Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Majestic Gardens At Memphis Rehab & Snc during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment was observed sitting in a Geri chair with a tray attached, with no order, consent, restraint assessment, or care plan documentation for the device. Staff confirmed the tray was used most of the time, had been in use for weeks, and could not be removed by the resident; the MDS Coordinator and DON stated that a Geri chair with tray is a restraint when the resident cannot remove it.
Failure to Timely Report Allegations of Abuse: The facility did not timely report allegations of staff-to-resident abuse for two cognitively intact residents. One resident alleged a CNA touched him inappropriately during care, and another resident alleged a CNA responded inappropriately when asked to shave him. The DON confirmed abuse allegations should be reported within 2 hours, but the incidents were not reported to the administrator and appropriate agencies in a timely manner.
Failure to provide ADL assistance for bathing and personal hygiene was identified for four residents with significant care needs. One resident with hemiparesis and morbid obesity went 10 days without a documented shower, another resident with dementia had long toenails that needed cutting, a third resident with Alzheimer’s disease and dementia had thick, curling toenails despite a care plan to check and trim nails, and a fourth resident with multiple diagnoses had no shower documentation since admission and stated she had not been showered since early in the month.
Medication and treatment administration was not consistently documented or given per physician orders. A resident received amlodipine multiple times even though the BP was below the hold parameter, another resident had missing documentation for ordered wound treatment to the eyebrow, and a third resident had no MAR documentation showing ordered IV ceftriaxone was administered for UTI treatment. The DON confirmed the medication was given outside parameters and that blank MAR entries meant the medication was not given.
Unsecured medications were found at the bedsides of four residents, contrary to the facility's medication storage policy. Items observed included earwax removal aid, OTC antacid, wound cleanser, moisture barrier ointment, and antifungal ointment. The residents had diagnoses including arthritis, diabetes, pressure ulcer, vascular dementia, and other conditions, and staff including an LPN and the DON confirmed the items should not have been left unattended at the bedside.
Failure to Disinfect Reusable Blood Pressure Monitor: An LPN obtained a resident’s blood pressure with an automatic wrist BP monitor and did not clean the reusable equipment before or after use. The resident had dementia, HTN, and schizophrenia, and the MDS showed moderate cognitive impairment. The facility policy required reusable resident-care equipment to be cleaned and disinfected between residents, and the DON confirmed this expectation.
A resident with a history of psychotic disorder, dementia, and hypertension was discharged, but the facility did not refund the resident's personal funds within the required 30-day period. The responsible party confirmed the refund was received late, and facility staff acknowledged the delay.
The facility failed to maintain safe hot water temperatures and provide adequate supervision, resulting in dangerously elevated water temperatures and injuries to residents. Maintenance staff lacked proper training, and there was a significant communication breakdown among the staff. Additionally, improper use of a mechanical lift led to a resident's lumbar compression fracture, and another resident fell due to inadequate supervision.
The facility failed to provide information regarding a resident's right to formulate an Advance Directive for 21 of 32 sampled residents. Despite the facility's policy, medical records revealed no documentation indicating that residents or their legal representatives were informed about their right to formulate an Advance Directive upon admission. The Director of Nursing confirmed that this should have been done.
The facility failed to provide effective housekeeping and maintenance services, resulting in strong urine odors, dirty privacy curtains, standing water in sinks, and a loose handrail. Staff interviews revealed gaps in communication and follow-through on maintenance requests, compromising residents' right to a safe, clean, and comfortable environment.
The facility failed to ensure food was stored, prepared, and served under sanitary conditions. Staff used bare hands to handle food, and multiple food items were found unlabeled and undated. The deep fryer contained dark grease and crumbs, and uncovered noodles were observed on a shelf. The Certified Dietary Manager confirmed these practices were against the facility's policies.
The facility failed to maintain safe operating equipment in four shower rooms and one elevator. Shower stalls in multiple halls were capped off due to water issues, and the 200 hall elevator had been out of order for nearly a year.
The facility failed to treat all residents with dignity and respect when three staff members, including two CNAs and one LPN, did not knock or announce themselves before entering residents' rooms during dining. The DON confirmed that staff should knock before entering a resident's room.
