Special Focus Facility Inspection > 2 years ago

Overview

Address
4343 ASHLAND CITY HIGHWAY, NASHVILLE, TN 37218
Phone
6157260492
Certified beds
124
Avg daily residents
97 (78% of beds filled)
Ownership
For-profit corporation
Provider type
Medicare and Medicaid
Medicare/Medicaid since
1991-03-08
Setting
Urban
Rating not available

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
Footnote 18.
— Not Available
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
Footnote 18.
— Not Available
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
Footnote 18.
— Not Available
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
Footnote 18.
— Not Available

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
3.69 4.42 3.22 ≥ 3.48
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
0.55 0.77 0.48 ≥ 0.55 Below floor
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
0.91 0.98 0.80
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
2.23 2.66 1.95
Licensed (RN + LPN)
Combined licensed nurse coverage.
1.46
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
0.01

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
2.99
hrs / resident / day
RN (weekend)
0.35
hrs / resident / day
Total nurse (adjusted, weekend)
2.62
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
61.9%
annual
RN turnover
45.5%
annual
Administrators departed
1
last 12 months

Resident acuity

Nursing Case-Mix Index
1.56
higher acuity than avg
Case-Mix Index Ratio
1.14
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2023-08-30 9 9 9 68 1 68
Cycle 2/3 (prior) 2019-05-21 24 6 18 1,100 1 1,100
Total weighted health score
326.0
lower is better

Deficiencies (35)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

23 D/E/F Actual harm — potential for minor
2 G/H/I Actual harm
10 J/K/L Immediate jeopardy
Tag Description Scope/Severity Survey date Corrected
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. G 2025-02-06 2025-03-11
0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. L 2024-11-07 2024-12-09
0602 Protect each resident from the wrongful use of the resident's belongings or money. D 2024-11-07 2024-12-09
0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. K 2024-11-07 2024-12-09
0610 Respond appropriately to all alleged violations. K 2024-11-07 2024-12-09
0622 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. D 2024-11-07 2024-12-09
0625 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. D 2024-11-07 2024-12-09
0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. D 2024-11-07 2024-12-09
0677 Provide care and assistance to perform activities of daily living for any resident who is unable. D 2024-11-07 2024-12-09
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. D 2024-11-07 2024-12-09
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. D 2024-11-07 2024-12-09
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. J 2024-11-07 2024-06-27
0692 Provide enough food/fluids to maintain a resident's health. K 2024-11-07 2024-12-09
0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. D 2024-11-07 2024-12-09
0727 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. D 2024-11-07 2024-12-09
0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. L 2024-11-07 2024-12-09
0837 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. L 2024-11-07 2024-12-09
0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. L 2024-11-07 2024-12-09
0565 Honor the resident's right to organize and participate in resident/family groups in the facility. D 2023-08-30 2023-09-29
0584 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. D 2023-08-30 2023-09-29
0610 Respond appropriately to all alleged violations. D 2023-08-30 2023-09-29
0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. D 2023-08-30 2023-09-29
0625 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. D 2023-08-30 2023-09-29
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. D 2023-08-30 2023-09-29
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. J 2023-08-30 2022-09-26
0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. J 2023-08-30 2022-09-26
0880 Provide and implement an infection prevention and control program. D 2023-08-30 2023-09-29
0583 Keep residents' personal and medical records private and confidential. D 2019-05-21 2019-06-30
0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. D 2019-05-21 2019-06-30
0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted D 2019-05-21 2019-06-30
0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. D 2019-05-21 2019-06-30
0761 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. D 2019-05-21 2019-06-30
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. D 2019-05-21 2019-06-30
0658 Ensure services provided by the nursing facility meet professional standards of quality. D 2018-04-25 2018-06-02
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. G 2018-04-25 2018-06-02

Penalties (4)

Fines issued
3
last 3 years
Total fines
$122,242
Payment denials
1
Date Type Fine amount
2023-08-30 Fine $11,346
2025-02-06 Fine $15,512
2024-11-07 Fine $95,384
2024-11-07 Payment Denial

Source: CMS Nursing Home Penalties.

Financial Health (FY 2023)

Payer mix (share of resident days)

Medicare 2.8% Medicaid 80.2% Other 17.0%

Operating performance

Operating Margin
-23.4%
Total Margin
-4.7%
Occupancy Rate
81.7%
Cost per Resident Day
$20

Revenue & costs

Net Patient Revenue
$9.6M
Total Costs
$741K
Net Income
-$533K

Balance sheet

Total Assets
$5.2M
Total Liabilities
$13.8M
Fund Balance
-$8.6M
Current Ratio
0.13

Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Chain: PACS GROUP

Chain ID
690
Facilities in chain
264
Legal business name
NASHVILLE SNF HEALTHCARE LLC
Chain-average star ratings (for peer context)
Overall
2.9
Health
2.6
Staffing
2.4
QM
4.2

