Cycle 1
Health 2023-08-30 · Fire 2023-08-30
9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Nashville, TN
Eaton Creek Post Acute
0-star overall rating with 0-star inspections with Special Focus status with $122,242 in total fines with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
4343 Ashland City Highway, Nashville, TN
(615) 726-0492
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
97
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1991-03-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.55
Registered nurse staffing
LPN hours / resident day
0.91
Licensed practical nurse staffing
Aide hours / resident day
2.23
Nurse aide staffing
Weekend hours
2.99
Weekend nurse staffing
RN turnover
46%
Annual RN turnover
Total nurse turnover
62%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 56.5% |
89.9%
33.4 pts worse
|
93.4%
36.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
94.5%
1.7 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.6%
1.1 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 29.1% |
11.8%
17.3 pts worse
|
11.4%
17.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.7% |
6.2%
2.5 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.7% |
32.2%
0.5 pts better
|
19.6%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 7.2% |
18.1%
10.9 pts better
|
16.7%
9.5 pts better
|
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 | 32.2% |
19.9%
12.3 pts worse
|
16.3%
15.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.1% |
15.3%
8.8 pts worse
|
14.9%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
1.9%
1.2 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.0% |
20.2%
10.2 pts better
|
19.8%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.8% |
5.4%
2.4 pts worse
|
5.1%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 38.7% |
79.6%
40.9 pts worse
|
81.7%
43 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 37.7% |
79.8%
42.1 pts worse
|
79.7%
42 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-05-21 · Fire 2019-05-21
24 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2018-04-25 · Fire 2018-04-25
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-08-30
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-08-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-12
D · Potential for more than minimal harm
2019-05-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-21
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 2019-08-01
D · Potential for more than minimal harm
2019-05-21
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-21
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2019-06-28
D · Potential for more than minimal harm
2019-05-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-06-28
D · Potential for more than minimal harm
2018-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-05-18
Inspection history
Recent health citations
G · Actual harm
2025-02-06
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 2025-03-11
L · Immediate jeopardy
2024-11-07
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 2024-12-09
L · Immediate jeopardy
2024-11-07
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-12-09
L · Immediate jeopardy
2024-11-07
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2024-12-09
L · Immediate jeopardy
2024-11-07
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-12-09
K · Immediate jeopardy
2024-11-07
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 2024-12-09
K · Immediate jeopardy
2024-11-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-09
K · Immediate jeopardy
2024-11-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-09
J · Immediate jeopardy
2024-11-07
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 2024-06-27
D · Potential for more than minimal harm
2024-11-07
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-07
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 2024-12-09
D · Potential for more than minimal harm
2024-11-07
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-07
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-12-09
D · Potential for more than minimal harm
2024-11-07
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 2024-12-09
J · Immediate jeopardy
2023-08-30
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 2022-09-26
J · Immediate jeopardy
2023-08-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-09-26
D · Potential for more than minimal harm
2023-08-30
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-30
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 2023-09-29
D · Potential for more than minimal harm
2023-08-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-30
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-30
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-29
D · Potential for more than minimal harm
2019-05-21
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-06-30
D · Potential for more than minimal harm
2019-05-21
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2019-06-30
D · Potential for more than minimal harm
2019-05-21
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-06-30
D · Potential for more than minimal harm
2019-05-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-06-30
D · Potential for more than minimal harm
2019-05-21
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 2019-06-30
D · Potential for more than minimal harm
2019-05-21
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 2019-06-30
G · Actual harm
2018-04-25
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 2018-06-02
D · Potential for more than minimal harm
2018-04-25
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-06-02
Penalties and ownership
What sits behind the stars
$15,512
2025-02-06
Fine
Fine · fine $15,512
Fine
$95,384
2024-11-07
Fine
Fine · fine $95,384
Fine
$0
2024-11-07
Payment Denial
Payment Denial · denial start 2024-11-14 · 25 days
25 day denial
$11,346
2023-08-30
Fine
Fine · fine $11,346
Fine
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Branch Banking & Trust Company
5% Or Greater Security Interest · Organization
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hearns, Edward
Operational/Managerial Control · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Providence Administrative Consulting Services Inc
Operational/Managerial Control · Organization
Truist Bank
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Whites Creek Wellness And Rehabilitation Center
Whites Creek, TN
4-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Advanced Health Care Of Nashville
Nashville, TN
0-star overall rating with 0-star inspections with $125,508 in total fines
#3
The Health Center At Richland Place
Nashville, TN
3-star overall rating with 2-star inspections with $56,378 in total fines with 9 recent health deficiencies
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