NHC Healthcare: Care Planning Failures - TN
The November inspection at NHC Healthcare found staff routinely ignored transfer protocols designed to prevent falls among vulnerable residents. Four residents received improper transfers that contradicted their documented care requirements.
Resident #5 needed a Hoyer mechanical lift operated by two people, according to facility assessments. But CNA I told inspectors she handled the transfers alone. "I did her myself with the Hoyer, it just takes 1 person with her," the aide said. "She grabs onto the bars, there's no issues, like no one needs to hold her legs up or anything."
The resident's functional assessment clearly stated she required "2 person transfer with Hoyer lift."
Resident #6 presented an even more complex case. Admitted with heart disease, kidney disease, and a history of falling, the patient scored an 8 on cognitive testing, indicating moderate impairment. Physical therapy determined she needed "substantial/maximal assistance" for transfers and used both a walker and wheelchair.
The facility's own Can-Do Information Sheet specified "2 person for safety due to bad left knee" and noted "Fall Precautions: inconsistent transfers/use walker or use 2x staff."
Yet CNA G told inspectors the resident "needs 1 person for transfer, sometimes we will use 2, it depends." The aide added that the resident "is terrified of falling."
The disconnect between documented requirements and actual practice extended beyond individual cases. Director of Nursing confirmed during the October interview that care plans for Residents #3, #4, #5, and #6 had never been updated to reflect their specific transfer needs.
"The care plans did not match the Can-Do information sheets," the nursing director acknowledged.
This created a dangerous gap in resident safety protocols. While facility assessments identified precise transfer requirements, the formal care plans that guide daily nursing care remained outdated and incomplete.
Resident #3 required "2 person transfer with walker," according to facility documentation. But staff performed single-person transfers, contradicting the safety assessment.
Resident #4's situation was equally concerning. Facility records showed specific transfer requirements, but the care plan failed to incorporate these critical safety measures.
The inspection revealed a systematic breakdown in communication between assessment teams and direct care staff. Physical therapists, nurses, and other professionals documented detailed transfer protocols, but these requirements never made it into the care plans that CNAs use during their shifts.
For residents with cognitive impairment and fall histories, proper transfer techniques represent the difference between safety and serious injury. A two-person transfer provides stability and support that a single aide cannot match, particularly for residents who are "terrified of falling."
The facility's own assessments recognized these vulnerabilities. One resident's care plan noted she was "at risk for falls" and had a "history of falling," requiring "staff assist" with "minimum to moderate assistance with transfers."
But the plan failed to specify the two-person requirement documented elsewhere in her file.
CNA G's comment about using two people "sometimes" depending on circumstances highlighted the inconsistent approach that put residents at risk. Transfer protocols exist to eliminate such discretionary decisions, ensuring consistent safety measures regardless of which staff members are working.
The nursing director's admission that multiple care plans remained unrevised suggested the problem extended beyond individual oversights to systemic failures in care plan maintenance.
Residents #5 and #6 continued living with transfer methods that contradicted their documented safety needs, while their care plans remained frozen in outdated assessments that no longer reflected their actual functional status.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nhc Healthcare, Hendersonville from 2025-11-04 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 20, 2026 · Our methodology
NHC HEALTHCARE, HENDERSONVILLE in HENDERSONVILLE, TN was cited for violations during a health inspection on November 4, 2025.
The November inspection at NHC Healthcare found staff routinely ignored transfer protocols designed to prevent falls among vulnerable residents.
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.