Owner / manager organizations (6)

Organization Role Association
PROVIDENCE GROUP NH, LLC 5% OR GREATER DIRECT OWNERSHIP INTEREST since 02/01/2025
PACS GROUP, INC. 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 02/01/2025
PACS HOLDINGS, LLC 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 02/01/2025
PROVIDENCE ADMINISTRATIVE CONSULTING SERVICES INC OPERATIONAL/MANAGERIAL CONTROL since 02/01/2025
BRANCH BANKING & TRUST COMPANY 5% OR GREATER SECURITY INTEREST since 02/01/2025
TRUIST BANK 5% OR GREATER SECURITY INTEREST since 02/01/2025

Owner / manager individuals (6)

Name Role Association
HANCOCK, MARK 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 02/01/2025
MURRAY, JASON 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 02/01/2025
HEARNS, EDWARD OPERATIONAL/MANAGERIAL CONTROL since 02/01/2025
APT, FREDERICK CORPORATE OFFICER since 02/01/2025
JERGENSEN, JOSHUA CORPORATE OFFICER since 02/01/2025
MITCHELL, JOHN CORPORATE OFFICER since 02/01/2025

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
No
Resident / family council
Resident
Sprinkler systems
Yes
Special focus status
SFF
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

Download CSV

Show 113 rows
Source Metric Value Raw key
Cost Report Cost per Resident Day ($) $20 metrics.cost_per_resident_day
Cost Report Current Ratio 0.13 metrics.current_ratio
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Medicaid Day Share (%) 80.2% metrics.medicaid_day_share
Cost Report Medicare Day Share (%) 2.8% metrics.medicare_day_share
Cost Report Net Income ($) $-533,030 metrics.net_income
Cost Report Net Patient Revenue ($) $9,584,237 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 81.7% metrics.occupancy_rate
Cost Report Operating Margin (%) -23.4% metrics.operating_margin
Cost Report Total Assets ($) $5,196,110 metrics.total_assets
Cost Report Total Costs ($) $740,805 metrics.total_costs
Cost Report Total Fund Balances ($) $-8,560,428 metrics.fund_balance
Cost Report Total Liabilities ($) $13,756,538 metrics.total_liabilities
Cost Report Total Margin (%) -4.7% metrics.total_margin
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 0.79601 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 1.95006 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 0.47867 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 3.22474 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 2.61610 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 96.7 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 0.98032 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 2.66429 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.77271 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 4.41731 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 3.89339 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 2.6 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 2.9 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 4.2 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 2.4 Chain Average Staffing Rating
Provider Information Chain ID 690 Chain ID
Provider Information Chain Name PACS GROUP Chain Name
Provider Information City/Town NASHVILLE City/Town
Provider Information CMS Certification Number (CCN) 445262 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Davidson County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 1991-03-08 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote Geocoding Footnote
Provider Information Health Inspection Rating Health Inspection Rating
Provider Information Health Inspection Rating Footnote 18 Health Inspection Rating Footnote
Provider Information Latitude 36.2078 Latitude
Provider Information Legal Business Name NASHVILLE SNF HEALTHCARE LLC Legal Business Name
Provider Information Location 4343 ASHLAND CITY HIGHWAY,NASHVILLE,TN,37218 Location
Provider Information Long-Stay QM Rating Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote 18 Long-Stay QM Rating Footnote
Provider Information Longitude -86.859 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago Y Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 1 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 124 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 264 Number of Facilities in Chain
Provider Information Number of Fines 3 Number of Fines
Provider Information Number of Payment Denials 1 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.56486 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 1.13589 Nursing Case-Mix Index Ratio
Provider Information Overall Rating Overall Rating
Provider Information Overall Rating Footnote 18 Overall Rating Footnote
Provider Information Ownership Type For profit - Corporation Ownership Type
Provider Information Physical Therapist Staffing Footnote Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 4343 ASHLAND CITY HIGHWAY Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name EATON CREEK POST ACUTE Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 180 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating QM Rating
Provider Information QM Rating Footnote 18 QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 68 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 9 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 9 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2023-08-30 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 68 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 9 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 6 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2019-05-21 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 1100 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 18 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 1 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 1100 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 24 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 0.35266 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 45.5 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 1.45837 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 0.91072 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 2.23108 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.00751 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 0.54765 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 3.68944 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote 18 Short-Stay QM Rating Footnote
Provider Information Special Focus Status SFF Special Focus Status
Provider Information Staffing Rating Staffing Rating
Provider Information Staffing Rating Footnote 18 Staffing Rating Footnote
Provider Information State TN State
Provider Information Telephone Number 6157260492 Telephone Number
Provider Information Total Amount of Fines in Dollars 122242.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 2.99310 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 4 Total Number of Penalties
Provider Information Total nursing staff turnover 61.9 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 326.000 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Resident With a Resident and Family Council
Provider Information ZIP Code 37218 ZIP Code