Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

TREVECCA CENTER FOR REHABILITATION AND HEALING LLC

NASHVILLE, TN · 240 certified beds · Last Life Safety survey June 21, 2023

CMS Certification Number 445112 · first certified October 1976

Ownership

Operated by CARERITE CENTERS · For profit - Limited Liability company

Ownership changed March 1, 2017 (change of ownership)from AVALON HEALTH CARE, LLC.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within TN

16 citations — more than 83% 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

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 3 citations; the earlier surveys in the window averaged 6.5. 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: September 2024 to February 2027. This facility’s last Life Safety survey was June 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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1 inspection-and-testing tag has 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

1 of the 16 citations on file is 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

E-0030

Physical environment (health survey)

2 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 16 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-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

How that compares

Citations on file over three years

Compared with the median facility in TN, and nationally. Surveyors differ markedly between states, so the TN figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	16
Median facility in TN	8
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
March 14, 2018	5
April 10, 2019	8
June 21, 2023	3

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2019-04-10
K-0920	Ensure proper usage of power strips and extension cords.	2	2019-04-10
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	2023-06-21
K-0363	Install corridor and hallway doors that block smoke.	1	2019-04-10
K-0351	Install an approved automatic sprinkler system.	1	2018-03-14
K-0232	Have corridors or aisles that are unobstructed and are at least 8 feet in width.	1	2019-04-10
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	1	2023-06-21
E-0030	List the names and contact information of those in the facility.	1	2023-06-21

What the citations cover

Citations by CMS category

Smoke Deficiencies 8
Gas, Vacuum, and Electrical Systems Deficiencies 3
Miscellaneous Deficiencies 2
Egress Deficiencies 2
Other 1

Citations by CMS category
Category	Citations
Smoke Deficiencies	8
Gas, Vacuum, and Electrical Systems Deficiencies	3
Miscellaneous Deficiencies	2
Egress Deficiencies	2
Emergency Preparedness Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

June 21, 2023 — 3 citations

Citations issued on June 21, 2023
Tag	What the surveyor checks	Status
E-0030	List the names and contact information of those in the facility.	Deficient, Provider has date of correction (August 1, 2023)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (August 1, 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 (August 1, 2023)

April 10, 2019 — 8 citations

Citations issued on April 10, 2019
Tag	What the surveyor checks	Status
K-0232	Have corridors or aisles that are unobstructed and are at least 8 feet in width.	Deficient, Provider has date of correction (April 23, 2019)
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 (April 12, 2019)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (April 22, 2019)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (April 9, 2019)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (April 25, 2019)
K-0754	Provide properly sized and located linen or trash receptacles.	Deficient, Provider has date of correction (April 30, 2019)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (April 9, 2019)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (May 13, 2019)

March 14, 2018 — 5 citations

Citations issued on March 14, 2018
Tag	What the surveyor checks	Status
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (April 10, 2018)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (March 29, 2018)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (March 22, 2018)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (March 29, 2018)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (March 23, 2018)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.