Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cordova Wellness And Rehabilitation Center during CMS and state inspections, most recent first.
Inaccurate MDS assessments were completed for three residents. One resident was incorrectly coded as receiving dialysis without an order, another resident with severe cognitive impairment was not coded for a wander guard despite an order and DON confirmation, and a third resident with a gastrostomy was observed receiving enteral feeding but was not coded for tube feeding on the MDS.
A resident with respiratory failure, tracheostomy, and gastrostomy was observed without an ambu bag in the room despite facility policy requiring emergency respiratory supplies to be easily accessible for immediate care. The resident was severely cognitively impaired, dependent for all ADLs, and had orders for trach care, oral care, daily inner cannula changes, and suctioning as needed; both an LPN and the DON stated the ambu bag should be kept in the room near the bed.
Controlled medication counts on a medication cart were not accurately reconciled for a resident with traumatic brain injury, paralytic syndrome, diabetes, and anxiety. An RN documented Gabapentin administration on the wrong narcotic log, leaving the counts for Gabapentin and Eszopiclone incorrect when an LPN and RN checked the cart at shift change; the DON stated the narcotic count was expected to be correct.
Staff failed to follow infection control practices during resident care and med administration. An ICP and an LPN provided wound care to a resident with a stage 3 neck pressure ulcer and EBP orders without gowns or gloves. An LPN failed to perform hand hygiene after handling a used glucometer before preparing insulin for a resident with DM, and an RN used the same BP cuff on two residents without cleaning it and did not perform hand hygiene between residents or before administering meds.
Administration allowed an unlicensed individual to be hired twice and function as an LPN using another LPN’s Tennessee license. During the first hire, conflicting SSNs appeared on the application and tax forms, the I‑9 identified the imposter by her own name and out‑of‑state driver’s license, and the license verification was for a different nurse with only the same first name; no Tennessee Abuse Registry check was documented, and the imposter worked multiple shifts before resigning. During the second hire, a different SSN was used, no I‑9 or supporting identity documents were on file, and the same other nurse’s license was again used for verification; the imposter worked several days before resigning. The Administrator reported that the same resume was used for both hires and that the facility had no formal hiring policy, only a checklist.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to complete accurate MDS assessments for 3 of 33 residents reviewed for MDS discrepancies. Review of the facility policy on RAI-MDS 3.0 Completion stated that residents are assessed using a comprehensive assessment process to identify care needs. For Resident #3, the quarterly MDS was coded to show dialysis in section O0110, but the medical record and physician orders showed no dialysis order; during interview, the MDS Coordinator stated it was not ordered and should not have been on the MDS. For Resident #147, the quarterly MDS showed a BIMS score of 6 and did not code use of a wander/elopement alarm, even though the Order Review History showed an order to check wander guard function every day, and the DON confirmed the resident should have been coded for a wander guard. For Resident #181, the quarterly MDS showed a BIMS score of 00 and did not code enteral feeding, although the resident had a gastrostomy and was observed receiving Jevity 1.5 and a water flush through a feeding tube; the MDS Coordinator stated enteral feeding was not coded and confirmed it should have been coded.
Missing Ambu Bag at Bedside for Resident with Tracheostomy
Penalty
Summary
The facility failed to maintain emergency respiratory supplies at the bedside for a resident who received tracheostomy care. Facility policy required that residents needing respiratory care, including tracheostomy care and tracheal suctioning, have a suction machine, suction catheters, correctly sized cannulas, and an ambu bag easily accessible for immediate emergency care. Resident #11 was admitted with diagnoses including respiratory failure, tracheostomy, and gastrostomy, and was severely cognitively impaired and dependent on staff for all ADLs. Physician orders directed trach care, oral care, daily inner cannula changes, and suctioning as needed. During observation in the resident’s room, there was no ambu bag present, and an LPN stated it should be in the room and kept close to the bed. The DON also stated the ambu bag should be within close proximity and available in the room for easy access.
Controlled Medication Count Was Not Accurately Reconciled
Penalty
Summary
The facility failed to ensure that an account of all controlled medications was accurately reconciled for one medication cart on the 700 Hall. The facility policy for Medication Administration stated that if a medication is a controlled substance, staff should sign the narcotic book and correct any discrepancies and report to the nurse manager. During review of Resident #43’s record, the resident was noted to have diagnoses including traumatic brain injury, paralytic syndrome, diabetes, and anxiety, and the quarterly MDS showed a BIMS score of 12, indicating moderate cognitive impairment. Physician orders included Gabapentin 100 mg three times daily and Eszopiclone 1 mg at bedtime for insomnia. During observation of medication cart #4, the controlled drug record showed 27 Gabapentin capsules left and 3 Eszopiclone tablets left, but the actual count in the cart was 26 Gabapentin capsules and 4 Eszopiclone tablets. The LPN confirmed the counts did not match the record. The RN stated she had charted the administration on the wrong log, explaining that she had documented Gabapentin administration on the Eszopiclone record, which resulted in one medication being counted as too many and the other as too few. Both nurses stated they had completed a narcotic count at shift change, and the DON stated that nurses were expected to complete a narcotic count at shift change and that the count should be correct.
