. Interviews with staff and family members revealed a lack of communication and understanding regarding the resident's needs and the capabilities of the receiving facility. The resident's daughter was under the impression that her mother would be transferred to a secured memory care unit, which was not the case. The receiving facility was not equipped with the necessary security features, such as locked doors or a wanderguard system, to safely accommodate the resident, leading to further complications and the need for another transfer to a more suitable facility.
Failure to Develop Comprehensive Discharge Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed discharge plans for a resident with severe cognitive impairment. The resident, who had a history of Dementia, Obsessive-compulsive disorder, Unspecified Psychosis, Depression, Alcohol Dependence with alcohol-induced persisting Dementia, Anxiety Disorder, and Pseudobulbar affect, was admitted and readmitted to the facility. Despite the resident's severe cognitive impairment, indicated by a BIMS score of 4, and the need for specialized care as noted by the Psychiatric Nurse Practitioner, the care plan lacked a discharge plan. The deficiency was identified through a review of the resident's medical records, care plan, and interviews with facility staff. Although a care conference was held, and a referral to a memory care unit was agreed upon by the resident's daughter, the discharge plan was not documented in the resident's care plan. The social worker and the administrator both confirmed the absence of a discharge plan in the care plan during interviews, highlighting the facility's failure to ensure a comprehensive care plan was in place for the resident's discharge needs.
Inadequate Supervision and Fall Prevention for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with severe cognitive impairment and a history of multiple unwitnessed falls. The resident, who required extensive assistance for mobility and was dependent on a mechanical lift with two-person assistance, experienced numerous falls, many of which resulted in injuries. Despite the resident's known fall risk and cognitive limitations, the facility did not ensure consistent supervision or effective fall prevention measures. The resident's care plan indicated the need for a mechanical lift and two-person assistance for transfers, yet there were instances where this protocol was not followed. The resident was often found on the floor after unwitnessed falls, and alarms intended to alert staff were frequently found unattached or not functioning properly. The facility's documentation and interviews with staff revealed a lack of consistent adherence to the care plan and insufficient monitoring, particularly when the resident was placed in isolation far from the nurse's station. The facility's failure to adequately supervise the resident and implement effective fall prevention strategies resulted in multiple injuries, including a significant hematoma requiring hospitalization. Interviews with family members and staff highlighted concerns about the resident's safety and the facility's inability to provide timely assistance. The lack of a comprehensive approach to address the resident's fall risk and cognitive impairment contributed to the ongoing incidents and injuries.
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What surveyors actually found near you
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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 | 1.6 mi | ★★★★★ | 4 | 0 |
| Adamsplace, Llc | 2 mi | ★★★★★ | 7 | 0 |
| Stones River Manor, Inc | 2.9 mi | ★★★★★ | 0 | 0 |
| Tennessee Veterans Home | 4.3 mi | ★★★★★ | 2 | 0 |
| Community Care Of Rutherford | 5.7 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.