THE MCKENDREE POST ACUTE & REHABILITATION
Open-data reference.
THE MCKENDREE POST ACUTE & REHABILITATION is a non profit - corporation facility in HERMITAGE, TN with 180 certified beds and a 1-star overall CMS rating. The facility has 37 deficiency records on file. Total penalties: $252K.
4347 LEBANON ROAD, HERMITAGE, TN 37076
Phone: 6158718200
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 445491
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 180
- Residents
- 172
- In Hospital
- No
- County
- Davidson
- Last Inspection
- Oct 3, 2023
- Special Focus
- SFF Candidate
Staffing Data
- RN Hours
- 0.55 (nat'l avg: 0.68)
- LPN Hours
- 0.97
- CNA Hours
- 2.07
- Total Nursing Hours
- 3.58 (nat'l avg: 3.89)
- PT Hours
- 0.11
- Nursing Turnover
- 54.8%
- RN Turnover
- 42.1%
What the CMS Record Reveals About THE MCKENDREE POST ACUTE & REHABILITATION
THE MCKENDREE POST ACUTE & REHABILITATION operates 180 certified beds in HERMITAGE, TN with approximately 172 residents currently in care, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (2★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 37 deficiency records from recent surveys, of which 4 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $252K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.58 total nursing hours per resident day (national average 3.89), with RN coverage at 0.55 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature. This facility is currently designated "SFF Candidate" under the CMS Special Focus Facility program, reserved for providers with a persistent pattern of serious quality problems.
Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, THE MCKENDREE POST ACUTE & REHABILITATION falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 54.8%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (37 most recent)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Dec 3, 2025
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: Nov 7, 2023
Keep all essential equipment working safely.
Category: Environmental Deficiencies
Corrected: Nov 7, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Nov 3, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: Nov 2, 2023
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.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 3, 2023
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.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 3, 2023
Provide care or services that was trauma informed and/or culturally competent.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 2, 2023
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 3, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 3, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 14, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Nov 3, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 14, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 14, 2023
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 3, 2023
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 3, 2023
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Nov 3, 2023
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.
Category: Resident Rights Deficiencies
Corrected: Nov 3, 2023
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Nov 3, 2023
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Nov 3, 2023
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Nov 3, 2023
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Nov 3, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Nov 3, 2023
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Nov 3, 2023
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Category: Resident Rights Deficiencies
Corrected: Jan 22, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Nov 1, 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.
Category: Nursing and Physician Services Deficiencies
Corrected: Nov 1, 2023
Keep all essential equipment working safely.
Category: Environmental Deficiencies
Corrected: Aug 2, 2019
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 2, 2019
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Aug 2, 2019
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 2, 2019
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 2, 2019
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 23, 2019
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.
Category: Pharmacy Service Deficiencies
Corrected: Jul 20, 2018
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 20, 2018
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 20, 2018
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Category: Resident Rights Deficiencies
Corrected: Jul 20, 2018
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 13.5% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 13.1% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.6% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.4% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 28.5% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 4.1% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 37.9% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 3.4% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.7% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 16.6% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 18.4% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 79.9% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 8.0% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 6.4% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 26.3% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 14.3% | Yes |
Penalty History 1 penalties totaling $252K
| Date | Type | Amount |
|---|---|---|
| Oct 3, 2023 | Fine | $252K |
| Oct 3, 2023 | Payment Denial | - |
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Understanding Nursing Home Data
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County Health Data
Health outcomes, access, and quality metrics for Davidson on PlainHealth
Frequently Asked Questions
What is the overall CMS rating for THE MCKENDREE POST ACUTE & REHABILITATION?
What are the staffing levels at THE MCKENDREE POST ACUTE & REHABILITATION?
How many beds does THE MCKENDREE POST ACUTE & REHABILITATION have?
Does THE MCKENDREE POST ACUTE & REHABILITATION have any deficiencies on record?
Has THE MCKENDREE POST ACUTE & REHABILITATION received any fines or penalties?
Who owns THE MCKENDREE POST ACUTE & REHABILITATION?
When was THE MCKENDREE POST ACUTE & REHABILITATION last inspected?
What quality measures are tracked for THE MCKENDREE POST ACUTE & REHABILITATION?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.