SNF
THE MCKENDREE POST ACUTE & REHABILITATION
CCN: 445491 · HERMITAGE, TN 37076 · Davidson County
SFF Candidate Abuse citation flag Inspection > 2 years ago CCRC
Overview
- Address
- 4347 LEBANON ROAD, HERMITAGE, TN 37076
- Phone
- 6158718200
- Certified beds
- 180
- Avg daily residents
- 172 (95% of beds filled)
- Ownership
- Non-profit corporation
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 2009-01-13
- Setting
- Urban
1 /5
★★★★★
CMS Overall Rating
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 3.58 | 4.18 | 3.31 | ≥ 3.48 | |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 0.55 | 0.73 | 0.51 | ≥ 0.55 | Below floor |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 0.97 | 0.93 | 0.89 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 2.07 | 2.52 | 1.91 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 1.52 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.11 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Total nurse (weekend)
3.28
hrs / resident / day
RN (weekend)
0.50
hrs / resident / day
Total nurse (adjusted, weekend)
3.03
hrs / resident / day
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Total nursing staff turnover
54.8%
annual
RN turnover
42.1%
annual
Administrators departed
0
last 12 months
Resident acuity
Nursing Case-Mix Index
1.48
higher acuity than avg
Case-Mix Index Ratio
1.07
facility / state ratio
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2023-10-03 | 27 | 26 | 26 | 423 | 2 | 635 |
| Cycle 2/3 (prior) | 2019-06-19 | 6 | 6 | 0 | 60 | 1 | 60 |
Total weighted health score
491.3
lower is better
Deficiencies (37)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
33 D/E/F Actual harm — potential for minor
1 G/H/I Actual harm
3 J/K/L Immediate jeopardy
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | 2025-11-20 | 2025-12-03 |
| 0726 | 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. | G | 2023-10-03 | 2023-11-01 |
| 0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | 2023-10-03 | 2023-11-01 |
| 0569 | Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | F | 2023-10-03 | 2024-01-22 |
| 0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | 2023-10-03 | 2023-11-03 |
| 0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | 2023-10-03 | 2023-11-03 |
| 0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D | 2023-10-03 | 2023-11-03 |
| 0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | 2023-10-03 | 2023-11-03 |
| 0610 | Respond appropriately to all alleged violations. | D | 2023-10-03 | 2023-11-03 |
| 0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D | 2023-10-03 | 2023-11-03 |
| 0625 | 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. | D | 2023-10-03 | 2023-11-03 |
| 0640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | D | 2023-10-03 | 2023-11-03 |
| 0641 | Ensure each resident receives an accurate assessment. | D | 2023-10-03 | 2023-11-03 |
| 0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D | 2023-10-03 | 2023-11-03 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2023-10-03 | 2023-11-14 |
| 0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | 2023-10-03 | 2023-11-14 |
| 0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | 2023-10-03 | 2023-11-03 |
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | 2023-10-03 | 2023-11-14 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | 2023-10-03 | 2023-11-03 |
| 0697 | Provide safe, appropriate pain management for a resident who requires such services. | D | 2023-10-03 | 2023-11-03 |
| 0699 | Provide care or services that was trauma informed and/or culturally competent. | D | 2023-10-03 | 2023-11-02 |
| 0700 | 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. | K | 2023-10-03 | 2023-11-03 |
| 0742 | 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. | D | 2023-10-03 | 2023-11-03 |
| 0758 | 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. | D | 2023-10-03 | 2023-11-02 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | 2023-10-03 | 2023-11-03 |
| 0908 | Keep all essential equipment working safely. | F | 2023-10-03 | 2023-11-07 |
| 0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | D | 2023-10-03 | 2023-11-07 |
| 0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | 2019-06-19 | 2019-07-23 |
| 0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | 2019-06-19 | 2019-08-02 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | 2019-06-19 | 2019-08-02 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F | 2019-06-19 | 2019-08-02 |
| 0880 | Provide and implement an infection prevention and control program. | F | 2019-06-19 | 2019-08-02 |
| 0908 | Keep all essential equipment working safely. | F | 2019-06-19 | 2019-08-02 |
| 0578 | 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. | D | 2018-06-06 | 2018-07-20 |
| 0640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | D | 2018-06-06 | 2018-07-20 |
| 0658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | 2018-06-06 | 2018-07-20 |
| 0758 | 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. | D | 2018-06-06 | 2018-07-20 |
Penalties (2)
Fines issued
1
last 3 years
Total fines
$252,242
Payment denials
1
| Date | Type | Fine amount |
|---|---|---|
| 2023-10-03 | Fine | $252,242 |
| 2023-10-03 | Payment Denial | — |
Source: CMS Nursing Home Penalties.
