Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Cedar Creek Post Acute during CMS and state inspections, most recent first.
Unsecured cleaning chemicals were left on the outer side of a housekeeping cart on a hall with resident access, and multiple resident rooms and bathrooms contained unsecured sharps. A resident with ESRD had scissors on a bedside table, another resident with MRSA had a disposable razor on the back of the toilet, two residents shared a bathroom where a razor was left on the toilet, and another resident had a razor in the bathroom and later on the nightstand. Staff, including an LPN, CNA, housekeeping manager, and DON, confirmed the items should not have been left unsecured.
Resident funds were not properly monitored or refunded. Four residents had account balances above the eligibility limit without documented notice to the resident or representative, including residents with hemiplegia, dementia, bipolar disorder, depression, anxiety, and other diagnoses; one resident who died had a $279.26 account balance that was not mailed to the funeral home until well after the 30-day timeframe. The BOM confirmed the missing notice documentation and delayed refund.
Failure to Follow Physician Orders for Medications, Monitoring, and Treatments: The facility did not consistently follow MD orders for medication administration, blood glucose notification, shift monitoring, trach care, or hold parameters. Examples included a resident with diabetes and dementia who had missed MAR documentation, a resident who received Midodrine despite BP being above the hold parameter, a resident whose BG was over 400 without physician notification, missing shift monitoring for depression/sleep orders, missing trach care/TAR documentation, and a resident who received Carvedilol despite HR being below 60. The DON confirmed several of these entries should have been held, reported, or documented per order.
An LPN failed to perform hand hygiene before and after glove use while giving meds to two residents, and reusable equipment such as a BP machine and stethoscope was not disinfected between residents. During wound care for a resident with MRSA and pressure ulcers, an LPN did not clean his hands or change gloves after removing soiled dressings and moved room items with soiled gloves; the DON confirmed the expected hand hygiene and equipment-cleaning practices.
The facility failed to protect residents from abuse and neglect, resulting in Immediate Jeopardy. A resident exhibited inappropriate sexual behaviors towards another resident, and the facility did not implement adequate interventions. Another resident was neglected after a fall, leading to their death. Additionally, a resident was physically abused by another resident, resulting in pain and injury. The facility's policies and procedures for abuse prevention and response were not effectively implemented.
The facility failed to ensure proper infection control practices when using a multi-use glucometer, as multiple nurses did not follow the required disinfection procedures, placing residents at risk for bloodborne pathogen contamination. This deficiency was identified as Immediate Jeopardy.
A resident experienced an unwitnessed fall and a subsequent change in mental status, but the facility failed to notify the Physician/NP and the resident's family. The fall was not documented until several days later, and no neuro checks were initiated. The resident was eventually transferred to the hospital, where he expired in the emergency room.
The facility failed to communicate critical information during the transfer of a resident to the hospital. The resident had an unwitnessed fall and a subsequent change in mental status, but the LPN only reported the change in mental status, omitting the fall. This omission likely resulted in a delay of treatment in the emergency department.
The facility failed to implement comprehensive care plans for three residents, leading to unaddressed risks of abuse, improper transfer procedures, and inadequate protection from inappropriate sexual behavior. Despite clear indications of distress and pain, the care plans lacked necessary interventions and adherence to prescribed care procedures.
A resident with a history of falls was found on the floor after an unwitnessed fall. The facility failed to document a post-fall assessment, neuro checks, or an incident report. The resident was later transferred to the hospital due to a change in mental status and expired from septic shock. Staff interviews revealed a lack of proper documentation, assessment, and communication.
