Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Nhc Healthcare, Tullahoma during CMS and state inspections, most recent first.
A resident with emphysema who was receiving nebulized medications had their nebulizer mask left uncovered and open to air on the bedside table, rather than being stored in a labeled bag as required by facility policy. This improper storage was observed and confirmed by an LPN and the Infection Preventionist.
Dietary staff did not fully comply with facility policy requiring complete hair coverage during food preparation. The ADM was observed with hair protruding from her covering while preparing meals, and another staff member plated meals without a beard covering. The Food and Nutrition Director confirmed these lapses in proper hair restraint use.
The facility did not complete required quarterly MDS assessments within the mandated time frames for several residents with complex medical conditions, as confirmed by medical record review and staff interviews. MDS assessments were either completed late or left undated, in violation of regulatory requirements.
A resident with multiple diagnoses was admitted with an indwelling urinary catheter, which was later discontinued following a hospital stay and readmission. Despite observations and staff confirmation that the catheter was no longer present, the care plan was not updated to reflect this change.
Two residents were found with medications left unsecured at their bedsides after administration, despite facility policy requiring medications to be stored securely and only accessible to licensed staff unless a resident is assessed for self-administration. Both an RN and an LPN confirmed that no such assessments had been completed, and the DON verified the lack of documentation for self-administration for these residents.
Surveyors observed that the facility failed to properly contain garbage and maintain the outside dumpster area in a sanitary condition, with broken furniture, pallets, and disposable gloves scattered behind two dumpsters. Staff confirmed that these items were not disposed of properly and that the area was not kept sanitary, contrary to facility policy.
A resident receiving hospice services for a traumatic subdural hemorrhage and dementia did not have a hospice provider's plan of care available in the medical record, despite facility policy and contract requirements. Staff, including the DON and an LPN, were unaware of how to locate this plan, and confirmed it was not present in the record.
Staff did not consistently use required PPE, such as gowns and gloves, during high-contact care activities for two residents on Enhanced Barrier Precautions due to invasive devices. Additionally, three residents were not offered or assisted with hand hygiene before meals, despite needing help with personal hygiene. These lapses were confirmed through observation and staff interviews, revealing gaps in infection prevention practices.
The facility failed to accurately complete an MDS assessment for a resident admitted with multiple diagnoses, including a stage 1 pressure ulcer. The MDS inaccurately documented a stage 2 pressure ulcer, which was not supported by medical records, wound management reports, or observations. Interviews with the WCN, the resident, and the DON confirmed the inaccuracy.
The facility failed to revise the comprehensive care plans to include new fall prevention interventions after falls for two residents. Despite implementing immediate interventions, the care plans were not updated to reflect these changes, as confirmed by the DON.
A Wound Care Nurse failed to perform proper hand hygiene after removing soiled gloves and before applying new gloves while treating a resident's stage 3 pressure ulcer. The Director of Nursing confirmed the lapse in protocol, although the resident's wound showed no signs of infection during the observation.
Nebulizer Mask Not Stored per Policy After Use
Penalty
Summary
A deficiency occurred when staff failed to store a nebulizer mask appropriately for a resident who required nebulized medications. Facility policy required that after use, nebulizer equipment should be allowed to dry completely and then stored in a plastic bag labeled with the resident's name and date. The resident in question had a history of emphysema and was receiving both scheduled and PRN nebulizer treatments, as documented in the medical record and care plan. During observations, the nebulizer mask was found lying uncovered and open to air on the bedside table, rather than being stored in a bag as required. This was confirmed by both an LPN and the Infection Preventionist, who acknowledged that the mask was not stored according to facility policy. The failure to follow proper storage procedures was directly observed and verified through staff interviews.
Failure to Ensure Proper Use of Hair Coverings During Food Preparation
Penalty
Summary
Dietary workers failed to wear protective hair coverings in accordance with facility policy during food preparation in the kitchen. Observations revealed that the Assistant Dietary Manager (ADM) had hair protruding from her hair covering, leaving parts of her forehead and the back of her head uncovered while preparing desserts and salads for lunch meal service. Additionally, the Lead staff member was observed plating resident meals without a protective beard covering to cover his facial hair. The Food and Nutrition Director confirmed that all dietary workers are required to have their hair completely covered while in food preparation areas, and acknowledged that the ADM and Lead staff did not comply with this requirement.
