The McKendree Post Acute & Rehabilitation
4347 Lebanon Road, Hermitage, TN 37076 · Davidson County · 180 certified beds · avg 173 residents/day · certified since Jan 13, 2009
Abuse citation flag (CMS)SFF Candidate
Part of chain: HILL VALLEY HEALTHCARE (43 facilities, chain avg rating 1.8★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
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 · Oct 3, 2023 · F-0700 · triggered by a complaint
The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Why it matters: Improperly used bed rails can trap or injure residents — in the worst cases, causing serious harm.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Nov 3, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Oct 3, 2023 · F-0600 · triggered by a complaint
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 (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 3, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Oct 3, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 3, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 3, 2023 · 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 1, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (37)
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 |
|---|---|---|
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Oct 3, 2023 | ▲ K · Immediate jeopardy, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · from a complaint |
| Oct 3, 2023 | ▲ J · Immediate jeopardy, 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 3, 2023 | ▲ J · Immediate jeopardy, 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 |
| Oct 3, 2023 | ▲ G · Actual harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Oct 3, 2023 | F · Potential for harm, facility-wide | The facility did not properly notify residents about the balance of money it holds for them, or failed to return those funds when a resident was discharged, evicted, or died. · from a complaint |
| Oct 3, 2023 | F · Potential for harm, facility-wide | 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. · from a complaint |
| Oct 3, 2023 | F · Potential for harm, facility-wide | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · from a complaint |
| Oct 3, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Oct 3, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Oct 3, 2023 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Oct 3, 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 3, 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 3, 2023 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint |
| Oct 3, 2023 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · from a complaint |
| Oct 3, 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. · from a complaint |
| Oct 3, 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. · from a complaint |
| Oct 3, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · from a complaint |
| Oct 3, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Oct 3, 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. · from a complaint |
| Oct 3, 2023 | D · Potential for harm, one-off | 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. · from a complaint |
| Oct 3, 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. · from a complaint |
| Oct 3, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Oct 3, 2023 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · from a complaint |
| Oct 3, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). · from a complaint |
| Oct 3, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint |
| Oct 3, 2023 | D · Potential for harm, one-off | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Jun 19, 2019 | F · Potential for harm, facility-wide | 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. |
| Jun 19, 2019 | F · Potential for harm, facility-wide | 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. |
| Jun 19, 2019 | F · Potential for harm, facility-wide | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Jun 19, 2019 | 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. |
| Jun 19, 2019 | 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 19, 2019 | 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. |
| Jun 6, 2018 | 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 6, 2018 | 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 6, 2018 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jun 6, 2018 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 26).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2018 | 4 | 0 | D |
| 2019 | 6 | 0 | F |
| 2023 | 26 | 4 | K ▲ |
| 2025 | 1 | 0 | D |
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)
1 fine totaling $252,242, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Oct 3, 2023 | Fine | $252,242 |
| Oct 3, 2023 | Payment Denial | 74 days from Nov 9, 2023 |
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) | 2.97 | 3.62 | 3.95 | bottom 15% in Tennessee; bottom 13% in the U.S. |
| Registered Nurse hours | 0.46 | 0.57 | 0.69 | bottom 39% in Tennessee; bottom 31% in the U.S. |
| Weekend total nurse staffing | 2.62 | 3.15 | 3.50 | bottom 20% in Tennessee; bottom 13% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.35 | 0.39 | 0.48 | bottom 50% in Tennessee; bottom 41% in the U.S. |
| Total nursing staff turnover (%) | 58.0 | 48.9 | 45.8 | bottom 23% in Tennessee; bottom 20% in the U.S. |
| RN turnover (%) | 70.0 | 43.2 | 42.9 | bottom 12% in Tennessee; bottom 12% 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 3.50, RN 0.54, weekend 3.09. Staffing rating: 1/5.
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: 2/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| TN 2 SNF Operations Holdings LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 06/17/2024 |
| Garafola, Joseph | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/17/2024 |
| Garafola, Joseph | Individual | ADP of the SNF | NOT APPLICABLE | 06/17/2024 |
| Idels, Shimon | Individual | Corporate Officer | NOT APPLICABLE | 06/17/2024 |
| Idels, Shimon | Individual | ADP of the SNF | NOT APPLICABLE | 06/17/2024 |
| TN 2 SNF Operations Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/27/2026 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "If you manage my family member's personal funds, how often will we get statements and how quickly are funds returned?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you inspect and maintain essential equipment, and how quickly are repairs made?"
- "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 |
|---|---|---|---|---|---|
| Heartland | 3.5 mi | Nashville, TN | ★★★★★ | 4/5 | |
| Life Care Center of Old Hickory Village | 4.5 mi | Old Hickory, TN | ★★★☆☆ | 2/5 | |
| Cedar Creek Post Acute | 5.4 mi | Mount Juliet, TN | ★☆☆☆☆ | 1/5 | |
| Creekside Center for Rehabilitation and Healing | 6.8 mi | Madison, TN | ★★★★☆ | 4/5 | |
| NHC Healthcare, Hendersonville | 8.0 mi | Hendersonville, TN | ★★★☆☆ | 3/5 | |
| Trevecca Center for Rehabilitation and Healing LLC | 8.8 mi | Nashville, TN | ★★★☆☆ | 3/5 | |
| Alta Heights Post Acute | 9.1 mi | Goodlettsville, TN | ★★★★☆ | 4/5 | |
| Nashville Center for Rehabilitation and Healing LL | 10.7 mi | Nashville, TN | ★★☆☆☆ | 2/5 | |
| Whites Creek Wellness and Rehabilitation Center | 10.8 mi | Whites Creek, TN | ★★★☆☆ | 3/5 | |
| Antioch TN Opco, LLC | 10.9 mi | Antioch, TN | ★★☆☆☆ | 1/5 | abuseSFF |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 445491.