Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alta Heights Post Acute during CMS and state inspections, most recent first.
The facility failed to properly label, date, and store food items in the kitchen and the 300 Hall nourishment room. Opened containers of chicken salad and pimento cheese were not dated, and raw bacon was left uncovered on the countertop. In the nourishment room, grapes, oranges, and juice were found unlabeled and undated. The Admission Nurse incorrectly stated that juice could remain open until the expiration date, contrary to policy.
The facility failed to maintain infection control practices, with LPNs not cleaning equipment, using protective barriers, or wearing PPE in enhanced barrier precaution rooms. Observations included improper hand hygiene and equipment disinfection, affecting residents with severe cognitive impairment and chronic diseases.
The facility failed to maintain a safe and sanitary environment, with deficiencies observed in 11 rooms, including broken furniture, exposed screws, and strong odors. Interviews confirmed the need for repairs and replacements, and staff acknowledged issues with room conditions and odors. Despite daily cleaning, some rooms remained cluttered and malodorous, with no further actions taken.
The facility failed to provide adequate hot water for resident bathing, affecting three residents. Observations showed water temperatures below the required range, with residents and CNAs reporting cold water during bed baths. The Maintenance Director noted the hot water system's inefficiency, requiring multiple bathrooms to run water simultaneously to reach the desired temperature. Despite awareness of the issue, the facility did not ensure compliance with water temperature standards.
A resident with intact cognitive abilities experienced a breach of privacy when two CNAs entered her room without knocking during a surveyor interview. The facility's policy requires staff to treat residents with respect and ensure their privacy, which was not adhered to in this instance. The resident expressed dissatisfaction with the lack of respect shown by the CNAs.
A resident with severe cognitive impairment reported being spun around in his wheelchair by a staff member, resulting in a fractured arm. The incident, related to a disagreement over room temperature, was reported to the DON but not to state agencies as required. The resident's family confirmed the injury, and the staff member was later identified and terminated for unrelated reasons.
The facility failed to update care plans for two residents, one with a DNR status not reflected in their care plan and another with a recent leg fracture lacking specific transfer interventions. The DON confirmed these oversights, and the Rehab Director noted a lack of recent evaluation for one resident.
A resident with moderately impaired cognition was not provided adequate assistance with ADLs, including toileting hygiene and facial hair removal, despite her care plan indicating a need for such support. Observations showed the resident in a soiled brief and with facial hair she wanted removed, but staff did not offer assistance. The DON confirmed staff should notify the charge nurse and document refusals, but this was not done, leading to a deficiency.
A resident with severe cognitive impairment and a high risk for elopement left the facility unsupervised, resulting in a fall and minor injuries. Despite documented wandering behaviors and confusion, the care plan lacked specific interventions to prevent elopement. The resident was found by EMS after falling on a sidewalk, highlighting the need for improved supervision and care planning.
A resident with a history of thrombosis and embolism was prescribed Eliquis, an anticoagulant, but the facility failed to monitor for bleeding as required by their anticoagulation policy. The resident's Medication Administration Records for several months showed no monitoring for bleeding, which was confirmed by the DON.
Two LPNs in an LTC facility failed to properly administer medications, resulting in a 12.5% error rate. One resident received Levothyroxine and Potassium Chloride ER incorrectly via PEG tube, while another resident's Carbidopa-Levodopa was improperly crushed and administered. The DON confirmed these actions were against facility policy.
The facility failed to ensure proper medication storage, as LPNs left medication carts unlocked and medications unattended during administration. An LPN admitted to leaving a treatment cart unlocked, and medications were found on a resident's over-the-bed table. The DON confirmed these actions were against policy.