Failure to Complete Quarterly MDS Assessments Within Regulatory Time Frames
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required regulatory time frames for seven residents. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual, quarterly assessments must be completed at least every 92 days following the previous OBRA assessment, with the MDS completion date no later than 14 days after the Assessment Reference Date (ARD). Medical record reviews revealed that for seven residents with various diagnoses including heart failure, dementia, chronic kidney disease, diabetes, hypertension, anxiety disorder, polyneuropathy, adult failure to thrive, and depression, the quarterly MDS assessments were either completed late or not dated as required. Specific examples included assessments that were completed weeks after the required due dates or left undated. During an interview, the MDS Coordinators confirmed responsibility for signing and verifying the completion of MDS assessments and acknowledged that the assessments for the identified residents were completed late. The deficiency was identified through a review of medical records and staff interviews, which confirmed that the facility did not adhere to the mandated timelines for completing quarterly MDS assessments for these residents.
Failure to Update Care Plan After Discontinuation of Indwelling Catheter
Penalty
Summary
The facility failed to revise the care plan for a resident following a significant change in their medical status. The resident, who had diagnoses including heart failure, malignant neoplasm of the pancreas, and anxiety, was admitted with an indwelling urinary catheter. The comprehensive care plan documented the presence of the catheter. However, after the resident was hospitalized and subsequently readmitted without the catheter, the care plan was not updated to reflect the discontinuation of the device. Observations on multiple dates confirmed that the resident no longer had an indwelling urinary catheter. Interviews with nursing staff and the Director of Nursing further verified that the care plan had not been revised to address the change in the resident's condition. This failure was identified through facility policy review, medical record review, direct observation, and staff interviews.
Failure to Secure Medications and Assess for Self-Administration
Penalty
Summary
The facility failed to ensure that medications were stored and secured properly for two residents. According to facility policy, medications are to be stored safely, securely, and only accessible to licensed nursing personnel, with medications kept in a medication cart unless a resident has been assessed for self-administration. For one resident with heart failure, pancreatic cancer, and anxiety, an Incruse Ellipta inhaler was observed left on the bedside table after administration by an RN, who confirmed that the resident had not been assessed for self-administration. Similarly, for another resident with a history of joint replacement and emphysema, an unopened vial of Budesonide Inhalation Suspension was found on the bedside table after administration by an LPN, who also confirmed the absence of a self-administration assessment in the medical record. Both the RN and LPN acknowledged that medications should not be left at the bedside unless the resident has been properly assessed for self-administration, and the DON confirmed that neither resident had such an assessment documented. Observations and interviews confirmed that the medications were not secured or stored according to facility policy, and that the medications were accessible to the residents without proper authorization or assessment.
Improper Disposal and Unsanitary Dumpster Area
Penalty
Summary
The facility failed to properly contain garbage and refuse and did not maintain the outside dumpster area in a sanitary and orderly condition. Review of the facility's waste management policy indicated that refuse containers and dumpsters should be kept in a safe and sanitary manner and checked routinely for debris, with items removed to minimize odors and conditions that attract insects and rodents. During an observation, surveyors found that the area behind two dumpsters contained four broken wooden pallets, a broken chair, a broken television, a broken table, and fifteen disposable gloves scattered on the ground. Interviews with the Food and Nutrition Director and the Maintenance Assistant confirmed that these items had not been disposed of properly and that the dumpster area was not maintained in a sanitary condition.
Missing Hospice Plan of Care in Medical Record
Penalty
Summary
The facility failed to ensure that a coordinated plan of care with the hospice provider was available in the medical record for one resident receiving hospice services. Review of facility policy and the hospice contract indicated that a written, coordinated plan of care should be developed and maintained jointly by the facility and the hospice provider, and that this plan should be present in the resident's medical record. However, upon review of the medical record for a resident admitted with traumatic subdural hemorrhage and dementia, there was no hospice provider's plan of care present. The comprehensive care plan referenced the need to develop a coordinated care plan, but the actual hospice plan of care was missing from the record. Interviews with facility staff, including an RN, the DON, and an LPN Unit Manager, revealed that they were unaware of how to locate the hospice provider's plan of care in the medical record. The LPN Unit Manager confirmed that hospice documentation was in the computer chart but acknowledged that the hospice provider's plan of care was not included in the resident's medical record. The DON also confirmed that the hospice provider's plan of care was supposed to be available in the medical record. Observation of the resident showed the individual was comfortable and without concerns at the time.
Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure proper implementation of its infection prevention and control program, specifically regarding the use of Enhanced Barrier Precautions (EBP) and hand hygiene assistance. For two residents on EBP due to the presence of invasive devices such as a PEG tube, PICC line, and indwelling urinary catheter, staff did not consistently don the required personal protective equipment (PPE) during high-contact care activities. In one instance, a CNA and an LPN repositioned a resident with a feeding tube while wearing gloves but not gowns, despite facility policy and care plans indicating that both gown and gloves were required for such activities. The staff involved were either unaware of the specific requirements or misunderstood when gowns were necessary. Additionally, another resident with a PICC line and catheter had linens changed by CNAs who did not wear any PPE, and an LPN managed the resident's PICC line with gloves only, omitting the gown. Staff interviews confirmed knowledge gaps and lapses in following EBP protocols. The report also documents failures in providing hand hygiene assistance to residents prior to meals. Three residents, each with varying levels of cognitive and physical impairment, were observed receiving meal trays without being offered or encouraged to perform hand hygiene. In each case, the CNA responsible for meal delivery did not assist or prompt the resident to clean their hands before eating. Interviews with the residents and staff confirmed that hand hygiene was not offered or performed prior to the meal service, despite facility policy and care plans indicating the need for such assistance, especially for residents with limited self-care abilities. The Director of Nursing acknowledged that staff were expected to offer hand hygiene assistance to all residents before meals and confirmed that infection prevention and control practices were not maintained during the observed meal service. The deficiencies were identified through policy review, medical record review, direct observation, and staff and resident interviews, highlighting specific instances where established infection control protocols were not followed.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident admitted with multiple diagnoses, including a displaced intertrochanteric fracture of the left femur, chronic obstructive pulmonary disease, heart failure, and a stage 1 pressure ulcer of the sacral region. The admission MDS assessment inaccurately documented the presence of a stage 2 pressure ulcer, which was not corroborated by subsequent medical records, wound management reports, or direct observations by the wound care nurse (WCN). Interviews with the WCN, the resident, and the Director of Nursing (DON) confirmed that the resident only had a stage 1 pressure ulcer upon admission and no other wounds during their stay. The discrepancy was identified during a review of the Resident Assessment Instrument (RAI) Manual and through interviews and observations conducted by surveyors. The WCN and the resident both confirmed that the resident had only one stage 1 pressure ulcer, which had resolved by the time of the survey. The DON and the MDS Coordinator acknowledged that the MDS assessment completed on the specified date was inaccurate, as it incorrectly indicated the presence of a stage 2 pressure ulcer. This inaccuracy in the MDS assessment reflects a failure to provide an accurate picture of the resident's current health status as required by regulatory standards.
Failure to Revise Care Plans After Falls
Penalty
Summary
The facility failed to revise the comprehensive care plan to include added fall prevention interventions after falls for two residents. Resident #5, who has diagnoses including Osteoporosis, Pathological Fracture to the Left Femur, Dementia, and a History of Falling, experienced a fall on 1/28/2024. Despite the implementation of immediate interventions such as a non-slip pad to the wheelchair, a motion sensor, and a scoop mattress, the care plan was not updated to reflect these new interventions. Observations confirmed the presence of these interventions, and the Director of Nursing (DON) acknowledged that the care plan should have been revised accordingly but was not updated after the fall on 1/28/2024. Resident #27, with diagnoses including Parkinson's Disease, Alzheimer's Disease, Dementia, and Chronic Kidney Disease, sustained a fall on 7/11/2023. The immediate intervention was to declutter the room of trip hazards from bead boxes. However, the comprehensive care plan was not revised to include this new fall intervention. The DON confirmed that the care plan had not been updated to reflect the new intervention after the fall. Observations showed that the bead boxes were arranged to prevent blockage of the room entrance, but the care plan did not document this intervention.
Failure to Perform Proper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention practices were followed during wound care for a resident. The Wound Care Nurse (WCN) did not perform hand hygiene after removing soiled gloves and before applying new gloves while treating a stage 3 pressure ulcer on the resident's coccyx. This lapse in protocol was observed during a wound care session, and the WCN confirmed the failure to perform hand hygiene. The Director of Nursing (DON) also confirmed that adequate hand hygiene was not performed during the wound care treatment. The resident involved was admitted with diagnoses including Multiple Sclerosis, a stage 3 pressure ulcer in the sacral region, and muscle wasting. The resident's care plan included specific instructions for wound care, which were not followed correctly by the WCN. Despite the improper hand hygiene, the resident's wound showed no signs of infection during the observation. The facility's policy on aseptic treatment technique clearly outlined the need for hand hygiene after removing soiled gloves, which was not adhered to in this instance.
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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 Tullahoma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Tullahoma | 0.4 mi | ★★★★★ | 5 | 0 |
| Lynchburg Nursing Center | 9.1 mi | ★★★★★ | 5 | 0 |
| Legacy Health And Rehab | 10.4 mi | ★★★★★ | 0 | 0 |
| Manchester Center For Rehabilitation And Healing L | 12.1 mi | ★★★★★ | 1 | 0 |
| Elk River Health & Nursing Center Of Winchester | 15.8 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.