Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Heartland during CMS and state inspections, most recent first.
A resident with a PEG tube, dysphagia, dementia, and ileus had a physician order for Osmolite 1.5 to run at 50 ml/hr, but staff observed the feeding running at 55 ml/hr during multiple checks. The ADON was unsure of the ordered rate, nursing notes documented the incorrect rate, and the DON confirmed staff should follow MD orders and that the feeding should not have been running above the ordered rate.
The facility failed to report alleged abuse incidents involving four residents within the required timeframe. Incidents included physical altercations between residents, which were not reported to the state agency as required. Despite being aware of these incidents, the facility did not adhere to its policy of reporting allegations of abuse immediately, but not later than two hours after the allegation is made.
Two residents had incomplete MDS assessments due to the absence of the MDS Coordinator, resulting in Section GG being left incomplete. One resident, with diagnoses including COPD and chronic pain, had a BIMS score indicating cognitive intactness, while the other, with conditions like cerebral infarction and dysphagia, had a BIMS score showing moderate cognitive impairment. The assessments were completed late, outside the required timeframe.
A resident, dependent on staff for bathing due to impaired cognition, did not receive scheduled showers as per facility policy. Despite being scheduled for three showers per week, the resident's family reported only four showers since mid-February. Observations showed the resident often wore the same clothes for days, and staff interviews revealed a lack of proper documentation for showers or refusals.
The facility failed to follow physician orders for two residents, leading to deficiencies in care. One resident did not receive a prescribed inhaler due to unavailability, despite confirmation of delivery. Another resident experienced a delay in Vancomycin administration due to improper lab scheduling and communication issues. Staff interviews revealed a lack of coordination in medication and lab processes.
A resident with a PEG tube experienced significant weight loss and consistently refused tube feedings and medications. The facility failed to notify the physician and the resident's representative of these changes, contrary to its policies. Interviews with staff confirmed the lack of communication, and observations indicated potential dehydration. The deficiency was due to the facility's failure to adhere to its notification policies.
The facility did not ensure that 8 out of 13 CNAs received the required 12 hours of in-service training. Despite the facility's policy and the Facility Educator's efforts, several CNAs did not meet the training requirements, with some completing as few as 3.25 hours. The issue was reported to the DON and Administrator, leading to suspensions, but compliance was not achieved.
The facility failed to properly store and secure medications for two residents. One resident, cognitively intact but with poor safety awareness, had unsecured Tums Antacid without a physician's order or self-administration assessment. Another resident, with moderately impaired cognition, self-applied Asper Creme without a self-administration assessment, despite having an order for it. Both incidents were confirmed by the LPN and DON, highlighting deficiencies in medication management.
The facility failed to ensure a safe, sanitary, and comfortable environment for residents, as multiple rooms and bathrooms contained unsecured and unlabeled personal items. Observations revealed items like wash basins, denture cups, and personal care products left uncontained. Interviews with an LPN and the DON confirmed that these items should be properly labeled and stored, especially given the presence of wandering residents.
Incorrect PEG Tube Feeding Rate
Penalty
Summary
The facility failed to follow a physician’s order for a resident’s PEG tube feeding. Resident #7 was readmitted to the facility with diagnoses including dysphagia, dementia, and ileus. The quarterly MDS assessment documented a BIMS score of 15, indicating the resident was cognitively intact. A physician’s order dated 4/10/2026 directed Osmolite 1.5 enteral nutrition at 50 ml/hr. During multiple observations on 4/13/2026, the resident’s tube feeding was running at 55 ml/hr instead of the ordered 50 ml/hr. When the ADON was asked about the tube feeding rate, she stated she would have to check and that it was supposed to be running at 50 ml. Nursing notes documented that the continuous Osmolite feed was noted to be running at the incorrect rate of 55 ml per hour, and the pump was corrected to 50 ml. The DON stated she expected staff to follow MD orders and confirmed that a tube feeding ordered at 50 ml/hr should not be running at 55 ml/hr.
