Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MULBERRY HEALTH & REHABILITATION
FRANKLIN, TN · 157 certified beds · Last Life Safety survey September 27, 2023
CMS Certification Number 445157 · first certified June 1983
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within TN
24 citations — more than 95% 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 1 citation; the earlier surveys in the window averaged 7.7. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: December 2024 to June 2027. This facility’s last Life Safety survey was September 2023. Facilities in TN are typically surveyed 15–44 months after the last one (median 33), measured over 279 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 three years in Maryland. How the window is measured
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3 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 ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
4 of the 24 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)
6 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 24 Life Safety citations above. The Physical Environment Index
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 | 24 |
| Median facility in TN | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 19, 2019 | 18 |
| July 19, 2021 | 0 |
| June 15, 2023 | 5 |
| September 27, 2023 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2023-06-15 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2023-06-15 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2023-09-27 |
| 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. | 2 | 2023-06-15 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2023-06-15 |
| E-0032 | Provide primary/alternate means for communication. | 1 | 2019-11-19 |
| E-0030 | List the names and contact information of those in the facility. | 1 | 2019-11-19 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2019-11-19 |
What the citations cover
- Smoke Deficiencies 9
- Egress Deficiencies 6
- Emergency Preparedness Deficiencies 4
- Services Deficiencies 3
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Egress Deficiencies | 6 |
| Emergency Preparedness Deficiencies | 4 |
| Services Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 27, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 9, 2023) |
June 15, 2023 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| 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 (July 28, 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 (July 28, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 28, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 28, 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 (July 28, 2023) |
November 19, 2019 — 18 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (January 22, 2020) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (January 22, 2020) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (January 22, 2020) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (January 22, 2020) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (January 22, 2020) |
| 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 (January 22, 2020) |
| K-0227 | Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Deficient, Provider has date of correction (January 22, 2020) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (January 22, 2020) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (January 22, 2020) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (January 22, 2020) |
| 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 (January 22, 2020) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (January 22, 2020) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 22, 2020) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 22, 2020) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (January 22, 2020) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (January 22, 2020) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (January 22, 2020) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (January 22, 2020) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.