The facility failed to notify the Ombudsman of an emergency transfer for a resident with multiple diagnoses, including dementia and congestive heart failure. The resident was transferred to a hospital after being found on the floor, but the facility did not document the notification to the Ombudsman. A staff member confirmed that the required list had not been completed or sent.
The facility failed to accurately assess residents for BIMS scores, falls, discharge disposition, and diagnoses. One resident's quarterly MDS lacked a required BIMS assessment, another had multiple falls not reflected in the MDS, and a third had a fall not updated in the MDS. Additionally, a resident's MDS inaccurately marked Quadriplegia instead of Paraplegia, and another's discharge MDS incorrectly indicated discharge to a hospital instead of home.
The facility failed to provide scheduled bathing assistance for two residents, as evidenced by incomplete Skin Check sheets and missed showers on multiple occasions. Interviews with staff confirmed the residents' scheduled shower days and the lack of documentation.
A resident with multiple medical conditions did not receive the required monthly catheter change as per the facility's policy and physician's orders. The Director of Nursing confirmed that the catheter was not changed as scheduled, which was documented in the medical records.
The facility failed to ensure secure medication storage when medications were left unattended in a resident's room and two medication carts were found unlocked and unattended. The DON and LPNs confirmed that medications should not be left unsecured.
The facility failed to maintain accurate medical records for a resident, documenting a neurological check at 12:45 PM when the resident was not present in the facility. The resident had multiple diagnoses and severe cognitive impairment, and the error was confirmed by the Director of Nursing.
Improper Use of Geri Chair Tray as a Restraint
Penalty
Summary
The facility failed to ensure Resident #14 was free from physical restraints when the resident was observed sitting in a Geri chair with a tray in place, with no food or activity on the tray. Resident #14 was admitted with diagnoses including dementia, psychotic disorder with delusions, pseudobulbar affect, depression, and insomnia, and a significant change MDS assessment showed a BIMS score of 3, indicating severe cognitive impairment. The resident was not coded for restraint use, and the physician's orders did not include an order for a Geri chair or tray. The medical record contained no documentation of a restraint assessment, no resident representative consent, and no documentation of Geri chair or tray use. The care plan also had no interventions that included the use of a Geri chair or tray. Observations showed Resident #14 sitting in a Geri chair with a tray at the nurses' station and later in the resident's room, and staff interviews confirmed the tray was attached most of the time, had been used for the last couple of weeks, and could not be removed by the resident. The MDS Coordinator and DON both confirmed that a Geri chair with a tray would be considered a restraint if the resident could not remove it and that its use should be documented in the medical record and care plan.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure staff reported allegations of staff-to-resident abuse to the appropriate agencies in a timely manner for 2 of 3 sampled residents. The facility policy titled, Facility Responsibility for Reporting Allegations, stated that all allegations or occurrences of staff-to-resident abuse must be reported to the administrator and to other officials, including the State Survey Agency and adult protective services. The report identified that the facility did not timely notify the State Survey Agency of an allegation involving Resident #65, who was admitted with diagnoses including cerebral infarction, chronic kidney disease, and diabetes and had a BIMS score of 14, indicating cognitive intactness. Resident #65 reported that CNA C took his hand and placed it on her stomach, side of her hip, and on her behind while providing care. The allegation was not reported to the DON or administrator until weeks after the incident, and the administrator confirmed the staff failed to report it immediately. The facility also did not timely report an allegation involving Resident #107, who was admitted with diagnoses including chronic kidney disease, COPD, and peripheral vascular disease and had a BIMS score of 15, indicating cognitive intactness. The investigation report stated that Resident #107 alleged CNA F came into his room and, after he asked her to shave him, she told him to say "Please," and he responded that he did not think he had to beg. The administrator later contacted the resident's daughter and identified CNA F as matching the description provided. CNA F had already been terminated, but the allegation was not reported to the administrator until after the incident and was not reported until 9/11/2025. The DON confirmed that allegations of abuse should be reported within 2 hours of the allegation.