Infection Control Failures During Wound Care, Hand Hygiene, and Equipment Cleaning
Penalty
Summary
The facility failed to maintain and ensure infection prevention and control practices during resident care and medication administration. The report states that 4 of 8 staff members, including the Infection Preventionist LPN A and B and RN C, failed to use PPE during wound care, failed to perform proper hand hygiene, and failed to clean reusable equipment between residents. Facility policies reviewed addressed medication administration, hand hygiene, cleaning and disinfecting resident-care equipment, and enhanced barrier precautions for residents with wounds and certain devices. Resident #11 was admitted with diagnoses including respiratory failure, tracheostomy, gastrostomy, myocardial infarction, contracture of feet, peripheral vascular disease, and cerebral infarction. The resident’s quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment. The resident had an order for enhanced barrier precautions and an order for a stage 3 pressure ulcer to the back of the neck requiring daily wound care. During observation in the resident’s room, the ICP and LPN A were touching the resident at the neck area while providing wound care without gowns or gloves. When asked, the ICP stated they were doing wound care and acknowledged that both staff should have had on a gown and gloves. Resident #145 was admitted with chronic diastolic heart failure, chronic kidney disease, and diabetes mellitus, and had a BIMS score of 15 indicating cognitive intactness. During observed blood glucose monitoring and medication administration, LPN B sanitized hands, performed fingerstick testing, removed gloves, and washed hands, but then returned to the cart, put on clean gloves without performing hand hygiene after handling the used glucometer, and prepared insulin for the resident. The observation documented that LPN B failed to perform hand hygiene between handling the used glucometer and putting on gloves to prepare medication. Resident #155 had diagnoses including osteoporosis, dementia, and repeated falls, and a BIMS score of 4 indicating severe cognitive impairment. Resident #193 had diagnoses including dementia, depression, anxiety disorder, and psychosis. During medication administration observations, RN C used a blood pressure cuff on Resident #155, placed it on the med cart, performed hand hygiene, and administered medications, but then took the same cuff into Resident #193’s room without cleaning it and without performing hand hygiene. RN C obtained a blood pressure reading on Resident #193, then prepared and administered medications without hand hygiene between residents. RN C acknowledged that hand hygiene should be performed when entering and leaving resident rooms and after care, and that the blood pressure cuff should be cleaned between residents.
Imposter Nurse Hired Twice and Allowed to Function as LPN Without Proper Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and allowed to function as an LPN on two separate occasions using another nurse’s Tennessee license. For the first hire, the personnel file showed an employment application dated 02/08/2023 with a Social Security Number (SSN) that did not match the SSN on the W‑4 form dated 02/13/2023. The I‑9 form dated 02/13/2023 listed the imposter’s legal first and last name, supported by a birth certificate and an out‑of‑state driver’s license, and the last name on the I‑9 matched the driver’s license. However, the license verification form in the file was for a different individual, an LPN with the same first name but a different last name, and there was no evidence that a Tennessee Abuse Registry check was completed prior to the 02/13/2023 hire date. Time punch records showed the imposter worked multiple shifts in February, March, April, and May 2023 before being terminated on 06/06/2023, with the termination form citing voluntary resignation due to chronic absenteeism and tardiness. For the second hire, the imposter was rehired with a personnel file showing that the SSN on the employment application, W‑4, and background check matched each other but differed from the two SSNs used during the first hire, meaning three different SSNs were used across the two employment periods. There was no I‑9 form or supporting identity documents in the file for the rehire. A license verification form again showed a nursing license in the name of the same LPN whose license had been used previously, with the same first name as the imposter but a different last name and a later expiration date. The background screening report dated 02/13/2024 used the SSN from the employee application, which did not match the SSN previously submitted on the I‑9 form from the first hire. Time punch data showed the imposter worked several days in May 2024 before a termination dated 06/24/2024, which documented voluntary resignation after failing to provide a schedule and not returning after orientation. In an interview, the Administrator stated the facility used the same resume for both hires and that the facility did not have a hiring policy, only a checklist.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cordova
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Memphis Jewish Home | 0 mi | ★★★★★ | 3 | 0 |
| Applingwood Post Acute | 0 mi | ★★★★★ | 9 | 1 |
| The Village At Germantown | 4.3 mi | ★★★★★ | 11 | 1 |
| The Kings Daughters And Sons | 5.1 mi | ★★★★★ | 1 | 0 |
| Rainbow Rehab And Healthcare | 5.1 mi | ★★★★★ | 0 | 0 |
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