Failure to Report Alleged Abuse Incidents Timely
Penalty
Summary
The facility failed to report alleged abuse incidents involving four residents within the required timeframe. According to the facility's policy, any allegations of abuse must be reported immediately, but not later than two hours after the allegation is made. However, the facility did not adhere to this policy for four residents who were reviewed for abuse. The incidents involved physical altercations between residents, which were not reported to the state agency as required. Resident #1, who had severe cognitive impairment, was found with a laceration and bruising around the right eye. The facility's investigation suggested the injury was self-inflicted while reaching for an item on the nightstand. However, interviews with staff and residents indicated that Resident #209, who had no cognitive impairment, may have been involved in the incident. Despite these allegations, the facility did not report the incident to the state agency. Similarly, an incident involving Resident #24 and Resident #47, where Resident #47 allegedly hit Resident #24, was not reported. The facility's investigation downplayed the incident, suggesting it was non-aggressive. Interviews with staff revealed that the facility was aware of these incidents but failed to report them as required. The Administrator and other staff members were informed of the allegations, but the incidents were not communicated to the state agency. The facility's failure to report these incidents in a timely manner constitutes a deficiency in adhering to federal and state regulations regarding the reporting of abuse allegations.
Incomplete MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments, specifically Section GG (Functional Abilities), were completed for two residents. Resident #20, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Insomnia, Sleep Apnea, Cardiomyopathy, and Chronic Pain Syndrome, had an annual MDS assessment with a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitive intactness. However, Section GG was left incomplete. Similarly, Resident #21, admitted with diagnoses such as Cerebral Infarction, Hypertension, Seizure Disorder, and Dysphagia, had a quarterly MDS assessment with a BIMS score of 9, indicating moderate cognitive impairment, but Section GG was also incomplete. The MDS Coordinator was on vacation during the assessment period for both residents, and the assessments were not completed within the required timeframe. For Resident #21, the assessment was due on 2/13/2025 but was completed late on 2/18/2025 by the Assistant Director of Nursing (ADON), outside the assessment period. Similarly, Resident #20's assessment was due on 2/12/2025, but it was not completed until 2/18/2025. The MDS Coordinator confirmed that the assessments were incomplete and inaccurate as they were not completed at least two days prior to the Assessment Reference Date (ARD). The failure to complete Section GG resulted in dashed entries, indicating incompleteness.
Failure to Provide Scheduled Showers for a Resident
Penalty
Summary
The facility failed to provide scheduled showers or baths for a resident, who was dependent on staff for bathing due to moderately impaired cognition and other medical conditions. The facility's policy required residents to be placed on a shower schedule three times a week, with documentation of any refusals. However, the resident's family reported that since mid-February, the resident had only received four showers, despite being scheduled for three showers per week on the night shift. The family raised concerns during care meetings, but no improvements were noted. Observations and interviews revealed that the resident often wore the same clothes for multiple days, indicating a lack of bathing. A CNA confirmed that there was no way to chart showers unless a resident refused, which would then be reported to a nurse. The LPN and DON confirmed that there were no shower sheets or documented refusals for the resident, despite the resident being scheduled for showers. This lack of documentation and adherence to the shower schedule led to the deficiency in care for the resident.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to deficiencies in care. For Resident #8, who was admitted with conditions including Chronic Obstructive Pulmonary Disease, the facility did not administer the prescribed Breo Ellipta inhaler as it was not found in the medication cart. Despite the pharmacy confirming delivery of the inhaler, the resident did not receive the medication, and the nurse failed to ensure its availability. Resident #207, admitted with a history of knee surgeries and infections, was prescribed Vancomycin intravenously every 12 hours. However, the morning dose on a specific date was not administered on time due to a delay in obtaining a required lab trough level. The lab was scheduled to draw the trough at an inappropriate time, and the nurse did not contact the physician until several hours after the scheduled administration time. Consequently, the resident's medication was delayed, and the trough was drawn late, affecting the accuracy of the dosage adjustment. Interviews with staff revealed a lack of coordination and communication regarding lab work and medication administration. The Assistant Director of Nursing and other staff members acknowledged the issues with lab scheduling and the failure to administer medication as ordered. The Director of Nursing confirmed the expectation for staff to follow physician orders, highlighting the deficiencies in the facility's processes.
