Cycle 1
Health 2022-09-21 · Fire 2022-09-21
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Nashville, TN
The Meadows
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
8044 Coley Davis Road, Nashville, TN
(615) 646-4466
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
113
Certified beds
Average residents
93
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-04-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.94
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.33
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.80
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.95
CMS adjusted RN staffing hours
Adjusted total hours
3.86
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,872
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9914
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.06
Baseline 17.95% · Performance 18.16% · Measure score 7.06 · Achievement 7.06 · Improvement 0
Healthcare-associated infections
6.31
Baseline 6.05% · Performance 5.95% · Measure score 6.31 · Achievement 6.31 · Improvement 0.46
Total nurse turnover
0.01
Baseline 66.67% · Performance 64.55% · Measure score 0.01 · Achievement 0 · Improvement 0.01
Adjusted total nurse staffing
1.94
Baseline 4.09 hours · Performance 3.63 hours · Measure score 1.94 · Achievement 1.94 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.36% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 13.13% · Lower 95% interval 7.93% |
| Discharge to community | 52.47% |
50.57%
1.9 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 44.3% · Lower 95% interval 41.1% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.83% |
95.27%
0.6 pts better
|
Numerator 69 · Denominator 72 |
| Falls with major injury | 1.39% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 72 |
| Discharge self-care score | 70.59% |
53.69%
16.9 pts better
|
Numerator 36 · Denominator 51 |
| Discharge mobility score | 70.59% |
50.94%
19.7 pts better
|
Numerator 36 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 72 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.95% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 1.75% · Lower 95% interval 3.04% |
| Staff COVID-19 vaccination coverage | 48.48% |
8.2%
40.3 pts better
|
Numerator 64 · Denominator 132 |
| Staff flu vaccination coverage | 54.27% |
42%
12.3 pts better
|
Numerator 127 · Denominator 234 |
| Discharge function score | 76.47% |
56.45%
20 pts better
|
Numerator 39 · Denominator 51 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 93.75% |
96.28%
2.5 pts worse
|
Numerator 30 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 39.62% |
25.2%
14.4 pts better
|
Numerator 21 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.1 |
1.6
1.5 pts better
|
1.8
1.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.1 · Observed 0.1 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
89.9%
8.9 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.6% · Q4 97.6% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
94.5%
4.4 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.6%
0.2 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.5% · Q3 3.5% · Q4 1.2% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
11.8%
11 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
6.2%
4.2 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.4% · Q3 1.5% · Q4 1.6% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
32.2%
14.2 pts better
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 17.5% · Q3 16.9% · Q4 14.1% · 4Q avg 18.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
18.1%
11.9 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.3% · Q3 6.6% · Q4 8.3% · 4Q avg 6.2% · 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 | 15.0% |
19.9%
4.9 pts better
|
16.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.2% |
15.3%
8.1 pts better
|
14.9%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 7.7% · Q3 5.3% · Q4 5.5% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 1.0% · Q4 1.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.9%
1 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.7% |
20.2%
2.5 pts better
|
19.8%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 25.9% · Q3 12.5% · Q4 14.5% · 4Q avg 17.7% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
5.4%
3.8 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.8% · Q3 2.3% · Q4 1.6% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.6% |
79.6%
13 pts better
|
81.7%
10.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.4% · Q2 92.2% · Q3 91.5% · Q4 95.4% · 4Q avg 92.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.2% |
11.2%
4 pts better
|
12.0%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.2% · Observed 6.6% · Expected 10.2% · Used in QM five-star |
| 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 | 91.0% |
79.8%
11.2 pts better
|
79.7%
11.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.8% |
22.2%
6.4 pts better
|
23.9%
8.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 13.1% · Expected 19.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-06-05 · Fire 2019-06-05
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2018-08-01 · Fire 2018-08-01
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-09-21
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 2022-10-19
D · Potential for more than minimal harm
2022-09-21
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 2022-10-19
D · Potential for more than minimal harm
2022-09-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-19
D · Potential for more than minimal harm
2022-09-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-10-19
D · Potential for more than minimal harm
2022-09-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-19
D · Potential for more than minimal harm
2022-09-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-19
D · Potential for more than minimal harm
2022-09-21
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 2022-10-19
D · Potential for more than minimal harm
2019-06-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-06-05
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2019-06-21
D · Potential for more than minimal harm
2019-06-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-05
D · Potential for more than minimal harm
2019-06-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-06-04
D · Potential for more than minimal harm
2019-06-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-06-04
D · Potential for more than minimal harm
2018-08-01
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 2018-09-07
D · Potential for more than minimal harm
2018-08-01
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-09-07
C · Minimal harm
2018-08-01
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2018-08-24
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-09-21
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 2022-11-04
F · Potential for more than minimal harm
2022-09-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-09-21
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 2022-11-04
D · Potential for more than minimal harm
2022-09-21
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 2022-11-04
D · Potential for more than minimal harm
2022-09-21
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-09-21
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 2022-11-04
D · Potential for more than minimal harm
2022-09-21
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 2022-11-04
D · Potential for more than minimal harm
2022-09-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-09-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-11-04
E · Potential for more than minimal harm
2019-06-05
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
C · Minimal harm
2019-06-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-06-30
D · Potential for more than minimal harm
2018-08-01
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 2018-08-24
D · Potential for more than minimal harm
2018-08-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2018-08-24
D · Potential for more than minimal harm
2018-08-01
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 2018-08-24
D · Potential for more than minimal harm
2018-08-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-08-24
D · Potential for more than minimal harm
2018-08-01
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 2018-08-24
Penalties and ownership
What sits behind the stars
Ownership
Lakeshore Estates, Inc.
5% Or Greater Direct Ownership Interest · Organization
Acuff, Emily
Corporate Director · Individual
Acuff, Emily
Corporate Officer · Individual
Hilbers, Zach
W-2 Managing Employee · Individual
Outhier, Barbara
Corporate Director · Individual
Outhier, Barbara
Corporate Officer · Individual
Purkey, Roy
Corporate Director · Individual
Robinson, John
Corporate Director · Individual
Robinson, John
Corporate Officer · Individual
Shelly, Timothy
Operational/Managerial Control · Individual
Thweatt, John
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Nhc Place At The Trace
Nashville, TN
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
West Meade Place
Nashville, TN
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 10 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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