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Complaint Investigation

Nhc Healthcare, Springfield

September 15, 2025 · Springfield, TN · 608 8th Ave East
Citations 4
CMS Rating 2/5
Beds 107
Provider ID 445088
Healthcare Facility
Nhc Healthcare, Springfield
Springfield, TN  ·  View full profile →
Inspection Summary

NHC HEALTHCARE, SPRINGFIELD in SPRINGFIELD, TN — inspection on September 15, 2025.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Immediate Jeopardy

Review of the Police Incident Report Form dated [DATE] 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] 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] 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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Healthcare, Springfield

608 8th Ave East Springfield, TN 37172

SUMMARY STATEMENT OF DEFICIENCIES

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?

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Healthcare, Springfield

608 8th Ave East Springfield, TN 37172

SUMMARY STATEMENT OF DEFICIENCIES

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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Nhc Healthcare, Springfield

608 8th Ave East Springfield, TN 37172

SUMMARY STATEMENT OF DEFICIENCIES

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.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SPRINGFIELD, TN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from NHC HEALTHCARE, SPRINGFIELD or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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