Failure to Notify Physician and Representative of Resident's Condition Changes
Penalty
Summary
The facility failed to provide adequate care and services for a resident with a percutaneous endoscopic gastrostomy (PEG) tube, as staff did not notify the physician or the resident's representative of significant changes in the resident's condition. The resident, who had a history of dementia, dysphagia, and other medical conditions, experienced a significant weight loss of 7.77% over 30 days and consistently refused tube feedings and medications. Despite these refusals, there was no documentation of notification to the physician or the resident's power of attorney (POA). The facility's policies required that any change in a resident's condition, such as consistent refusal of feedings or medications, should be reported to the physician and the resident's representative. However, the staff failed to adhere to these policies, as evidenced by the lack of communication with the physician and the POA regarding the resident's refusals and weight loss. Interviews with staff, including the Assistant Director of Nursing (ADON), Licensed Practical Nurse (LPN), and the Nurse Practitioner (NP), confirmed that the refusals were not communicated as required. Observations and interviews revealed that the resident had dry, chapped lips and was lying in bed, indicating potential dehydration. The resident's refusal of feedings and medications was not addressed promptly, and the facility did not take appropriate action to involve the resident's representative in decision-making. The failure to notify the physician and the POA of the resident's condition changes and refusals contributed to the deficiency in care provided to the resident.
Failure to Ensure Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that 8 out of 13 Certified Nursing Assistants (CNAs) employed for a full year received the required 12 hours of in-service training. The facility's policy mandates that the in-service training program should provide additional training based on individual needs and comply with state and federal regulations. However, a review of the in-service training hours revealed that several CNAs, including those hired as early as June 2023, did not meet the required training hours. For instance, CNA F, hired in October 2023, completed only 5.76 hours, while CNA G, hired in June 2023, completed 10.26 hours. Other CNAs also fell short of the 12-hour requirement, with some completing as few as 3.25 hours. During an interview, the Facility Educator confirmed the requirement of 12 hours of yearly in-service training and acknowledged responsibility for ensuring compliance. The educator mentioned that despite providing verbal warnings and written notices, some CNAs habitually failed to complete the required training. The issue was reported to the Director of Nursing (DON) and the Administrator, resulting in some CNAs being taken off the schedule and suspended for noncompliance. However, these measures did not lead to the completion of the required training hours by the CNAs.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure medications were properly stored and secured for two residents, leading to deficiencies in medication management. Resident #20, who was cognitively intact but had a care plan indicating forgetfulness and poor safety awareness, was found with unsecured Tums Antacid on their bedside stand. There was no physician's order for the antacid, and the resident had not been assessed for self-administration of medications until after the observation. The Licensed Practical Nurse (LPN) confirmed that medications should be securely locked and was unaware of any assessment or order for the resident's self-administration of the medication. The Director of Nursing (DON) also confirmed the lack of assessment and order, acknowledging that the medication should not have been at the bedside. Resident #36, with moderately impaired cognition and requiring substantial assistance with activities of daily living, was observed with Asper Creme in their room, which they self-applied without a self-administration assessment. Although there was an order for the medication, the LPN noted that the resident should not have the medication in their room or self-administer it. The DON confirmed that the Asper Creme should not have been in the resident's room and that the resident should not have been self-administering the medication.
Failure to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents, as evidenced by observations in multiple resident rooms and bathrooms. In the shared bathroom for two residents, teal wash basins were found stacked on the floor, unlabeled and uncontained. Another shared room had a bottle of facial astringent unsecured on a dresser. In a different shared room, various personal care items, including a bottle of sterile water, shampoo, cleansing gel, and air fresheners, were found uncontained and unsecured. Additionally, several items such as wash basins, denture cups, and hand soap were found unlabeled and uncontained in the bathroom. Further observations revealed similar issues in other shared rooms and bathrooms, where personal items like body wash, bedpans, and toothbrushes were left unsecured and unlabeled. A clear plastic spray bottle was also found in a resident's room. Interviews with an LPN and the Director of Nursing confirmed that personal items should be labeled, contained, and stored properly, and that chemicals like air fresheners should be secured in the medication cart or room. The facility acknowledged the presence of wandering residents, which underscores the importance of securing personal and potentially hazardous items.
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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 Nashville
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 | 3.5 mi | ★★★★★ | 1 | 0 |
| Trevecca Center For Rehabilitation And Healing Llc | 5.3 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Old Hickory Village | 5.3 mi | ★★★★★ | 2 | 0 |
| Creekside Center For Rehabilitation And Healing | 6 mi | ★★★★★ | 0 | 0 |
| Nashville Center For Rehabilitation And Healing Ll | 7.1 mi | ★★★★★ | 0 | 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.