Mulberry Health & Rehabilitation
200 Strahl Street, Franklin, TN 37064 · Williamson County · 157 certified beds · avg 86 residents/day · certified since Jun 23, 1983
SFF Candidate
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Jul 19, 2021 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Aug 30, 2021 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Jul 19, 2021 · F-0726
The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Why it matters: Undertrained caregivers are more likely to miss warning signs and make care mistakes.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Aug 30, 2021 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Jul 19, 2021 · F-0744
The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience.
Why it matters: Poor dementia care can lead to distress, unsafe wandering, or unnecessary sedating medication.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Aug 30, 2021 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Jul 19, 2021 · F-0835
The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents.
Why it matters: Poor administration often shows up as understaffing, supply shortages, and care problems across the whole facility.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Aug 30, 2021 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Jul 19, 2021 · F-0867
The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Why it matters: Without a working quality program, the same care problems tend to repeat instead of getting fixed.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Aug 30, 2021 (Deficient, Provider has date of correction)
All citations in the current public record (35)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Oct 27, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Oct 27, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 27, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Oct 27, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 15, 2023 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Jun 15, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 19, 2021 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Jul 19, 2021 | ▲ K · Immediate jeopardy, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Jul 19, 2021 | ▲ K · Immediate jeopardy, repeated | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Jul 19, 2021 | ▲ K · Immediate jeopardy, repeated | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| Jul 19, 2021 | ▲ K · Immediate jeopardy, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Jul 19, 2021 | E · Potential for harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jul 19, 2021 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 19, 2021 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 19, 2021 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Jul 19, 2021 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jul 19, 2021 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jul 19, 2021 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 19, 2021 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Nov 19, 2019 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Nov 19, 2019 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 19, 2019 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Nov 19, 2019 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Nov 19, 2019 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Nov 19, 2019 | D · Potential for harm, one-off | The facility did not have firmly secured handrails on both sides of its hallways. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (13 → 12).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 6 | 0 | E |
| 2021 | 13 | 5 | K ▲ |
| 2023 | 16 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Tennessee avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.85 | 3.62 | 3.95 | top 28% in Tennessee; top 46% in the U.S. |
| Registered Nurse hours | 0.32 | 0.57 | 0.69 | bottom 13% in Tennessee; bottom 12% in the U.S. |
| Weekend total nurse staffing | 3.46 | 3.15 | 3.50 | top 21% in Tennessee; top 44% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.27 | 0.39 | 0.48 | bottom 31% in Tennessee; bottom 25% in the U.S. |
| Total nursing staff turnover (%) | 67.9 | 48.9 | 45.8 | bottom 7% in Tennessee; bottom 7% in the U.S. |
| RN turnover (%) | 66.7 | 43.2 | 42.9 | bottom 16% in Tennessee; bottom 15% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.81, RN 0.32, weekend 3.42. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 1/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ownership Data Not Available |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "What specific dementia training do your staff receive, and how do you handle difficult moments without medication?"
- "What were the findings behind this administration citation, and what has leadership changed since?"
- "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Franklin Wellness and Rehabilitation Center | 0.3 mi | Franklin, TN | ★★☆☆☆ | 1/5 | |
| NHC Healthcare, Franklin | 0.5 mi | Franklin, TN | ★★☆☆☆ | 2/5 | |
| NHC Place at Cool Springs | 2.9 mi | Franklin, TN | ★★★★☆ | 4/5 | |
| Somerfield at the Heritage | 7.8 mi | Brentwood, TN | ★★★★★ | 5/5 | |
| NHC Place at the Trace | 9.7 mi | Nashville, TN | ★★★★★ | 4/5 | |
| West Meade Place | 12.0 mi | Nashville, TN | ★★★★★ | 4/5 | |
| The Meadows | 12.1 mi | Nashville, TN | ★★★☆☆ | 2/5 | |
| The Reserve at Spring Hill | 12.6 mi | Spring Hill, TN | ★★★★★ | 5/5 | |
| Woodcrest at Blakeford | 12.8 mi | Nashville, TN | ★★★★☆ | 3/5 | |
| Bethany Center for Rehabilitation and Healing LLC | 12.9 mi | Nashville, TN | ★☆☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 445157.