Unsecured cleaning chemicals and sharps found in resident areas
Penalty
Summary
The facility failed to provide an environment free of accident hazards on the 200 hall when a bottle of bleach germicidal spray cleaner and a bottle of disinfectant spray were left unattended and out of sight of the housekeeper on the outer side of the cleaning cart while resident traffic was present. The housekeeping manager stated the chemicals should be kept in the cart and locked up, and confirmed they should not be left in the hall on the side of the cart while cleaning resident rooms. The housekeeper stated she thought the chemicals could be kept on the side of the cart while she was using them, but had been told they had to be locked away. Unsecured sharps were also observed in multiple resident rooms. In Resident #2's room, scissors were observed on the bedside table in the bath basin; the resident had ESRD, renal dialysis, anxiety, and a BIMS score of 14 indicating cognitive intactness. An LPN and the ADON confirmed residents should not have scissors at the bedside. In Resident #75's bathroom, a disposable razor was found in a plastic bag on the back of the toilet; the resident had stage 2 pressure ulcer, HTN, depression, anxiety, MRSA, and a BIMS score of 15. An LPN confirmed the razor should not be unsecured in the bathroom. Additional unsecured razors were found in other resident areas. In the shared bathroom of Residents #76 and #90, a gray disposable razor was left on the back of the toilet; Resident #76 had chronic respiratory failure, diabetes, anxiety, and partial to moderate assistance needs, while Resident #90 had depression, dementia, a BIMS score of 5, and required maximum assistance for ADLs. In Resident #88's bathroom, a blue disposable razor was observed on the sink behind the faucet, and later on the resident's nightstand; Resident #88 had Alzheimer's disease, dementia, diabetes, a BIMS score of 14, and required partial to moderate staff assistance with bathing and personal care. The DON confirmed the razor should not have been in the bathroom or on the nightstand.
Resident Funds Not Properly Monitored or Refunded
Penalty
Summary
The facility failed to notify residents and/or their representatives when resident fund account balances exceeded the eligibility limit for 4 of 37 residents reviewed. The facility policy titled Resident Trust Fund stated that Medicaid-eligible residents would be notified when the amount in the resident's account reached $200 less than the Medicaid resource limit for one person, and that residents would also be notified if their account balance plus other nonexempt resources affected Medicaid or SSI eligibility. Review of resident fund statements showed ending balances above the limit for Resident #45, who had diagnoses including hemiplegia, diabetes, malnutrition, and bipolar disorder and a BIMS score of 9; Resident #59, who had hemiplegia, depression, and anxiety and a BIMS score of 15; Resident #86, who had metabolic encephalopathy, COPD, dementia, and bipolar disorder and a BIMS score of 6; and Resident #87, who had hypertension, depression, anxiety, and glaucoma and a BIMS score of 14. The Business Office Manager confirmed that documentation could not be provided showing that residents and/or representatives were informed of account balances over the eligibility limit. The facility also failed to refund a resident's funds within 30 days of discharge/death for 1 sampled resident. Resident #103 had diagnoses including heart failure, malnutrition, dementia, and pseudobulbar disorder, and was pronounced dead at 5:55 PM on 2/4/2025. Review of the refund check showed that $279.26 was mailed to the funeral home on 3/31/2025. During interview, the Business Office Manager confirmed that the refund for Resident #103's account balance was not sent to the funeral home until 3/31/2025.
