Cycle 1
Health 2023-10-03 · Fire 2023-10-03
27 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Hermitage, TN
The Mckendree Post Acute & Rehabilitation
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $252,242 in total fines with 27 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
4347 Lebanon Road, Hermitage, TN
(615) 871-8200
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
172
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Hill Valley Healthcare
Operator or chain grouping
Approved since
2009-01-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.55
Registered nurse staffing
LPN hours / resident day
0.97
Licensed practical nurse staffing
Aide hours / resident day
2.07
Nurse aide staffing
Weekend hours
3.28
Weekend nurse staffing
RN turnover
42%
Annual RN turnover
Total nurse turnover
55%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 37.9% |
89.9%
52 pts worse
|
93.4%
55.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 79.9% |
94.5%
14.6 pts worse
|
95.5%
15.6 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
3.6%
0.5 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 28.5% |
11.8%
16.7 pts worse
|
11.4%
17.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 13.1% |
6.2%
6.9 pts worse
|
5.4%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
32.2%
13.8 pts better
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
18.1%
3.8 pts better
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.6% |
19.9%
3.3 pts better
|
16.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.5% |
15.3%
1.8 pts better
|
14.9%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.9%
1.5 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.3% |
20.2%
6.1 pts worse
|
19.8%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
5.4%
1 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 3.4% |
79.6%
76.2 pts worse
|
81.7%
78.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
11.2%
0.1 pts worse
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.6%
0.1 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 8.0% |
79.8%
71.8 pts worse
|
79.7%
71.7 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.3% |
22.2%
4.1 pts worse
|
23.9%
2.4 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-06-19 · Fire 2019-06-19
6 health deficiencies
Top issue: Environmental (1 deficiency)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Cycle 3
Health 2018-06-06 · Fire 2018-06-06
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-10-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-13
D · Potential for more than minimal harm
2023-10-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-13
D · Potential for more than minimal harm
2023-10-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-13
D · Potential for more than minimal harm
2023-10-03
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-11-13
D · Potential for more than minimal harm
2023-10-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-13
D · Potential for more than minimal harm
2023-10-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-13
D · Potential for more than minimal harm
2019-06-19
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-08-02
D · Potential for more than minimal harm
2019-06-19
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2019-08-02
D · Potential for more than minimal harm
2019-06-19
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2019-08-02
D · Potential for more than minimal harm
2019-06-19
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2019-08-02
D · Potential for more than minimal harm
2019-06-19
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2019-08-02
D · Potential for more than minimal harm
2019-06-19
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2019-08-02
D · Potential for more than minimal harm
2019-06-19
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2019-08-02
D · Potential for more than minimal harm
2019-06-19
K251 · Egress Deficiencies
Fire Safety
Conform to length requirements for dead end corridors.
Corrected 2019-08-02
D · Potential for more than minimal harm
2019-06-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-08-02
D · Potential for more than minimal harm
2018-06-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2018-06-20
D · Potential for more than minimal harm
2018-06-06
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2018-06-20
D · Potential for more than minimal harm
2018-06-06
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2018-06-20
D · Potential for more than minimal harm
2018-06-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-06-20
D · Potential for more than minimal harm
2018-06-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-06-20
D · Potential for more than minimal harm
2018-06-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2018-06-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-03
K · Immediate jeopardy
2023-10-03
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-11-03
J · Immediate jeopardy
2023-10-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-03
J · Immediate jeopardy
2023-10-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-03
G · Actual harm
2023-10-03
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-11-01
F · Potential for more than minimal harm
2023-10-03
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-01-22
F · Potential for more than minimal harm
2023-10-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-10-03
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-11-07
D · Potential for more than minimal harm
2023-10-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-10-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-03
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-03
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-03
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-03
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-03
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-03
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-03
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-11-02
D · Potential for more than minimal harm
2023-10-03
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-03
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-11-02
D · Potential for more than minimal harm
2023-10-03
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-11-07
F · Potential for more than minimal harm
2019-06-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-08-02
F · Potential for more than minimal harm
2019-06-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-02
F · Potential for more than minimal harm
2019-06-19
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2019-08-02
D · Potential for more than minimal harm
2019-06-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2019-07-23
D · Potential for more than minimal harm
2019-06-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-08-02
D · Potential for more than minimal harm
2019-06-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-08-02
D · Potential for more than minimal harm
2018-06-06
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2018-07-20
D · Potential for more than minimal harm
2018-06-06
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2018-07-20
D · Potential for more than minimal harm
2018-06-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-07-20
D · Potential for more than minimal harm
2018-06-06
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2018-07-20
Penalties and ownership
What sits behind the stars
$252,242
2023-10-03
Fine
Fine · fine $252,242
Fine
$0
2023-10-03
Payment Denial
Payment Denial · denial start 2023-11-09 · 74 days
74 day denial
Ownership
Tn 2 SNF Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Garafola, Joseph
Operational/Managerial Control · Individual
Idels, Shimon
Corporate Officer · Individual
Lion 26 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Sabrina 1818 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Saessy Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Tatiriq Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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3-star overall rating with 2-star inspections with $7,901 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Life Care Center Of Old Hickory Village
Old Hickory, TN
3-star overall rating with 2-star inspections with $13,520 in total fines with 12 recent health deficiencies
#3
Cedar Creek Post Acute
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1-star overall rating with 1-star inspections with $211,244 in total fines with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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