Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
EATON CREEK POST ACUTE
NASHVILLE, TN · 124 certified beds · Last Life Safety survey July 22, 2026
CMS Certification Number 445262 · first certified March 1991
Ownership
Operated by PACS GROUP · For profit - Limited Liability company
- New ownershipOwnership changed February 1, 2025 (change of ownership)from CUMBERLAND HEALTH CARE AND REHABILITATION LLC
Position within TN
26 citations — more than 96% of the 303 certified nursing homes in TN. Compared within TN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys on file averaged 11. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens October 2027 — about 11 months from now. This facility’s last Life Safety survey was July 2026. Facilities in TN are typically surveyed 15–44 months after the last one (median 32), measured over 322 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
6 of the 26 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 26 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-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.
How that compares
Compared with the median facility in TN, and nationally. Surveyors differ markedly between states, so the TN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 26 |
| Median facility in TN | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 30, 2023 | 13 |
| March 4, 2026 | 9 |
| July 22, 2026 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-07-22 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 3 | 2026-07-22 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2026-03-04 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2026-03-04 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2023-08-30 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2023-08-30 |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | 1 | 2023-08-30 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2023-08-30 |
What the citations cover
- Smoke Deficiencies 7
- Emergency Preparedness Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Egress Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Emergency Preparedness Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Egress Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 22, 2026 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (August 20, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 20, 2026) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (August 20, 2026) |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Deficient, Provider has date of correction (August 20, 2026) |
March 4, 2026 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (May 20, 2026) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (April 24, 2026) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (April 24, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 28, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 20, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 24, 2026) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (April 24, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 24, 2026) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (April 24, 2026) |
August 30, 2023 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (October 12, 2023) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (October 12, 2023) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (October 12, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0754 | Provide properly sized and located linen or trash receptacles. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 12, 2023) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.