Failure to Follow Physician Orders for Medications, Monitoring, and Treatments
Penalty
Summary
The facility failed to follow physician orders and treatment/monitoring instructions for multiple residents. The report cites a policy requiring medications to be administered in accordance with prescriber orders and documented on the MAR or TAR when given, withheld, refused, or administered outside the scheduled time. Surveyors identified deficiencies involving medication administration, blood glucose reporting, shift monitoring documentation, tracheostomy care documentation, and holding medications based on ordered parameters. Resident #3 had diagnoses including schizoaffective disorder, bipolar type, diabetes, dementia, and anxiety, and was severely cognitively impaired with a BIMS score of 2. The resident had physician orders for multiple medications including insulin, Tradjenta, Furosemide, Lamotrigine, Clozapine, Allopurinol, Amlodipine, Bisacodyl, Famotidine, Fluoxetine, and Insulin Glargine. The MAR showed no medications were administered on July 8, 2025 from 7:30 AM to 12:00 PM, and the DON confirmed that a blank indicated medications were not administered and that medications should be signed out when administered. Resident #6 had diagnoses including depression, anxiety, and insomnia, and a BIMS score of 13. The physician ordered Midodrine 2.5 mg before meals for hypotension, hold if systolic blood pressure was greater than 110. The MAR showed Midodrine was administered on multiple occasions when the blood pressure was above the ordered hold parameter, including readings such as 112/78, 118/70, 122/78, 124/78, 112/64, 124/68, 118/50, 113/70, 119/52, 112/88, 123/64, 114/59, and 120/62. The DON confirmed the medication should have been held and not administered according to the physician orders. Resident #7 had diagnoses including paraplegia, neuromuscular dysfunction of bladder, diabetes, anxiety, and depression, with a BIMS score of 15. The physician ordered staff to notify the physician if blood sugar was greater than 400. The MAR showed blood glucose readings above 400 on several occasions, including 403, 408, 462, 428, and 408, but the facility failed to notify the physician. Resident #11 had diagnoses including paraplegia, neuromuscular dysfunction of bladder, diabetes, anxiety, and depression, and orders for monitoring episodes of sadness and difficulty sleeping every shift related to Mirtazapine, Trazodone, and Duloxetine. The MAR showed multiple shifts where the monitoring was not documented as performed. Resident #12 had diagnoses including diabetes, spinal stenosis, anxiety, depression, and legal blindness, with a BIMS score of 15. The MAR showed no medications were administered on multiple shifts, including July 3 and July 6 from 7:00 PM to 7:00 AM and July 8 from 7:00 AM to 7:00 PM. Resident #14 had diagnoses including COPD, hypothyroidism, and tracheostomy status, with a BIMS score of 15. Physician orders required trach care, changing the disposable inner cannula, monitoring tolerance of trach care, and cleaning the trach stoma with normal saline. The TAR showed missing documentation for tracheostomy care, inner cannula changes, and monitoring tolerance on several evening shifts. Resident #45 had diagnoses including hemiplegia, memory deficit, diabetes, bipolar disorder, and dysphagia, with a BIMS score of 9. The physician ordered Carvedilol 25 mg twice daily for hypertension, hold for heart rate less than 60 and notify the NP if held. The MAR showed Carvedilol was administered when the resident's heart rate was 56, 57, 56, and 59. The DON confirmed the medication should have been held when the heart rate was less than 60.
Failure to Follow Hand Hygiene and Equipment Cleaning Practices
Penalty
Summary
Infection prevention and control practices were not followed during medication administration and resident care. During observation, an LPN failed to perform hand hygiene before donning gloves and after removing gloves while administering medications to Resident #1 and Resident #18. The same LPN used a blood pressure machine for Resident #18 and then took it into the hallway without disinfecting it. During another medication pass, an RN failed to disinfect a stethoscope after using it on Resident #45. The DON confirmed that staff should wash hands between glove changes and clean reusable equipment between residents. During wound care for Resident #75, who was readmitted with diagnoses including pressure ulcer, HTN, depression, anxiety, and MRSA, the resident had a BIMS score of 15 and stage 2 and stage 3 pressure ulcers that were not present on admission. The resident had a physician order for contact isolation due to MRSA of the wound and wound treatment orders for both gluteal wounds. During observation, an LPN failed to perform hand hygiene and put on new gloves after removing soiled dressings, moved the overbed table and wheelchair to the resident's bedside with soiled gloves, and stated that he did not sanitize after changing gloves. The DON confirmed that staff should remove and change gloves during wound care, perform hand hygiene after glove removal, and not touch items in the resident's room with soiled gloves.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to ensure residents were free from abuse and neglect, resulting in Immediate Jeopardy for several residents. Resident #11, who had a BIMS score of 12, exhibited inappropriate sexual behaviors towards Resident #15, who had a BIMS score of 4, during group activities. Despite Resident #15's attempts to push Resident #11 away, the inappropriate behaviors continued over several days. Additionally, Resident #11 exposed himself and made sexual comments to other female residents. The facility did not implement adequate interventions to protect Resident #15 or other residents from Resident #11's behaviors, and Resident #11 was not transferred to a psychiatric facility until eight days after the initial incident. Furthermore, Resident #3 reported that Resident #11 had placed his genitals in his hand during the night, causing emotional and mental distress. The facility failed to monitor Resident #3 for psychosocial harm or implement care plan interventions to address the risk of abuse. The facility also failed to prevent neglect in the case of Resident #7, who was found on the floor with his head under the bed. Staff did not complete a post-fall assessment, incident report, or notify the physician/NP. Three days after the fall, Resident #7 experienced a change in mental status, but the physician/NP was not notified until the following day. Resident #7 was transferred to the emergency room without a report of the recent fall with a head injury and expired after arrival. The facility's failure to address the fall and subsequent change in mental status resulted in neglect and contributed to Resident #7's death. Additionally, the facility failed to protect Resident #9 from physical abuse by Resident #14, who was observed hitting and punching Resident #9's hand and bending her fingers back, resulting in pain, bruising, and swelling. The facility's inability to prevent abuse and neglect for multiple residents led to Immediate Jeopardy, with serious harm and potential for further harm to the residents involved. The facility's policies and procedures for abuse prevention and response were not effectively implemented, and staff failed to take appropriate actions to protect residents from harm.
