9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Nashville, TN
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
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
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
RN hours / resident day
0.55
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.91
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
3.69
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.99
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.22
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0
Baseline 6.11% · Performance 8.33% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 56.07% · Performance 62.50% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.02 hours · Performance 3.11 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.79% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 10.34% · Lower 95% interval 7.4% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 96% |
95.27%
0.7 pts better
|
Numerator 24 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 25 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.34% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 14.81% · Lower 95% interval 4.35% |
| Staff COVID-19 vaccination coverage | 70.91% |
8.2%
62.7 pts better
|
Numerator 78 · Denominator 110 |
| Staff flu vaccination coverage | 26.38% |
42%
15.6 pts worse
|
Numerator 43 · Denominator 163 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
| 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 · Q1 93.9% · Q2 70.5% · Q3 18.8% · Q4 34.6% · 4Q avg 56.5% |
| 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 · 4Q avg 96.2% |
| 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 · Q1 1.0% · Q2 2.1% · Q3 3.5% · Q4 3.7% · 4Q avg 2.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 9.5% · Q3 46.2% · Q4 65.0% · 4Q avg 29.1% |
| 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 · Q1 6.6% · Q2 4.5% · Q3 0.0% · Q4 2.8% · 4Q avg 3.7% |
| 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 · Q1 30.8% · Q2 33.0% · Q3 31.2% · Q4 32.0% · 4Q avg 31.7% |
| 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 · Q1 8.9% · Q2 3.8% · Q3 8.8% · Q4 7.1% · 4Q avg 7.2% · 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 | 32.2% |
19.9%
12.3 pts worse
|
16.3%
15.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · 4Q avg 32.2% · Used in QM five-star |
| 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 · Q1 10.1% · Q2 12.2% · Q3 39.3% · Q4 41.7% · 4Q avg 24.1% · Used in QM five-star |
| 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 · Q1 0.9% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| 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 · Q1 4.1% · Q2 3.2% · Q3 1.2% · Q4 3.9% · 4Q avg 3.1% · Used in QM five-star |
| 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 · Q1 4.6% · Q2 7.4% · Q3 11.2% · Q4 18.4% · 4Q avg 10.0% |
| 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 · Q1 7.6% · Q2 10.2% · Q3 7.5% · Q4 5.3% · 4Q avg 7.8% · Used in QM five-star |
| 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 · Q1 54.3% · Q2 58.6% · Q3 28.3% · Q4 13.5% · 4Q avg 38.7% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 37.7% |
Survey summary
Top issue: Resident Rights (4 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-10-12
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-12
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-10-12
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-10-12
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-10-12
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
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-12
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-12
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-12
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-12
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2023-10-12
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
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-12
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-06-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-28
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
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-06-28
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-06-28
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2019-06-28
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-06-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-05-18
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-11
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
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-12-09
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
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-12-09
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-09
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-09
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-27
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-12-09
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
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
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
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-09
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-09
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-09
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
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-26
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-09-26
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-09-29
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
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-29
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
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
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-29
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-29
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-06-30
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2019-06-30
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
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
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
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-06-02
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-06-02
Penalties and ownership
Fine · fine $15,512
Fine
Fine · fine $95,384
Fine
Payment Denial · denial start 2024-11-14 · 25 days
25 day denial
Fine · fine $11,346
Fine
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
5% Or Greater Security Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Security Interest · Organization
Nearby options
Whites Creek, TN
4-star overall rating with 4-star inspections with 3 recent health deficiencies
Nashville, TN
0-star overall rating with 0-star inspections with $125,508 in total fines
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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