Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
THE MCKENDREE POST ACUTE & REHABILITATION
HERMITAGE, TN · 180 certified beds · Last Life Safety survey October 3, 2023
CMS Certification Number 445491 · first certified January 2009
Ownership
Operated by HILL VALLEY HEALTHCARE · Non profit - Corporation
- Ownership changed June 17, 2024 (change of ownership)from NASHVILLE SENIOR CARE LLC
Position within TN
21 citations — more than 93% 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 6 citations; the earlier surveys in the window averaged 7.5. With 3 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 October 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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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 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
7 of the 21 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 21 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0908 Keep all essential equipment working safely.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0880 Provide and implement an infection prevention and control program.
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 | 21 |
| Median facility in TN | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 6, 2018 | 6 |
| June 19, 2019 | 9 |
| October 3, 2023 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2019-06-19 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2023-10-03 |
| E-0030 | List the names and contact information of those in the facility. | 1 | 2019-06-19 |
| K-0251 | Conform to length requirements for dead end corridors. | 1 | 2019-06-19 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2023-10-03 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2023-10-03 |
| E-0015 | Address subsistence needs for staff and patients. | 1 | 2019-06-19 |
| K-0133 | Install a two-hour-resistant firewall separation. | 1 | 2018-06-06 |
What the citations cover
- Emergency Preparedness Deficiencies 7
- Smoke Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Construction Deficiencies 2
- Other 4
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 7 |
| Smoke Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Construction Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
| Egress Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 3, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 13, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 13, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 13, 2023) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (November 13, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 13, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 13, 2023) |
June 19, 2019 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (August 2, 2019) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (August 2, 2019) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (August 2, 2019) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (August 2, 2019) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (August 2, 2019) |
| E-0033 | Establish methods for sharing information. | Deficient, Provider has date of correction (August 2, 2019) |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (August 2, 2019) |
| K-0251 | Conform to length requirements for dead end corridors. | Deficient, Provider has date of correction (August 2, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 2, 2019) |
June 6, 2018 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (June 20, 2018) |
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (June 20, 2018) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (June 20, 2018) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 20, 2018) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 20, 2018) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 20, 2018) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.