Failure to Properly Disinfect Multi-Use Glucometer
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were maintained when using a multi-use blood glucose meter. Observations revealed that multiple nurses did not clean and disinfect the glucometer before and after use on each resident, as required by the facility's policy and manufacturer recommendations. Specifically, LPN P did not perform hand hygiene, don gloves, or disinfect the glucometer properly when performing blood glucose monitoring for Resident #18. Additionally, LPN P attempted to use the same dirty glucometer on Resident #17 without proper disinfection, and used an alcohol pad instead of the required germicidal cloth for cleaning the device. Further observations on the following day showed that LPN E, LPN O, and RN A also failed to follow the correct disinfection procedures for the multi-use glucometer. LPN E incorrectly used an alcohol pad for disinfection and was unsure of the required wet time for the disinfectant. LPN O used a germicidal cloth but did not follow the correct procedure for cleaning and disinfection, and RN A did not use the correct method or understand the required wet time for the disinfectant. These actions were not in accordance with the facility's policy or the manufacturer's guidelines, which require the use of specific germicidal wipes and adherence to a two-minute wet time for effective disinfection. The facility's failure to ensure proper disinfection of the multi-use glucometer placed residents at risk for potential contamination with bloodborne pathogens. This deficiency was identified as Immediate Jeopardy, indicating a situation where the provider's noncompliance with requirements has caused or is likely to cause serious injury, harm, impairment, or death to residents. The facility had 7 residents receiving blood glucose monitoring with a multi-use glucometer, and the failure had the potential to affect 11 residents in total.
Failure to Notify Physician and Family of Resident's Fall and Change in Condition
Penalty
Summary
The facility failed to notify and consult the Physician/Nurse Practitioner (NP) of a change in condition related to falls for a resident. The resident had an unwitnessed fall and was found on the floor with his head under the bed. While being placed back in bed by staff, the resident hit his head. The Physician/NP was not notified of the fall, and the resident experienced a change in mental status the following day. The NP was only notified one day after the change in mental status and four days after the fall. The resident was eventually transferred to the hospital, where he expired in the emergency room. The Director of Nursing (DON) confirmed that the fall was not documented until several days later and that no neuro checks were initiated. The DON stated that the Licensed Practical Nurse (LPN) responsible for the resident was unaware of the need to document the fall. The DON also indicated that the NP should have been notified immediately of the change in mental status. Interviews with staff revealed that the fall was observed by the Unit Manager, who also did not notify the NP, DON, or the resident's family. Family members confirmed that they were not notified of the fall or the change in mental status. The NP also confirmed that she was not notified of the fall or the change in mental status. The facility's failure to promptly inform the Physician/NP and the resident's family of the fall and subsequent change in condition resulted in Immediate Jeopardy, as the resident remained in the facility for four days following the fall and experienced a decline in mental status before being transferred to the hospital, where he later died.
