Mount Juliet, TN

Cedar Creek Post Acute

1-star overall rating with 1-star inspections with $211,244 in total fines with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

2650 North Mt Juliet Road, Mount Juliet, TN

(615) 758-4100

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

106

Certified beds

Average residents

88

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Pacs Group

Operator or chain grouping

Approved since

2002-01-07

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.45

Registered nurse staffing

LPN hours / resident day

1.27

Licensed practical nurse staffing

Aide hours / resident day

2.23

Nurse aide staffing

Weekend hours

3.08

Weekend nurse staffing

RN turnover

36%

Annual RN turnover

Total nurse turnover

72%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.7
1.6
0.1 pts worse
1.9
0.2 pts better
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 3.3
1.6
1.7 pts worse
1.8
1.5 pts worse
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 61.6%
89.9%
28.3 pts worse
93.4%
31.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 91.6%
94.5%
2.9 pts worse
95.5%
3.9 pts worse
Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury 1.6%
3.6%
2 pts better
3.3%
1.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 26.8%
11.8%
15 pts worse
11.4%
15.4 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 5.2%
6.2%
1 pts better
5.4%
0.2 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 65.3%
32.2%
33.1 pts worse
19.6%
45.7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 29.0%
18.1%
10.9 pts worse
16.7%
12.3 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained 0.0%
0.1%
0.1 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened 13.7%
19.9%
6.2 pts better
16.3%
2.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 9.2%
15.3%
6.1 pts better
14.9%
5.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.3%
0.9%
0.6 pts better
1.0%
0.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 2.0%
1.9%
0.1 pts worse
1.7%
0.3 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 20.0%
20.2%
0.2 pts better
19.8%
0.2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 2.7%
5.4%
2.7 pts better
5.1%
2.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 53.3%
79.6%
26.3 pts worse
81.7%
28.4 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 19.1%
11.2%
7.9 pts worse
12.0%
7.1 pts worse
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 1.9%
1.6%
0.3 pts worse
1.6%
0.3 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 77.4%
79.8%
2.4 pts worse
79.7%
2.3 pts worse
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 31.2%
22.2%
9 pts worse
23.9%
7.3 pts worse
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-30 · Fire 2025-07-30

5 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

8 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Cycle 2 Health 2021-12-15 · Fire 2021-12-15

17 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2020-03-10 · Fire 2020-03-10

12 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-07-30

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2025-12-02

E · Potential for more than minimal harm 2025-07-30

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-07-30

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2025-12-12

D · Potential for more than minimal harm 2025-07-30

E20 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures including evacuation.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-07-30

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-07-30

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-07-30

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-07-30

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-11-19

E · Potential for more than minimal harm 2021-12-15

K232 · Egress Deficiencies

Fire Safety

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Corrected 2022-01-15

D · Potential for more than minimal harm 2020-03-10

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2020-04-24

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-07-30

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-07-30

F569 · Resident Rights Deficiencies

Health

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-07-30

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-07-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-29

D · Potential for more than minimal harm 2025-07-30

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2025-08-29

K · Immediate jeopardy 2024-04-11

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-04-25

K · Immediate jeopardy 2024-04-11

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-25

J · Immediate jeopardy 2024-04-11

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-04-25

D · Potential for more than minimal harm 2024-04-11

F622 · Resident Rights Deficiencies

Health

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected 2024-04-25

D · Potential for more than minimal harm 2024-04-11

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-04-25

D · Potential for more than minimal harm 2024-04-11

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-04-25

D · Potential for more than minimal harm 2024-04-11

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Not marked corrected

D · Potential for more than minimal harm 2023-07-11

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-07-31

D · Potential for more than minimal harm 2023-04-06

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2023-05-12

F · Potential for more than minimal harm 2021-12-15

F809 · Nutrition and Dietary Deficiencies

Health

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Corrected 2022-01-18

F · Potential for more than minimal harm 2021-12-15

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-01-18

E · Potential for more than minimal harm 2021-12-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-01-18

D · Potential for more than minimal harm 2021-12-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2022-01-18

D · Potential for more than minimal harm 2021-12-15

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2022-01-18

D · Potential for more than minimal harm 2021-12-15

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2022-01-18

D · Potential for more than minimal harm 2021-12-15

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2022-01-18

D · Potential for more than minimal harm 2021-12-15

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2022-01-18

D · Potential for more than minimal harm 2021-12-15

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2022-01-18

D · Potential for more than minimal harm 2021-12-15

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2022-01-18

J · Immediate jeopardy 2020-03-10

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2020-04-24

J · Immediate jeopardy 2020-03-10

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2020-04-24

J · Immediate jeopardy 2020-03-10

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2020-04-24

J · Immediate jeopardy 2020-03-10

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2020-04-24

J · Immediate jeopardy 2020-03-10

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2020-04-24

J · Immediate jeopardy 2020-03-10

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2020-04-24

J · Immediate jeopardy 2020-03-10

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2020-04-24

J · Immediate jeopardy 2020-03-10

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2020-04-24

E · Potential for more than minimal harm 2020-03-10

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2020-04-24

D · Potential for more than minimal harm 2020-03-10

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2020-04-24

Penalties and ownership

What sits behind the stars

$211,244 2024-04-11

Fine

Fine · fine $211,244

Fine

$0 2024-04-11

Payment Denial

Payment Denial · denial start 2024-04-17 · 8 days

8 day denial

Ownership

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