Nhc Healthcare, Springfield

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

past, but I ask and hope you will forgive me also . Review of the Police Incident Report Form dated [DATE REDACTED] at 10:22 AM, revealed .Address of Incident: [Facility #1].Offense Number One.Sexual Battery.Offender #1.[Named Visitor P].Victim.[Named Resident #9].On.XXX[DATE REDACTED] at 1017 [10:17 AM] hours, I was dispatched to [Named Facility #1].in regards to Sexual Assault between a patient and a visitor.[Named Administrator] , who advised she has a resident, [Named Resident #9] who reported being sexually assaulted.[Named Resident #9] stated it had been happening for at least the last month and a half.[Named Administrator] stated that [Named Resident #9] has had a visitor, a family friend, [Named Visitor P] visit every Monday, Wednesday, and Friday. During the times [Named Visitor P] visits, [Named Administrator] stated she was told by [Named Resident #9] that [Named Visitor P] made numerous attempts to kiss her on

the mouth, touching her on the thigh and touching her breast.[Named Resident #9] is alert and oriented and is in good mental health.[Named Family Member O] advised she had a conversation with [Named Resident #9] on [DATE REDACTED] at [Facility #1].[Named Resident #9] told her that she was being touched inappropriately and that [Named Visitor P] leaned in for a kiss and grabbed her breast.touched inappropriately every Monday, Wednesday, and Friday.the incident occurs at bingo also.she used to be comfortable with her living arrangement but is not anymore due to [Named Visitor P]. She is in fear that he will still find his way into [Facility #1].[Named Resident #9] stated she never provided consent to being touched inappropriately.[Named Family Member O].stated that she made contact with [Named Lieutenant #1].he spoke with [Named Visitor P] and.admitted to touching and sexually assaulting [Named Resident #9].He admitted that this past Friday he was with her at [Facility #1] and that they were playing bingo. He stated that he was holding one side of the card and she was holding the other side. He stated that he leaned over so she could mark the box

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Healthcare, Springfield

608 8th Ave East Springfield, TN 37172

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

revealed, .I put [Named Resident #1] in bed cause [because] He was ready to lay down. I went to check on him to make sure he was still in bed. I knock on the door and find [Named Resident #6] on top of him. I asked him to get down off of him and he refused to get down off of him. I stay by the door hollering for the nurse to come down to the room to help to get [Named Resident #6] off of his roommate .? During a telephone interview on 9/8/2025 at 12:21 PM, LPN A stated, .I was called by a tech [CNA C].the CNA was

in shock.she kept saying come, come.I ran to her.I saw [Resident #6] on top of him [Resident #1] humping him, he [Resident #6] was naked from waist down, I turned the light on, I was saying get off of him.he was fighting us.he elbowed me.all the nurses in the building came to help me. During an interview on 9/9/2025 at 12:42 PM, the DOSS was asked as the Abuse Coordinator what would he want to make sure happened with (Named Resident #1). The DOSS stated, .make sure his psychosocial needs were met . The DOSS acknowledged the investigation should include statements from the staff that witnessed the incident, should be reported to the state in 2 hours, and follow up investigation due on the 5th day.??? During an interview

on 9/12/2025 at 3:30 PM, the Administrator stated, .I don't know that we talked about it [Incident between Resident #1 and Resident #6] in QAPI [Quality Assurance Performance Improvement] because we didn't report it [referring to not reporting to the state agency] .if we have a reportable, we would discuss the incident . She stated, .behaviors are discussed in morning meetings .from the information I got that night [referring to Resident #1, Resident #6's incident] I do not feel it should have been reported .?? Refer to F-F600 and F-F610?

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Healthcare, Springfield

608 8th Ave East Springfield, TN 37172

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

attempted to climb in bed with [Named Resident #1] and did not want to exit the bed, requiring multiple staff members to assist him. [Named Resident #1] was assessed and had no injuries. [Named Resident #6] was escorted to the dining room where he was notably confused. When questioned by Administrator he stated that he had not seen his roommate for several hours today and had been on the porch for most of the day.

Room change was provided for [Named Resident #1] and an inpatient psych referral was sent for [Named Resident #6] . 4. Review of the facility investigation dated 9/17/2024, revealed the following: a. A typed statement completed by the Administrator (not present during the allegation of sexual abuse) dated 9/17/2024. The Administrator's typed statement referred to interviews with staff that revealed [Named Resident #6] got into bed with his roommate and did not want to exit the bed. No time was noted in the typed statement. The facility investigation included only one written statement from Certified Nursing Assistant (CNA) C. No further staff interviews were provided with the investigation. The Administrator's statement noted [Named Resident #1] was assessed and had no injuries. The progress notes dated 9/17/2024 did not contain any physical assessment for Resident #1. No incident report was completed for Resident #1 or Resident #6. b. Review of the Director of Social Services (DOSS) (Abuse Coordinator)'s progress notes for Resident #6 dated 9/17/2024, revealed no documentation related to the incident which occurred with his roommate (Resident #1). Review of Resident #1's progress notes revealed no follow up note from the DOSS. During an interview on 9/9/2025 at 12:42 PM, DOSS was asked what should be included in a facility investigation when a resident-to-resident altercation happens in the facility. SSD stated, .the Administrator got the statements .I am the Abuse Coordinator .Administrator and I work on investigations together .the Administrator let me know about the incident . The DOSS was asked when the incident occurred between Resident #1 and Resident #6. DOSS stated, .I don't know the exact time .I don't recall when the Administrator called me .I wasn't involved in getting statements from staff .I didn't interview [Named Resident #1] . SSD was asked as the Abuse Coordinator what would he want to make sure happened with (Named Resident #1). SSD stated, .make sure his psychosocial needs were met . SSD confirmed no progress note was completed about the incident or why [Named Resident #1] changed rooms. SSD confirmed the investigation should include statements from the staff that witnessed the incident and the follow up investigation was due on the 5th day.???? During an interview on 9/12/2025 at 3:30 PM,

the Administrator confirmed that the incident between Resident #1 and Resident #6 was not reported to the state agency. The Administrator was unable to provide any further statements from the employees that witnessed the incident between Resident #1 and Resident #6 on 9/17/2024. Refer to F-F600 and F-F609

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Healthcare, Springfield

608 8th Ave East Springfield, TN 37172

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited NHC HEALTHCARE, SPRINGFIELD in SPRINGFIELD, TN for a deficiency under regulatory tag F-F0726 during a complaint investigation conducted on 2025-09-15.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.

Actual harm to residents was documented as a result of this deficiency.

This was one of 4 deficiencies cited during this inspection of NHC HEALTHCARE, SPRINGFIELD.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-11.