Ownership & Corporate Structure
Chain: HILL VALLEY HEALTHCARE
- Chain ID
270- Facilities in chain
- 40
- Legal business name
- MCKENDREE SNF OPERATIONS LLC
Chain-average star ratings (for peer context)
Overall
2.2
Health
1.9
Staffing
2.0
QM
3.8
Owner / manager organizations (5)
| Organization | Role | Association |
|---|---|---|
| TN 2 SNF OPERATIONS HOLDINGS LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 06/17/2024 |
| LION 26 HOLDINGS LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 06/17/2024 |
| SABRINA 1818 HOLDINGS LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 06/17/2024 |
| SAESSY IRREVOCABLE TRUST | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 06/17/2024 |
| TATIRIQ IRREVOCABLE TRUST | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 06/17/2024 |
Owner / manager individuals (2)
| Name | Role | Association |
|---|---|---|
| GARAFOLA, JOSEPH | OPERATIONAL/MANAGERIAL CONTROL | since 06/17/2024 |
| IDELS, SHIMON | CORPORATE OFFICER | since 06/17/2024 |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- Yes
- Hospital-based
- No
- Resident / family council
- Resident
- Sprinkler systems
- Yes
- Special focus status
- SFF Candidate
- Abuse citation flag
- Yes — last 2 cycles
Methodology & sources
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Penalties (
nh-penalties), vintage 2026, downloaded 2026-04-14 , 16,915 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 99 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Provider Information | Abuse Icon | Y | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 0.89331 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 1.90926 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 0.50760 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 3.31017 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 3.03265 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 171.5 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 0.92690 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.51910 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.73060 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 4.17660 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 3.68123 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | 1.9 | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | 2.2 | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | 3.8 | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | 2.0 | Chain Average Staffing Rating |
| Provider Information | Chain ID | 270 | Chain ID |
| Provider Information | Chain Name | HILL VALLEY HEALTHCARE | Chain Name |
| Provider Information | City/Town | HERMITAGE | City/Town |
| Provider Information | CMS Certification Number (CCN) | 445491 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | Y | Continuing Care Retirement Community |
| Provider Information | County/Parish | Davidson | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 2009-01-13 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 1 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 36.2067 | Latitude |
| Provider Information | Legal Business Name | MCKENDREE SNF OPERATIONS LLC | Legal Business Name |
| Provider Information | Location | 4347 LEBANON ROAD,HERMITAGE,TN,37076 | Location |
| Provider Information | Long-Stay QM Rating | 4 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -86.613 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | Y | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 0 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 180 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | — | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | 40 | Number of Facilities in Chain |
| Provider Information | Number of Fines | 1 | Number of Fines |
| Provider Information | Number of Payment Denials | 1 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.47958 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 1.07399 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 1 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | Non profit - Corporation | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 4347 LEBANON ROAD | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | THE MCKENDREE POST ACUTE & REHABILITATION | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 180 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 3 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 423 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 212 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 26 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 2 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 26 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2023-10-03 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 635 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 27 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 6 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2019-06-19 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 60 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 0 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 60 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 6 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.49754 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 42.1 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 1.51545 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 0.96635 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 2.06536 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.11055 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 0.54910 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 3.58082 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | 3 | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | — | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | SFF Candidate | Special Focus Status |
| Provider Information | Staffing Rating | 2 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | TN | State |
| Provider Information | Telephone Number | 6158718200 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 252242.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 3.28060 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 2 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 54.8 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 491.250 | Total Weighted Health Survey Score |
| Provider Information | Urban | Y | Urban |
| Provider Information | With a Resident and Family Council | Resident | With a Resident and Family Council |
| Provider Information | ZIP Code | 37076 | ZIP Code |