Improper Food Labeling and Storage
Penalty
Summary
The facility failed to adhere to its own policies regarding the labeling, dating, and storage of food items, both in the kitchen and in the 300 Hall nourishment room. During an initial kitchen walk-through, surveyors observed an opened container of chicken salad and an opened container of pimento cheese, neither of which were labeled with an open date or a use-by date. The Dietary Manager confirmed that these items should have been dated. Additionally, four uncovered pieces of raw bacon were found lying on the countertop, which is not in accordance with proper food storage practices. In the 300 Hall nourishment room, surveyors found an unlabeled and undated bag of grapes, an opened and undated bag of oranges, and an undated and opened container of juice in the refrigerator. The Admission Nurse incorrectly stated that juice could remain open in the refrigerator until the manufacturer's expiration date, contrary to the facility's policy that requires opened beverages to be discarded after 24 hours. The nurse also acknowledged that all items in the refrigerator should be labeled with the resident's name, which was not done in this case.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain infection prevention and control practices, as evidenced by multiple observations of staff not adhering to established protocols. Three nurses, identified as LPN O, LPN W, and LPN X, did not clean reusable equipment before and after use and failed to use protective barriers. Additionally, LPN X did not wear Personal Protective Equipment (PPE) in enhanced barrier precaution rooms, which is a requirement according to the facility's policy. Specific incidents included LPN O administering eye drops to a resident without performing hand hygiene between treating each eye, and failing to disinfect equipment such as a blood pressure machine and eye drop bottles after use. LPN O also did not use a protective barrier when placing medications on an over bed table. Similarly, LPN W and LPN X were observed placing items on over bed tables without protective barriers and not wearing PPE in rooms designated for enhanced barrier precautions. The report highlights the facility's policy failures, including the lack of adherence to hand hygiene protocols and the improper use of PPE. Interviews with staff, including the Director of Nursing and the Infection Control Preventionist, confirmed that these practices were not in line with the facility's infection control policies. The deficiencies were observed in residents with various medical conditions, including severe cognitive impairment, cerebral infarction, and chronic diseases, which could increase their vulnerability to infections.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents, as evidenced by numerous deficiencies observed in 11 of 48 occupied rooms. These deficiencies included broken or missing pieces on window blinds, exposed sharp screws on closet doors, holes in walls, missing hooks from privacy curtains, and air conditioners with missing front panels and filters. Additionally, there were issues with furniture, such as bulging and missing pieces from overbed tables, missing laminate pieces from dressers and nightstands, and peeling plaster from walls. A broken bed with no mattress was stored in a resident's room, and strong malodorous odors were present in some residents' rooms. Interviews with the Maintenance Supervisor confirmed the need for repairs and replacements in several rooms, including replacing dressers, repairing walls, and attaching cable cord boxes to walls. The Maintenance Director acknowledged issues with a broken shower and loose toilet seat in one resident's room, and the Administrator admitted to being unaware of a broken bed being stored in a resident's room. Housekeeping staff reported no special provisions to address wound-related odors, and the Environmental Supervisor noted a delay in receiving a specialty cleaner to help with the smell. The report highlights the facility's failure to provide a homelike environment, as confirmed by the Administrator, who acknowledged that the conditions observed did not meet this standard. The presence of strong odors, particularly in the room of a resident with skin cancer and copious wound drainage, was noted, with staff indicating that the smell was a known issue. Despite daily cleaning efforts, some rooms remained cluttered and malodorous, with no further actions taken to address these conditions.
Failure to Provide Adequate Hot Water for Resident Bathing
Penalty
Summary
The facility failed to provide reasonable accommodations for the water temperature needs of three residents during bathing activities. The facility's policy and state regulations require hot water to be available at temperatures between 105°F and 115°F at all times. However, observations and interviews revealed that the water temperature in the bathrooms of the affected residents was significantly below the required range, with temperatures recorded at 78°F and 97°F. Residents reported that the water was cold during bed baths, and CNAs confirmed that they had to let the water run for extended periods to try to achieve a warm temperature, often without success. The Maintenance Director explained that the hot water system on the 100 and 200 halls required multiple bathrooms to be running water simultaneously to reach the desired temperature, which was not always feasible. The Social Service Director acknowledged resident complaints about cold water, and the Administrator admitted that staff and residents should not have to wait for hot water. Despite awareness of the issue, the facility did not ensure that the water temperature met the required standards, leading to discomfort and dissatisfaction among residents.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to provide privacy for a resident, identified as Resident #28, during an incident involving two Certified Nursing Assistants (CNAs). The facility's policy on resident rights emphasizes the importance of treating residents with respect, kindness, and dignity, including ensuring their privacy and confidentiality. Resident #28, who has intact cognitive abilities as indicated by a Brief Interview for Mental Status (BIMS) score of 15, was admitted with diagnoses including Hypertensive Heart Disease, Anemia, Hyperlipidemia, and Atherosclerotic Heart Disease. During an observation, two CNAs entered Resident #28's room without knocking or asking for permission while a surveyor was conducting an interview. This action occurred immediately after the resident was asked if she felt treated with respect and dignity, to which she responded negatively after the CNAs entered unannounced. The facility administrator later confirmed that CNAs are expected to knock before entering a resident's room.
Failure to Report Allegation of Abuse Resulting in Injury
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who was admitted with multiple diagnoses, including cerebral infarction, dementia, and a fractured upper humerus. The incident occurred when the resident reported to his family that a staff member had taken him by the arm and spun him around in his wheelchair, which was related to a disagreement over the room's air conditioning. Despite the resident's severe cognitive impairment, he was able to identify the staff member involved after being shown several staff members. The incident was reported to the Director of Nursing by the resident's family, but it was not reported to state agencies as required. The resident's family confirmed that the resident complained of shoulder pain and numbness following the incident, and an x-ray later revealed a fracture in the right arm. The facility's investigation included a timeline of events, but the incident was not classified as an allegation of abuse or an injury of unknown origin, and thus was not reported to the appropriate authorities. The staff involved was later terminated for unrelated issues, and the facility educated staff on proper repositioning techniques, but these actions were not part of the initial response to the incident.