Failure to Communicate Critical Information During Resident Transfer
Penalty
Summary
The facility failed to ensure the appropriate information for transfer or discharge was communicated to the receiving healthcare facility for one of the sampled residents. Resident #7, who had a history of an unspecified fracture of the third lumbar vertebra, frontal lobe and executive function deficit, and urinary tract infection, was transferred to Hospital #1 Emergency Department for evaluation of a change in mental status. However, the facility nursing staff did not communicate the resident's unwitnessed fall on 1/25/2024 in the written report to the hospital, which was a critical piece of information that could have impacted the resident's treatment and care in the emergency department. The facility's policy on transfer and discharge required that all necessary information, including any other documentation to ensure a safe and effective transition of care, be provided to the receiving provider. Despite this policy, the clinical notes and the hospital transfer form did not include the unwitnessed fall or the subsequent change in mental status. During an interview, the LPN responsible for the transfer admitted to only reporting the change in mental status and not the fall. This omission likely resulted in a delay of treatment for Resident #7 in the emergency department.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for three residents, leading to significant deficiencies in their care. Resident #3, who had no cognitive impairment, reported an incident of nonconsensual sexual contact by his previous roommate. Despite the resident's emotional and mental distress, the care plan did not include any interventions to address the risk of abuse or provide psychosocial support. The resident expressed feeling unsafe and was tearful during the interview, indicating a lack of adequate response from the facility staff to his concerns and needs. Resident #10, who had no cognitive impairment and was at risk for falls, experienced knee pain after being transferred by two CNAs without using the recommended mechanical lift. The care plan specified the use of a Hoyer lift for transfers, but the CNAs used a gait belt and performed an underarm lift instead. This deviation from the care plan resulted in the resident experiencing pain and discomfort, highlighting a failure to adhere to the prescribed care procedures. Resident #15, who had severe cognitive impairment and exhibited wandering behavior, was a victim of inappropriate sexual behavior by Resident #11 and Resident #19. Despite multiple reports of such incidents, the care plan did not include any interventions to address the risk of further abuse or provide support for the resident. The facility staff, including the Activity Director and LPN, confirmed the repeated inappropriate behaviors but failed to implement measures to protect the resident and monitor for psychosocial harm.
Failure to Assess and Monitor Resident After Fall
Penalty
Summary
The facility failed to properly assess and care for a resident after an unwitnessed fall. Resident #7, who had a history of falls with injury, was found on the floor following an unwitnessed fall from bed. There was no documentation of a post-fall assessment, neuro checks, or an incident report. Additionally, no immediate interventions were documented following the fall. Four days later, Resident #7 was transferred to the hospital due to a change in mental status and subsequently expired from septic shock. The facility's policies on accidents and fall prevention were not followed, as evidenced by the lack of documentation and communication regarding the fall and subsequent change in condition. The Director of Nursing (DON) confirmed that the unwitnessed fall was not charted until several days later and that the nurse responsible was unaware of the need to document the fall. The DON also stated that the nurse should have conducted a head-to-toe assessment, neuro checks, and notified the necessary parties immediately. The nurse involved admitted to not completing an incident report or documenting neuro checks due to unfamiliarity with the computer system. The facility's Nurse Practitioner (NP) was not notified of the fall or the change in mental status until the day Resident #7 was transferred to the hospital. Interviews with other staff members revealed that the fall was witnessed by multiple staff, but no follow-up actions were taken. The Unit Manager did not notify the NP, DON, or family about the fall and did not follow up the next day. A Certified Nursing Assistant (CNA) noted a change in Resident #7's behavior after the fall but did not escalate the concern. The lack of proper documentation, assessment, and communication contributed to the failure to provide appropriate care for Resident #7 after the fall.
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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.
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Nursing homes near Mount Juliet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Mckendree Post Acute & Rehabilitation | 5.4 mi | ★★★★★ | 1 | 0 |
| Heartland | 8.7 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Old Hickory Village | 8.8 mi | ★★★★★ | 2 | 0 |
| Nhc Healthcare, Hendersonville | 9.8 mi | ★★★★★ | 4 | 1 |
| Nhc Place Sumner | 9.9 mi | ★★★★★ | 3 | 0 |
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