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Home / Tennessee / Franklin

Mulberry Health & Rehabilitation

200 Strahl Street, Franklin, TN 37064 · Williamson County · (615) 791-1103

157 certified beds, about 86 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1983

Special Focus Facility candidate Last standard inspection more than 2 years ago Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
2 of 5
Quality measures
3 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 445157 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on June 15, 2023, inspectors cited 12 health deficiencies (the Tennessee average is 4.4, the national average 9.2).

Of 35 health citations since November 2019, 5 were rated as actual harm or immediate jeopardy to residents (5 immediate jeopardy).

CMS lists no fines against this home in the last three years.

Nurses and nurse aides worked 3.81 hours per resident per day, against 3.80 across Tennessee and 3.86 nationally. Registered nurses accounted for 0.32 of those hours.

67.9% of nursing staff left within the year CMS measured (Tennessee average 48.9%).

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 35 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
5K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
24D
6E
0F
Potential for minimal harm
0A
0B
0C
October 27, 2023Complaint inspection · 4 citations
  1. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on policy review, document review, record review, and interview, the facility failed to protect the resident's right to be free from verbal abuse for 1 (Resident #4) of 7 residents reviewed for abuse. Dietary Staff (DS) DS #3 used profanity directed toward Resident #4 and called the resident a derogatory name.
  2. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on policy review, document review, record review, and interview, the facility failed to ensure allegations of abuse and injuries of unknown origin were reported to the State Agency within two hours of learning of the allegations for 1 (Resident #1) of 7 residents reviewed for abuse.
  3. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on policy review, document review, record review, and interview, the facility failed to ensure a thorough investigation of an injury of unknown origin was completed for 1 (Resident #1) of 7 residents reviewed for abuse.
  4. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 8, 2023
    Inspectors wroteBased on record review, facility document review, and interviews, the facility failed to ensure proper transfer methods were used for 1 (Resident #1) of 3 residents reviewed for falls.
June 15, 2023Standard inspection · 12 citations
  1. E
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) July 28, 2023
    Inspectors wroteBased on review of facility policy, medical record review, facility investigations and interview, the facility failed to report the investigative outcome within 5 working days of the alleged violation for 3 of 3 allegations reviewed involving 5 residents (Resident #82, Resident #64, Resident #62, Resident #44, and #241) sampled for abuse.
  2. D
    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.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 28, 2023
    Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to inform of/or provide written information regarding a resident's right to formulate an advanced directive for 12 of 24 sample residents (Resident #8, #12, #18, #19, #20, #37, #41, #44, #50, #61, #73, and #82) residents reviewed.
  3. D
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    F640 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 28, 2023
    Inspectors wroteBased on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete the admission assessment, using the Centers for Medicare & Medicaid Services-specific RAI (Resident Assessment Instrument) process within the regulatory time frames for 1 of 20 sampled residents (Resident #66) reviewed for completion of the MDS.
  4. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 28, 2023
    Inspectors wroteBased on medical record review and interview, the facility failed to accurately assess residents for hospice for 2 of 2 (Resident #36 and #88) sampled residents reviewed.
  5. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 28, 2023
    Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to conduct Care Plan meetings for 3 of 8 sampled residents (Resident #9, #44, and #50) and failed to revise the Care Plan for 1 of 19 sampled residents (Resident #41) reviewed for care planning.
  6. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 28, 2023
    Inspectors wroteBased on review of the facility policy, medical record review and interview the facility failed to monitor blood glucose levels as prescribed for 1 of 3 residents (Resident #13) reviewed related to blood glucose monitoring.
  7. D
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 28, 2023
    Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to follow the facility's policy for monitoring weights for 2 of 5 sampled residents (Resident #20 and #41) reviewed for nutrition.
  8. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 28, 2023
    Inspectors wroteBased on policy review, medical record, observation, and interview, the facility failed to ensure residents received appropriate respiratory and trach care for 1 of 1 sampled resident (Resident #11) reviewed for respiratory services.
  9. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 28, 2023
    Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to monitor for the side effects of antipsychotic medications for 2 of 5 sampled residents (Resident #44 and #391) reviewed for unnecessary medication.
  10. D
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 28, 2023
    Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure medications were properly labeled and stored in 1 of 4 medication storage areas (One East Nurse Station Medication Storage Room) when there were no clear identifiers on an insulin pen's label and when there were no documented temperatures for the medication refrigerator from 6/1/2023 thru 6/13/2023.
  11. D
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    F803 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 28, 2023
    Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure food preferences and menu choices for 2 of 8 (Resident #17, and #75) sampled residents.
  12. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 28, 2023
    Inspectors wroteBased on policy review, medical record review and interview, the facility failed to maintain and monitor an effective infection prevention and control program for 3 of 3 sample resident (Resident #9, #60 and #141) reviewed for Legionella Disease.
July 19, 2021Standard inspection · 13 citations
  1. K
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · Immediate jeopardy to resident health or safety, pattern · Corrected (the home has a date of correction) August 30, 2021
    Inspectors wroteBased on policy review, video camera footage review, medical record review, observation, and interview, the facility failed to ensure adequate supervision of residents and ensure interventions were implemented for residents with physically aggressive and wandering/exit-seeking behaviors for 5 of 14 sampled residents (Resident #34, #80, #81, #91 and #96) reviewed for abuse. The facility's failure resulted in Immediate Jeopardy when Resident #80 willfully pushed Resident #81. Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. The facility's failure resulted in Immediate Jeopardy when Resident #34, #80, #81, #91 and #96 did not have supervision and interventions implemented for their behaviors. [...]
  2. K
    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.
    F726 · Nursing and Physician Services · Immediate jeopardy to resident health or safety, pattern · Corrected (the home has a date of correction) August 30, 2021
    Inspectors wroteBased on policy review, agency contract review, employee personnel file review, observation, and interview, the facility failed to ensure licensed nurses and certified nursing assistants (CNA) had the knowledge and skills necessary to assess residents, prevent abuse, and provide appropriate care to meet the residents needs for 5 of 16 sampled residents (Resident #34, #80, #81, #91, and #96) with physically aggressive and wandering/exit-seeking behaviors. The facility's failure resulted in Immediate Jeopardy when Resident #80 willfully pushed Resident #81. Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. The facility's failure resulted in Immediate Jeopardy when Resident #34, #80, #81, #91, and #96 did not have supervision and interventions implemented for their aggressive behaviors. [...]
  3. K
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    F744 · Quality of Life and Care · Immediate jeopardy to resident health or safety, pattern · Corrected (the home has a date of correction) August 30, 2021
    Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide care and services to meet each resident's Dementia care and behavior needs for 6 of 16 residents (Resident #34, #80, #81, #91, #96, and #303) reviewed for Dementia care and behaviors. The facility's failure to provide care and services for Dementia and behaviors resulted in Immediate Jeopardy when a physical altercation occurred between Resident #80 and #81, Resident #80 willfully pushed Resident #81, Resident #81 fell to the floor, hit his head, began having seizures, was transferred to the hospital, and expired at the hospital. [...]
  4. K
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    F835 · Administration · Immediate jeopardy to resident health or safety, pattern · Corrected (the home has a date of correction) August 30, 2021
    Inspectors wroteBased on policy review, job description review, and interview, facility Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well-being of the residents with behaviors and dementia. The Administration failed to provide oversight to monitor and provide a safe resident environment related to residents with behaviors and dementia. The Administration failed to provide oversight and training of staff to prevent abuse and provide appropriate care to meet residents needs with behaviors and dementia. These failures resulted in Immediate Jeopardy for Resident #34, #80, #81, #91, #96, and #303. The facility's failure resulted in Immediate Jeopardy when Resident #80 willfully pushed Resident #81. [...]
  5. K
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    F867 · Administration · Immediate jeopardy to resident health or safety, pattern · Corrected (the home has a date of correction) August 30, 2021
    Inspectors wroteBased on policy review, Administrator job description review, Director of Nursing (DON) job description review, Registered Nurse (RN) job description review, Licensed Practical Nurse (LPN) job description review, medical record review, video camera footage review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to resident to resident abuse, failed to perform follow up on monitoring of residents with behaviors, failed to evaluate and re-evaluate interventions implemented for residents with behaviors, failed to ensure nursing staff were competent to provide care to residents with behaviors and Dementia, and failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to abuse, residents with Dementia and behaviors, and [...]
  6. E
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 30, 2021
