NHC Healthcare: Chair Restraints & 30+ Falls - TN
The restraint practice at NHC Healthcare continued despite warnings from nursing staff who found the setup multiple times and told colleagues "it's a restraint, she could get hurt, you can't do that."
Family Member O provided inspectors with an undated photograph showing Resident #3 lying in bed with one side pushed against the wall and two burgundy chairs positioned at the foot of the bed below the half side rail. The woman had severe cognitive impairment with a mental status score of 4 out of 15.
"I have found chairs next to her bed to keep her in the bed," Certified Nursing Assistant P told inspectors during a telephone interview. "I told the staff it's a restraint, she could get hurt, you can't do that. It was more than one time I found it that way."
An anonymous registered nurse confirmed the practice. "I have walked into the room when family had not been there and found two burgundy straight back chairs next to the bed and the other side of the bed against the wall," the nurse said. "The daughter reported that the second shift was doing it."
When asked if staff received training about restraints, the anonymous nurse replied: "No."
Administrator denial contradicted the evidence. When shown the photograph during the inspection, she confirmed it was taken in Resident #3's room but claimed no knowledge of the chair restraints. "Not that I know of," she said. "You can't leave chairs next to a bed, that is a restraint."
The chair restraints occurred as Resident #3 endured a relentless pattern of falls. Between November 2022 and October 2023, she suffered more than 30 unwitnessed falls in her room, most resulting in injuries including bruises, skin tears, and a fractured hip.
Her most serious fall occurred on September 30, 2023, after staff moved her to an isolation room 38 feet from the nurses' station for a shingles diagnosis. The severely impaired woman, who required a mechanical lift and two-person assistance for all transfers, was found on the floor with a massive hematoma on her right leg.
Hospital records revealed the hematoma measured 22 centimeters by 11.4 centimeters by 6.5 centimeters with "multiple areas of contrast with ongoing bleeding." The emergency room physician noted "ongoing small arterial bleeding" and classified it as "an acute or chronic illness with a high risk disease process that poses a threat to life or bodily function in the near term without treatment."
"She was shaking and hurting so bad," Family Member O told inspectors. "She said she laid in the floor and hollered for help. She was crying and said I didn't think they would come get me. She was begging for someone to come kill her she was hurting so bad."
The facility couldn't tell the family how long Resident #3 had been on the floor. The administrator called the next day but "couldn't tell me how long she laid in the floor or what time for sure it happened."
Staff failures compounded the danger. Family photographs showed Resident #3's clip alarm lying unattached next to the television on October 23, 2023, and again on October 26, sitting on top of sheets. "I never could get an explanation out of them," the family member said. "When I would come to visit her the alarm was either on the table or not hooked up to her gown."
CNA P confirmed finding the alarm disconnected "several times" and reporting it to staff.
The facility's care plan required mechanical lift transfers with two people, but incident reports suggest single staff members attempted transfers. On October 17, 2023, "CNA was getting ready to transfer pt to her chair and when she turned her back to but [put] the pad in the chair pt slide out of low bed onto the mat."
Medical Director's dismissive response revealed systemic indifference. When asked about tracking or analysis of Resident #3's numerous falls with injuries, he said: "I can't recall. Falls happen no way to prevent falls."
The administrator acknowledged moving Resident #3 to the distant isolation room contributed to her fall risk. "The family met with us after the fall, and they voiced concerns about her being moved at the end of the hall, we moved her back closer to the nurse's desk," she said.
But when asked if the facility performed root cause analysis or developed specific interventions for a resident with over 30 unwitnessed falls and major injuries, the administrator said: "Just what we have given you and what is in the chart. I don't know of anything else."
Resident #3's case also exposed dangerous discharge practices. The facility transferred another severely impaired resident to a facility without secured doors despite knowing she was "exit seeking." That resident required emergency psychiatric hospitalization within 24 hours and had to be moved again to a locked memory unit.
The inspection found the facility failed to complete required discharge summaries and sent inadequate referral information that omitted critical safety needs.
Resident #3 continued falling after her hospitalization, with additional incidents on October 9, 11, 15, 17, 18, and 20, 2023. Family photographs from October showed progressive bruising to her face, temple, and neck area.
She died without the facility ever addressing the fundamental failures that led to her repeated injuries and suffering.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nhc Healthcare, Murfreesboro from 2024-08-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
NHC HEALTHCARE, MURFREESBORO in MURFREESBORO, TN was cited for violations during a health inspection on August 2, 2024.
The woman had severe cognitive impairment with a mental status score of 4 out of 15.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at NHC HEALTHCARE, MURFREESBORO?
- The woman had severe cognitive impairment with a mental status score of 4 out of 15.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in MURFREESBORO, TN, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from NHC HEALTHCARE, MURFREESBORO or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 445108.
- Has this facility had violations before?
- To check NHC HEALTHCARE, MURFREESBORO's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.