A Robertson County nursing home is facing renewed questions after two troubling incidents surfaced within days of each other, reigniting concerns tied to a patient death earlier this year. The Waters of Springfield made headlines last week when a man was left in his wheelchair on the side of a busy road for an entire day, along with all of his belongings, after the facility refused to readmit him following a hospital visit.
That same week, emergency crews were called back to the facility after another resident rolled his wheelchair out a back door and into a large ditch in front of the building. The man was taken to the hospital with injuries. Two incidents in a matter of days is the kind of pattern that tends to raise eyebrows, and in this case it raised enough of them that investigators started digging into the facility’s history.
What they found points back to February, when a resident named Chris Rich died at the facility not long after being admitted for physical therapy. His daughter, Olivia Courage, had been told he was recovering well and close to going home. Instead, he fell and hit his head in the bathroom, and the 911 call that followed painted a very different picture than what she says she was initially told by staff.
State records obtained by investigators show a troubling gap between what staff reported in the moment and what actually happened in that bathroom. The findings led to significant fines against the facility and a temporary halt on new admissions, though normal operations reportedly resumed not long after.
What the 911 Call Revealed
According to News Channel 5, a nurse told the 911 dispatcher that CPR was already in progress when she called for help, despite being nowhere near the room at the time. The dispatcher asked her to physically go check and call back once she was actually with the patient. When she got there, she confirmed he had passed and was cold to the touch.
State investigators later determined that CPR was never actually performed, even though the resident’s own directives called for it. Two nursing assistants who were reportedly in the room were not certified to administer CPR, which raises the obvious question of who exactly was supposed to be responsible for that duty.
Facility footage reportedly shows a roommate pressing a call button between 5:35 and 5:45 that morning after Rich went into the bathroom and didn’t come back out. Staff aren’t seen responding until around 6:07, and the 911 call wasn’t placed until 6:17, more than half an hour after the initial alert.
Regulatory Fallout and What Comes Next
Regulators fined the Waters of Springfield $26,000 and issued an “immediate jeopardy” designation, the most serious classification a nursing home can receive, which temporarily barred the facility from accepting new residents. That restriction has since been lifted.
The facility declined an on-camera interview but issued a statement saying resident safety and dignity remain a top priority. It also confirmed that staff directly involved in the 911 call are no longer employed there, though the director of nursing overseeing the incident is reportedly still employed at the facility in a different role.
State inspectors reportedly visited the facility again this week, and results from that inspection have not yet been made public.
Families researching nursing homes for loved ones may find it harder than expected to check a facility’s inspection history. According to reporting, Tennessee’s state health department recently removed public access to its online database of nursing home investigations and inspection reports, a change that has drawn its own share of questions.