    Inspectors wroteBased on The National Pressure Ulcer Advisory Panel (NPUAP) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide 2019, Lippincott Manual of Nursing Practice 10th Edition, policy review, medical record review, observation, and interview, the facility failed to provide care and services for the treatment of pressure ulcers when facility staff failed to complete accurate assessments and document treatments as ordered for 3 of 3 sampled residents (Resident #59, #87, and #252) reviewed for pressure ulcers/injuries.
  7. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 30, 2021
    Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure 3 of 16 staff (Certified Nurse Assistant (CNA) #2, Registered Nurse (RN)#1, and Licensed Practical Nurse (LPN) #2) served food under sanitary conditions during dining as evidenced by staff touched food with their bare hands and used their fingernails to open milk cartons.
  8. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 30, 2021
    Inspectors wroteBased on Centers for Disease Control (CDC) guidelines, policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 2 of 3 sampled residents (Resident #301 and #302) reviewed for Transmission Based Precautions were not quarantined, when Licensed Practical Nurse (LPN) #2 washed Resident #49's hands with a cleansing wipe then used the same wipe to wipe down the dining table, when oxygen tubing was on the floor for 2 of 3 sampled residents (Resident #44 and #73) reviewed for respiratory care, when 1 of 2 Licensed Nurses (LPN) #3) failed to perform hand hygiene during wound care, and when 1 of 4 Licensed Nurses (LPN #4) touched medications with their bare hands.
  9. D
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    F636 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 30, 2021
    Inspectors wroteBased on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete a comprehensive assessment, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 1 of 28 sampled residents (Resident #252) reviewed.
  10. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 30, 2021
    Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) related to Oxygen and pressure injuries/ulcers for 2 of 28 sampled residents (Resident #73 and #87) reviewed for MDS assessments
  11. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 30, 2021
    Inspectors wroteBased on policy review, medical record review, observation and interview, the facility failed to revise a Care Plan based on the needs of the resident and in response to current interventions for Oxygen, pressure ulcers, unnecessary medications, and behaviors for 4 of 28 sampled residents (Resident #34, #87, #89, and #303) reviewed.
  12. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 30, 2021
    Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to follow the policy for incidents and accidents when they failed to complete a timely fall investigation for 1 of 2 residents (Resident #99) reviewed for falls.
  13. D
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    F693 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 30, 2021
    Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 2 nurses (Licensed Practical Nurse (LPN) #4) checked for placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube placed in the stomach for nutrition), failed to administer medications separately, and failed to flush before and after administration of medication through a PEG tube.
November 19, 2019Standard inspection · 6 citations
  1. E
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) January 3, 2020
    Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide nail care for 3 of 3 (Resident #30, #39, and #55) sampled residents reviewed for Activities of Daily Living (ADL) care.
  2. E
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) January 3, 2020
    Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure the environment was free of accident hazards when unsecured sharps and chemicals were observed in 2 of 74 (room [ROOM NUMBER] and room [ROOM NUMBER]) resident rooms, 1 of 6 (1 East Hall) storage rooms, 2 of 4 (1 East Hall and 1 [NAME] Hall) supply rooms, and 2 of 6 (1 [NAME] Hall bathroom and 1 East Hall shower room) common resident bathrooms.
  3. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 3, 2020
    Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter when nursing staff failed to keep the drainage bag off the floor for 1 of 1 (Resident #207) sampled residents reviewed with indwelling urinary catheters.
  4. D
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 3, 2020
    Inspectors wroteBased on review of the GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists, policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 5 (Licensed Practical Nurse (LPN) #3) nurses administered medications with an error rate of less than 5 percent. A total of 4 errors were observed out of 31 opportunities, resulting in an error rate of 12.90322581 percent (%).
  5. D
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 3, 2020
    Inspectors wroteBased on policy review, observation, and interview, it was determined the facility failed to ensure medications were not stored past their expiration dates, medications were dated when opened, medication carts were kept secure, and medications were stored properly in 4 of 13 (1 East Treatment Cart, 2 [NAME] Medication Room, 2 [NAME] Medication Cart, and 1 [NAME] Medication Cart) medication storage areas.
  6. D
    Put firmly secured handrails on each side of hallways.
    F924 · Environmental · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 3, 2020
    Inspectors wroteBased on observation and interview, the facility failed to maintain a safe environment when the handrails in the hallway were loose and hanging off the wall for 1 of 8 (1 [NAME] Hall) hallways.

