Cycle 1
Health 2022-04-20 · Fire 2022-04-20
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Brentwood, TN
Somerfield At The Heritage
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
900 Heritage Way, Brentwood, TN
(615) 564-4900
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
66
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Life Care Services
Operator or chain grouping
Approved since
2007-06-26
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 4 health / 4 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
1.13
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.26
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.69
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.35
CMS adjusted RN staffing hours
Adjusted total hours
5.11
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,750
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9918
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.26
Baseline 18.47% · Performance 20.38% · Measure score 2.26 · Achievement 2.26 · Improvement 0
Healthcare-associated infections
2.96
Baseline 6.19% · Performance 6.95% · Measure score 2.96 · Achievement 2.96 · Improvement 0
Total nurse turnover
2.35
Baseline 42.86% · Performance 54.05% · Measure score 2.35 · Achievement 2.35 · Improvement 0
Adjusted total nurse staffing
7.92
Baseline 5.19 hours · Performance 5.33 hours · Measure score 7.92 · Achievement 7.92 · Improvement 1.85
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.52% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 13% · Lower 95% interval 8.05% |
| Discharge to community | 58.89% |
50.57%
8.3 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 61.36% · Lower 95% interval 50.1% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 63.83% |
95.27%
31.4 pts worse
|
Numerator 30 · Denominator 47 |
| Falls with major injury | 2.13% |
0.77%
1.4 pts worse
|
Numerator 1 · Denominator 47 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 14 · Denominator 28 |
| Discharge mobility score | 25% |
50.94%
25.9 pts worse
|
Numerator 7 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 2.13% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 47 · Adjusted rate 2.52% |
| Healthcare-associated infections requiring hospitalization | 6.95% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 4.55% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 122 |
| Staff flu vaccination coverage | 32.65% |
42%
9.4 pts worse
|
Numerator 48 · Denominator 147 |
| Discharge function score | 42.86% |
56.45%
13.6 pts worse
|
Numerator 12 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 29.17% |
25.2%
4 pts better
|
Numerator 7 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
1.6
1.4 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.9%
10.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.5% |
94.5%
About the same
|
95.5%
1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.6%
0.8 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.0% · Q3 3.7% · Q4 5.5% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
11.8%
10 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.3% · Q3 2.2% · Q4 0.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
6.2%
0.9 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.7% · Q3 7.1% · Q4 6.8% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.4% |
32.2%
22.8 pts better
|
19.6%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 11.6% · Q3 9.5% · Q4 6.8% · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
18.1%
9.2 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 11.5% · Q3 8.8% · Q4 6.1% · 4Q avg 8.9% · 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 | 15.8% |
19.9%
4.1 pts better
|
16.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 13.4% · Q3 14.9% · Q4 19.2% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
15.3%
1.7 pts better
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 9.8% · Q3 10.0% · Q4 11.9% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
0.9%
1.7 pts worse
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 2.1% · Q3 1.8% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.9%
1.9 pts better
|
1.7%
1.7 pts better
|
Long 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 long-stay residents with new or worsened bowel or bladder incontinence | 12.3% |
20.2%
7.9 pts better
|
19.8%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 8.8% · Q3 18.3% · Q4 11.7% · 4Q avg 12.3% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
5.4%
2.9 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 3.6% · Q4 3.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
79.6%
17.9 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 97.5% · Q3 98.4% · Q4 96.4% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
11.2%
0.9 pts worse
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 10.4% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.6%
0.9 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.8% |
79.8%
9 pts better
|
79.7%
9.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.1% |
22.2%
11.9 pts worse
|
23.9%
10.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.1% · Observed 27.1% · Expected 19.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-18 · Fire 2019-12-18
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-01-29 · Fire 2019-01-29
4 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-04-20
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-04-19
D · Potential for more than minimal harm
2019-12-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-23
D · Potential for more than minimal harm
2019-12-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-01-29
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2019-02-18
D · Potential for more than minimal harm
2019-01-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-02-18
D · Potential for more than minimal harm
2019-01-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-02-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2022-04-20
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-04-25
D · Potential for more than minimal harm
2022-04-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-05-03
D · Potential for more than minimal harm
2019-01-29
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-02-18
D · Potential for more than minimal harm
2019-01-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-02-18
D · Potential for more than minimal harm
2019-01-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-02-18
D · Potential for more than minimal harm
2019-01-29
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 2019-02-18
Penalties and ownership
What sits behind the stars
Ownership
Heritage Investment Partners LLC
5% Or Greater Direct Ownership Interest · Organization
Harpeth Green Properties, LLC
5% Or Greater Direct Ownership Interest · Organization
Lcs Tn LLC
5% Or Greater Direct Ownership Interest · Organization
Bird, John
Corporate Officer · Individual
Cooper, John
5% Or Greater Indirect Ownership Interest · Individual
Cooper, John
Corporate Officer · Individual
Harpeth Green Properties, LLC
5% Or Greater Indirect Ownership Interest · Organization
Jordan, Dahlen
Operational/Managerial Control · Individual
Lahey, Daniel
Corporate Officer · Individual
Lcs Holding Company LLC
5% Or Greater Indirect Ownership Interest · Organization
Life Care Companies LLC
5% Or Greater Indirect Ownership Interest · Organization
Life Care Services Communities, LLC
5% Or Greater Indirect Ownership Interest · Organization
Lowe, Whitson
5% Or Greater Indirect Ownership Interest · Individual
Oak Investment Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Pinnacle Bank
5% Or Greater Security Interest · Organization
Pinnacle Bank
5% Or Greater Mortgage Interest · Organization
Rci Legacy Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Redwood Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Shaw, Gelynna
Corporate Officer · Individual
Sherman, Devin
Operational/Managerial Control · Individual
Tagatz, Jon
Operational/Managerial Control · Individual
Uhlemann, Bridgette
Corporate Officer · Individual
Victor, Jason
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Nhc Place At Cool Springs
Franklin, TN
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Bethany Center For Rehabilitation And Healing LLC
Nashville, TN
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Woodcrest At Blakeford
Nashville, TN
5-star overall rating with 3-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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