Failure to Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to revise comprehensive care plans for two residents, leading to deficiencies in their care. Resident #3, who was admitted with multiple diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety Disorder, had a documented DNR status that was not reflected in their care plan. The Director of Nursing confirmed the absence of a DNR order in the care plan during an interview, and the order was only added after the oversight was identified. Resident #64, admitted with conditions such as Cerebral Infarction and Hemiplegia, experienced a fracture to the left leg that was not addressed in their care plan. Despite the resident's need for assistance with ADLs and the use of an immobilizer brace, the care plan lacked specific interventions for safe transfers. The Rehab Director acknowledged that the resident had not been evaluated since July 2024, and the DON confirmed the care plan did not reflect the recent fracture or necessary transfer protocols.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate care and services related to activities of daily living (ADLs) for a resident with moderately impaired cognition. The resident, who was admitted with diagnoses including diabetes, hypertension, vitamin D deficiency, and cognitive communication deficit, required assistance with toileting hygiene and personal hygiene. Observations revealed that the resident was left in a soiled incontinent brief and had facial hair that she wanted removed, but staff did not offer assistance. The resident's care plan indicated a need for daily assistance with morning and evening care, including oral and grooming tasks, as well as toileting hygiene and incontinent care. Interviews with staff revealed that the resident often refused care, but the Certified Nursing Assistant (CNA) did not report these refusals to the nurse. The Director of Nurses (DON) confirmed that staff should notify the charge nurse, document refusals, and attempt different approaches if a resident refuses care. Despite the resident's expressed desire to have her facial hair removed, staff failed to recognize and address this need. The DON acknowledged that staff are expected to offer assistance in such situations, but this was not done, leading to a deficiency in the resident's care.
Resident Elopement and Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent an elopement incident involving a resident identified as being at high risk for wandering and elopement. The resident, who had a history of traumatic brain injury, lung cancer, and other significant medical conditions, was admitted with a high risk for elopement due to addiction-related behaviors. Despite this, the resident's care plan lacked specific interventions to address the elopement risk, and the resident was able to leave the facility unsupervised, resulting in a fall and minor injuries. The resident's medical records indicated a severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 5, and a history of wandering behaviors that intruded on the privacy of others. The resident exhibited confusion, agitation, and difficulty with redirection, as noted in multiple nursing progress notes. Despite these documented behaviors, the facility's care plan did not include adequate measures to prevent elopement, such as increased supervision or the use of assistive devices. On the day of the incident, the resident eloped from the facility and was found by emergency services after falling on a sidewalk. The resident was confused and had minor injuries, including a laceration on the toe and an abrasion on the arm. The emergency department report noted the resident's confusion and history of substance abuse, highlighting the need for a more comprehensive and effective care plan to prevent such incidents in the future.
Failure to Monitor Anticoagulant Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications by not monitoring for potential complications associated with the use of an anticoagulant. The facility's policy on anticoagulation required staff and physicians to identify and address potential complications and monitor for possible complications. However, for a resident with a history of thrombosis and embolism, who was prescribed Eliquis, an anticoagulant, there was no monitoring for bleeding documented in the Medication Administration Records for December 2024, January 2025, and February 2025. The resident, who had intact cognition and was receiving multiple medications including an anticoagulant, was not monitored for bleeding and bruising as confirmed by the Director of Nursing during an interview.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than 5%, resulting in a 12.5% error rate. This was due to improper medication administration by two LPNs for two residents. One resident, with diagnoses including esophagus cancer and dysphagia, had a physician's order for Levothyroxine to be administered via PEG tube at bedtime and Potassium Chloride ER to be given by mouth. However, the LPN crushed and administered both medications incorrectly, leading to a clogged PEG tube and a deviation from the prescribed administration method. Another resident, diagnosed with conditions such as Tourette's Disorder and chronic kidney disease, had an order for Carbidopa-Levodopa to be given by mouth. The LPN crushed the tablet and administered it via PEG tube without proper dilution, contrary to the order. Interviews with the DON confirmed that these practices were not in line with the facility's medication administration policies, contributing to the medication errors observed.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper storage of medications, as evidenced by several incidents involving Licensed Practical Nurses (LPNs) leaving medication storage areas unlocked and unattended. During a random observation, an LPN was found to have left a treatment cart unlocked and unattended in the 100 Hall. The LPN acknowledged the oversight, admitting that the cart should have been locked. Additionally, medications were observed left on an over-the-bed table in a resident's room, which was confirmed by the Director of Nursing (DON) as inappropriate storage. Further observations revealed that two LPNs left medications unattended and out of sight during medication administration. One LPN left pills and eye drops unattended while retrieving gloves and washing hands, while another LPN left medications unattended while getting water. Both LPNs admitted that they should not have left the medications unattended. The DON confirmed that medications should be stored in a way that is inaccessible to others, highlighting the facility's failure to adhere to its medication storage policy.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Goodlettsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creekside Center For Rehabilitation And Healing | 3.1 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Old Hickory Village | 4.6 mi | ★★★★★ | 2 | 0 |
| Nhc Healthcare, Hendersonville | 5.5 mi | ★★★★★ | 4 | 1 |
| Whites Creek Wellness And Rehabilitation Center | 6.6 mi | ★★★★★ | 3 | 0 |
| Stoneridge Health Care, Llc | 6.9 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.