The McKendree Post Acute & Rehabilitation
4347 Lebanon Road · Hermitage, TN · 37076 · 6158718200
180 certified beds Non profit - Corporation Chain: Hill Valley Healthcare Part of a CCRC
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (3 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
3 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
No standard inspection in over 2 years
The inspection record here is older than usual — conditions may have changed since.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.61 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.55 | 0.55–0.75 |
| Weekend hours / resident-day | 3.17 | ≈ weekday level |
| Nursing turnover / year | 55% | median 45% |
| Fines (3-yr window) | 1 · $252,242 |
Inspection citations (37 in the current record)
-
Potential for harm · D November 20, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 3, 2025 · Pharmacy Service
-
Immediate jeopardy · J October 3, 2023 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected November 3, 2023 · Freedom from Abuse, Neglect, and Exploitation
-
Immediate jeopardy · J October 3, 2023 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected November 3, 2023 · Quality of Life and Care
-
Immediate jeopardy · K October 3, 2023 · found via complaint
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 November 3, 2023 · Quality of Life and Care
-
Actual harm · G October 3, 2023
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 November 1, 2023 · Nursing and Physician Services
-
Potential for harm · D October 3, 2023 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected November 1, 2023 · Resident Rights
-
Potential for harm · F October 3, 2023 · found via complaint
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected January 22, 2024 · Resident Rights
-
Potential for harm · D October 3, 2023 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected November 3, 2023 · Resident Rights
-
Potential for harm · D October 3, 2023 · found via complaint
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected November 3, 2023 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D October 3, 2023 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected November 3, 2023 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D October 3, 2023 · found via complaint
Respond appropriately to all alleged violations.
Corrected November 3, 2023 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D October 3, 2023 · found via complaint
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected November 3, 2023 · Resident Rights
-
Potential for harm · D October 3, 2023 · found via complaint
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 November 3, 2023 · Resident Rights
-
Potential for harm · D October 3, 2023 · found via complaint
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected November 3, 2023 · Resident Assessment and Care Planning
-
Potential for harm · D October 3, 2023 · found via complaint
Ensure each resident receives an accurate assessment.
Corrected November 3, 2023 · Resident Assessment and Care Planning
-
Potential for harm · D October 3, 2023 · found via complaint
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected November 3, 2023 · Resident Assessment and Care Planning
-
Potential for harm · D October 3, 2023 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected November 14, 2023 · Resident Assessment and Care Planning
-
Potential for harm · D October 3, 2023 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected November 14, 2023 · Resident Assessment and Care Planning
-
Potential for harm · D October 3, 2023 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected November 3, 2023 · Quality of Life and Care
-
Potential for harm · D October 3, 2023 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected November 14, 2023 · Quality of Life and Care
-
Potential for harm · D October 3, 2023 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected November 3, 2023 · Quality of Life and Care
-
Potential for harm · D October 3, 2023 · found via complaint
Provide care or services that was trauma informed and/or culturally competent.
Corrected November 2, 2023 · Quality of Life and Care
-
Potential for harm · D October 3, 2023 · found via complaint
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 November 3, 2023 · Quality of Life and Care
-
Potential for harm · D October 3, 2023 · found via complaint
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 November 2, 2023 · Pharmacy Service
-
Potential for harm · F October 3, 2023 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected November 3, 2023 · Nutrition and Dietary
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| October 3, 2023 | Fine | $252,242 |
| October 3, 2023 | Payment Denial | 74 days |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 445491 · certified since January 13, 2009. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.