Fire safety inspections

24 fire safety citations on file: 1 on September 27, 2023, 5 on June 15, 2023, 18 on November 19, 2019.

Every fire safety citation24 citations
  1. D
    Have properly installed electrical wiring and gas equipment.
    K 511 · September 27, 2023 · Corrected (the home has a date of correction)
  2. D
    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
    K 222 · June 15, 2023 · Corrected (the home has a date of correction)
  3. D
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · June 15, 2023 · Corrected (the home has a date of correction)
  4. D
    Provide properly protected cooking facilities.
    K 324 · June 15, 2023 · Corrected (the home has a date of correction)
  5. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · June 15, 2023 · Corrected (the home has a date of correction)
  6. D
    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
    K 521 · June 15, 2023 · Corrected (the home has a date of correction)
  7. D
    Conduct risk assessment and an All-Hazards approach.
    E 6 · November 19, 2019 · Corrected (the home has a date of correction)
  8. D
    Create arrangements with other facilities to receive patients.
    E 25 · November 19, 2019 · Corrected (the home has a date of correction)
  9. D
    List the names and contact information of those in the facility.
    E 30 · November 19, 2019 · Corrected (the home has a date of correction)
  10. D
    Provide primary/alternate means for communication.
    E 32 · November 19, 2019 · Corrected (the home has a date of correction)
  11. D
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · November 19, 2019 · Corrected (the home has a date of correction)
  12. D
    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
    K 222 · November 19, 2019 · Corrected (the home has a date of correction)
  13. D
    Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
    K 227 · November 19, 2019 · Corrected (the home has a date of correction)
  14. D
    Have corridors or aisles that are unobstructed and are at least 8 feet in width.
    K 232 · November 19, 2019 · Corrected (the home has a date of correction)
  15. D
    Have exits that are accessible at all times.
    K 271 · November 19, 2019 · Corrected (the home has a date of correction)
  16. D
    Have an enclosure around a vertical opening shaft.
    K 311 · November 19, 2019 · Corrected (the home has a date of correction)
  17. D
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · November 19, 2019 · Corrected (the home has a date of correction)
  18. D
    Provide properly protected cooking facilities.
    K 324 · November 19, 2019 · Corrected (the home has a date of correction)
  19. D
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · November 19, 2019 · Corrected (the home has a date of correction)
  20. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · November 19, 2019 · Corrected (the home has a date of correction)
  21. D
    Properly select, install, inspect, or maintain portable fire extinguishes.
    K 355 · November 19, 2019 · Corrected (the home has a date of correction)
  22. D
    Have properly installed electrical wiring and gas equipment.
    K 511 · November 19, 2019 · Corrected (the home has a date of correction)
  23. D
    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
    K 741 · November 19, 2019 · Corrected (the home has a date of correction)
  24. D
    Ensure proper usage of power strips and extension cords.
    K 920 · November 19, 2019 · Corrected (the home has a date of correction)

Fines and payment denials

CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeTennesseeUnited States
All nursing staff (RN, LPN and aides)3.813.803.86
Registered nurses0.320.600.69
All nursing staff on weekends3.423.313.42
Nurse aides2.30
Licensed practical nurses1.20
Nursing staff turnover (share who left in a year)67.9%48.9%45.8%
Registered nurse turnover66.7%43.2%42.9%
Administrators who left1

CMS expects 3.79 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.97 on weekdays and 3.42 on weekends, 14% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 22.6% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.26 in April to June 2025 to 3.81 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.810.323.973.42 22.6%0 of 9086
Oct to Dec 20253.670.223.863.22 19.1%0 of 9289
Jul to Sep 20253.220.183.372.84 22.2%1 of 9290
Apr to Jun 20253.260.173.412.88 18.7%0 of 9192
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Tennessee, Jan to Mar 20263.750.563.953.274.0%0.7% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeTennesseeUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
8.214.013.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.20.70.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.31.81.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
6.03.43.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
5.11.71.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
7.717.214.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
7.65.04.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
33.216.915.4
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.71.71.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.11.61.8

Owners and operators

Legal business name: Legal Business Name Not Available.

NameRoleTypeShareSince
Ownership data not available

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 11 problems in this area, most recently on October 27, 2023: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
  2. When is the care plan meeting, and can family attend it?Inspectors cited 6 problems in this area, most recently on June 15, 2023: "Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment."
  3. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 5 problems in this area, most recently on October 27, 2023: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody."
  4. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 4 problems in this area, most recently on June 15, 2023: "Ensure each resident’s drug regimen must be free from unnecessary drugs."
  5. How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.

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Common questions

What is Mulberry Health & Rehabilitation's Medicare star rating?
CMS rates Mulberry Health & Rehabilitation 1 out of 5 stars overall, with 1 for health inspections, 2 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Mulberry Health & Rehabilitation get at its last inspection?
12 health deficiencies at the standard inspection on June 15, 2023. The Tennessee average is 4.4.
Has Mulberry Health & Rehabilitation been fined?
CMS lists no fines in the last three years.
Does Mulberry Health & Rehabilitation accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Mulberry Health & Rehabilitation?
CMS lists 1 owner or manager. Legal business name: Legal Business Name Not Available.

Sources

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