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
Staffing
Hours and turnover
RN hours / resident day
0.98
Registered nurse staffing
LPN hours / resident day
1.21
Licensed practical nurse staffing
Aide hours / resident day
2.10
Nurse aide staffing
Weekend hours
3.81
Weekend nurse staffing
RN turnover
61%
Annual RN turnover
Total nurse turnover
65%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 12.9% |
19.9%
7 pts better
|
16.3%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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#3
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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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