Cycle 1
Health 2022-09-06 · Fire 2022-09-06
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Nashville, TN
West Meade Place
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
1000 St Luke Drive, Nashville, TN
(615) 352-3430
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-07-17
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
0.98
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.29
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
2.19
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
1.12
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
2.97
CMS adjusted total nurse staffing hours
Case-mix index
1.98
Higher values indicate more complex resident acuity
RN turnover
61%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,564
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.36
Baseline 18.89% · Performance 19.87% · Measure score 3.36 · Achievement 3.36 · Improvement 0
Healthcare-associated infections
0
Baseline 5.77% · Performance 8.37% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.31
Baseline 64.71% · Performance 58.33% · Measure score 1.31 · Achievement 1.31 · Improvement 1.10
Adjusted total nurse staffing
0
Baseline 3.42 hours · Performance 2.93 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.61% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 88 · Observed rate 11.36% · Lower 95% interval 8.03% |
| Discharge to community | 53.52% |
50.57%
3 pts better
|
No Different than the National Rate · Eligible stays 95 · Observed rate 51.58% · Lower 95% interval 43.57% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.3% |
95.27%
2 pts better
|
Numerator 72 · Denominator 74 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 74 |
| Discharge self-care score | 39.39% |
53.69%
14.3 pts worse
|
Numerator 13 · Denominator 33 |
| Discharge mobility score | 54.55% |
50.94%
3.6 pts better
|
Numerator 18 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 74 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.37% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 10.53% · Lower 95% interval 5.08% |
| Staff COVID-19 vaccination coverage | 1.03% |
8.2%
7.2 pts worse
|
Numerator 2 · Denominator 195 |
| Staff flu vaccination coverage | 33.61% |
42%
8.4 pts worse
|
Numerator 121 · Denominator 360 |
| Discharge function score | 45.45% |
56.45%
11 pts worse
|
Numerator 15 · Denominator 33 |
| Transfer of health information to provider | 94.12% |
95.95%
1.8 pts worse
|
Numerator 48 · Denominator 51 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 41.46% |
25.2%
16.3 pts better
|
Numerator 17 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.5 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.6
1.2 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.5 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
89.9%
7.5 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.6% · Q3 96.6% · Q4 96.5% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
3.6%
2.4 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 1.1% · Q4 1.2% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.3% |
11.8%
5.5 pts better
|
11.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 6.7% · Q3 3.9% · Q4 6.5% · 4Q avg 6.3% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
6.2%
1.6 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 6.7% · Q3 2.6% · Q4 3.9% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.5% |
32.2%
7.7 pts better
|
19.6%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 22.7% · Q3 24.4% · Q4 25.0% · 4Q avg 24.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.2% |
18.1%
12.9 pts better
|
16.7%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 3.3% · Q3 5.5% · Q4 3.6% · 4Q avg 5.2% · 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 | 12.9% |
19.9%
7 pts better
|
16.3%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.1% |
15.3%
10.2 pts better
|
14.9%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 7.5% · Q3 5.3% · Q4 5.4% · 4Q avg 5.1% · 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 0.9% · Q2 0.0% · Q3 0.7% · Q4 1.4% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.9%
0.2 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 0.0% · Q3 1.1% · Q4 2.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.4% |
20.2%
5.8 pts better
|
19.8%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 18.9% · Q3 7.8% · Q4 18.8% · 4Q avg 14.4% |
| Percentage of long-stay residents with pressure ulcers | 8.7% |
5.4%
3.3 pts worse
|
5.1%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 8.8% · Q3 9.9% · Q4 8.9% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
79.6%
14 pts better
|
81.7%
11.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 96.2% · Q3 96.3% · Q4 91.6% · 4Q avg 93.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.5% |
11.2%
2.7 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 8.7% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
1.6%
1.6 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.2% · Q3 3.3% · Q4 4.2% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.1% |
79.8%
19.3 pts better
|
79.7%
19.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.1% |
22.2%
6.1 pts better
|
23.9%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 15.9% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-11 · Fire 2019-12-11
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-01-30 · Fire 2019-01-30
2 health deficiencies
Top issue: Infection Control (1 deficiency)
11 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-09-06
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-09-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-17
D · Potential for more than minimal harm
2022-09-06
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 2022-11-17
D · Potential for more than minimal harm
2022-09-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-09-06
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-09-06
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-09-06
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-09-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-09-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-09-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-11-17
E · Potential for more than minimal harm
2019-12-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-01-25
D · Potential for more than minimal harm
2019-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-25
E · Potential for more than minimal harm
2019-01-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-03-01
E · Potential for more than minimal harm
2019-01-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-03-01
D · Potential for more than minimal harm
2019-01-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-03-01
D · Potential for more than minimal harm
2019-01-30
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 2019-03-01
D · Potential for more than minimal harm
2019-01-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-03-01
D · Potential for more than minimal harm
2019-01-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-03-01
D · Potential for more than minimal harm
2019-01-30
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-03-01
D · Potential for more than minimal harm
2019-01-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-03-01
D · Potential for more than minimal harm
2019-01-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-03-01
D · Potential for more than minimal harm
2019-01-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-03-01
D · Potential for more than minimal harm
2019-01-30
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 2019-03-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2022-09-06
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 2022-10-15
D · Potential for more than minimal harm
2022-09-06
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 2022-10-15
D · Potential for more than minimal harm
2022-09-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-09-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-09-06
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 2022-10-15
D · Potential for more than minimal harm
2022-09-06
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 2022-10-15
D · Potential for more than minimal harm
2022-09-06
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-10-15
D · Potential for more than minimal harm
2019-12-11
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 2020-01-08
D · Potential for more than minimal harm
2019-12-11
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 2020-01-08
D · Potential for more than minimal harm
2019-12-11
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 2020-01-08
D · Potential for more than minimal harm
2019-12-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-01-08
D · Potential for more than minimal harm
2019-12-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-01-08
D · Potential for more than minimal harm
2019-12-11
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 2020-01-08
D · Potential for more than minimal harm
2019-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-01-08
F · Potential for more than minimal harm
2019-01-30
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 2019-02-20
D · Potential for more than minimal harm
2019-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-02-20
Penalties and ownership
What sits behind the stars
Ownership
Barbara J Friedbauer Rev Trust
5% Or Greater Direct Ownership Interest · Organization
Friedbauer, Elise
5% Or Greater Direct Ownership Interest · Individual
Friedbaurer, John
5% Or Greater Direct Ownership Interest · Individual
Warren, Nancy
5% Or Greater Direct Ownership Interest · Individual
Alexandra Group Inc
General Partnership Interest · Organization
Friedbauer, Elise
Limited Partnership Interest · Individual
Friedbaurer, John
Limited Partnership Interest · Individual
Friedbaurer, Rober
Operational/Managerial Control · Individual
Friedbaurer, Rober
Corporate Director · Individual
Rehman, Faiza
Operational/Managerial Control · Individual
Shelly, Timothy
Operational/Managerial Control · Individual
Shelly, Timothy
Corporate Officer · Individual
Tennessee Healthcare Advisors, LLC
Operational/Managerial Control · Organization
Vincent, Brandon
Operational/Managerial Control · Individual
Warren, Nancy
Limited Partnership Interest · Individual
Wright, James
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
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
#2
Green Hills Center For Rehabilitation And Healing
Nashville, TN
2-star overall rating with 1-star inspections with $16,801 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
The Meadows
Nashville, TN
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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