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)
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
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
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.27
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.95
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,282
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9825
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.98
Baseline 22.30% · Performance 19.94% · Measure score 3.98 · Achievement 3.22 · Improvement 3.98
Healthcare-associated infections
0.67
Baseline 6.92% · Performance 7.63% · Measure score 0.67 · Achievement 0.67 · Improvement 0
Total nurse turnover
1.81
Baseline 69.77% · Performance 59.38% · Measure score 1.81 · Achievement 1.05 · Improvement 1.81
Adjusted total nurse staffing
1.89
Baseline 2.77 hours · Performance 3.49 hours · Measure score 1.89 · Achievement 1.43 · Improvement 1.89
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.66% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 2.94% · Lower 95% interval 5.94% |
| Discharge to community | 46.38% |
50.57%
4.2 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 38.6% · Lower 95% interval 35.54% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.87% |
95.27%
2.6 pts better
|
Numerator 46 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 51.72% |
53.69%
2 pts worse
|
Numerator 15 · Denominator 29 |
| Discharge mobility score | 51.72% |
50.94%
0.8 pts better
|
Numerator 15 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 2.13% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 47 · Adjusted rate 2.17% |
| Healthcare-associated infections requiring hospitalization | 7.63% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 9.52% · Lower 95% interval 4.08% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 94 |
| Staff flu vaccination coverage | 18.75% |
42%
23.2 pts worse
|
Numerator 15 · Denominator 80 |
| Discharge function score | 44.83% |
56.45%
11.6 pts worse
|
Numerator 13 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 32 |
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 · Adjusted 1.7 · Observed 2.0 · Expected 2.3 · Used in QM five-star |
| 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 · Adjusted 3.3 · Observed 3.8 · Expected 1.9 · Used in QM five-star |
| 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 · Q1 73.0% · Q2 63.3% · Q3 61.5% · Q4 48.7% · 4Q avg 61.6% |
| 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 · 4Q avg 91.6% |
| 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 · Q1 0.0% · Q2 1.3% · Q3 2.6% · Q4 2.6% · 4Q avg 1.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 10.6% · Q3 41.4% · Q4 57.1% · 4Q avg 26.8% |
| 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 · Q1 0.0% · Q2 5.4% · Q3 9.2% · Q4 5.5% · 4Q avg 5.2% |
| 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 · Q1 68.6% · Q2 65.8% · Q3 67.5% · Q4 59.5% · 4Q avg 65.3% |
| 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 · Q1 32.6% · Q2 35.6% · Q3 29.4% · Q4 19.1% · 4Q avg 29.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 13.9% · Q2 14.5% · Q3 16.5% · Q4 9.4% · 4Q avg 13.7% · Used in QM five-star |
| 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 · Q1 10.9% · Q2 14.5% · Q3 7.1% · Q4 4.3% · 4Q avg 9.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| 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 · Q1 1.4% · Q2 3.9% · Q3 0.0% · Q4 2.7% · 4Q avg 2.0% · Used in QM five-star |
| 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 · Q1 14.2% · Q2 20.4% · Q3 19.2% · Q4 25.9% · 4Q avg 20.0% |
| 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 · Q1 1.2% · Q2 2.4% · Q3 2.7% · Q4 4.4% · 4Q avg 2.7% · Used in QM five-star |
| 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 · Q1 35.2% · Q2 54.3% · Q3 64.4% · Q4 62.4% · 4Q avg 53.3% |
| 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 · Adjusted 19.1% · Observed 19.7% · Expected 11.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 3.9% · Q4 3.2% · 4Q avg 1.9% · Used in QM five-star |
| 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 · 4Q avg 77.4% |
| 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 · Adjusted 31.2% · Observed 32.8% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
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
Nearby options
Other facilities in reach
#1
The Mckendree Post Acute & Rehabilitation
Hermitage, TN
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $252,242 in total fines with 27 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Heartland
Nashville, TN
3-star overall rating with 2-star inspections with $7,901 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Life Care Center Of Old Hickory Village
Old Hickory, TN
3-star overall rating with 2-star inspections with $13,520 in total fines with 12 recent health deficiencies
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