Failure to Provide ADL Assistance for Bathing and Personal Hygiene
Penalty
Summary
Activities of daily living assistance was not provided as required for four sampled residents who were unable to complete bathing, grooming, or personal hygiene independently. The facility policy stated residents unable to carry out ADLs independently were to receive necessary services, including bathing, dressing, grooming, and oral care. Resident #2, who had hemiparesis, morbid obesity, and a BIMS score of 13, required maximum assistance with personal hygiene. Although the shower schedule indicated showers on Tuesday and Friday, the resident stated she had not had a shower for at least a week, and the resident’s hair was observed to be oily and uncombed. The EMR showed no shower or bath documentation from 8/29/2025 through 9/10/2025, and the DON confirmed it was not acceptable for a resident dependent on staff for ADL care to go 10 days without a shower. Resident #3, who had diabetes, psychotic disorder with delusions, protein calorie malnutrition, and dementia, had a BIMS score of 3 and required substantial assistance with personal hygiene. During observation, Resident #3’s toenails were tan and extended about 1/2 inch beyond the toes, and the DON confirmed they were long and needed to be cut. Resident #89, who had Alzheimer’s disease, dementia, diabetes, anxiety, and colon cancer, had a BIMS score of 4 and required moderate to maximal assistance with ADLs. The care plan directed staff to check nail length and trim and clean nails on bath day and as necessary, but the resident’s toenails were observed to be thick, long, and curling upward, and the DON confirmed they were extremely long and needed to be cut. Resident #148, who had osteomyelitis, spinal stenosis, COPD, and anxiety, required substantial/maximal staff participation with bathing. The facility could not provide shower sheets, no documentation showed the resident received a shower since admission, and the resident stated she had not had a shower since 9/4/2025; the Unit Manager stated it did not look like the resident had received a shower.
Medication and Treatment Administration Not Per Physician Orders
Penalty
Summary
The facility failed to ensure medications and treatments were dispensed and administered according to Physician’s Orders for 4 of 32 residents reviewed. The facility policy stated medications are to be administered as prescribed and the resident’s MAR/EHR is to be initialed by the person administering the dose. Review of records and interviews showed that staff administered amlodipine to Resident #3 on multiple occasions when the resident’s systolic blood pressure was below the ordered hold parameter of 120. Resident #3 was admitted with diagnoses including diabetes, psychotic disorder with delusions, protein calorie malnutrition, and dementia, and the admission MDS showed a BIMS score of 7, indicating severe cognitive impairment. The DON confirmed the medication was given outside the ordered parameters and should have been held. For Resident #41, the physician ordered triple antibiotic external ointment to the right eyebrow every other day for wound healing, but the TAR had no documentation for 7 of 15 treatment dates in April and May 2025. The resident had diagnoses including Alzheimer’s disease, chronic kidney disease, encephalopathy, and hypertension, and the quarterly MDS indicated the BIMS could not be completed, showing severe cognitive impairment. For Resident #51, ceftriaxone sodium IV was ordered daily for 7 days for a UTI, but the MAR had no documentation that the medication was administered on two scheduled days, and a progress note documented that pharmacy said the medication would be delivered that night. The DON confirmed the blank MAR entries meant the medication was not given.
Unsecured Medications Found at Residents' Bedsides
Penalty
Summary
The facility failed to store medications in accordance with its policy when unsecured medications were found at the bedside for 4 of 32 residents. The facility policy titled, Medication Storage, dated 4/2025, stated that all medication must be stored according to state and federal laws and regulations, with oral solid medications stored in medication carts except those requiring refrigeration, and medications with routes other than PO stored in separate compartments in medication carts, medication room cabinets, or refrigerators. Resident #11, who had diagnoses including arthritis, chronic pancreatitis, anemia, and hypertension and a BIMS score of 15, had a 0.5 ml bottle of earwax removal aid observed at the bedside during room observations. Resident #72, who had diagnoses including diabetes, anemia, epilepsy, and hypertension and a BIMS score of 13, had an approximately one-half full roll of over-the-counter antacid wrapped in foil observed at the bedside. Resident #122, who had diagnoses including protein calorie malnutrition, diabetes, pressure ulcer, and encephalopathy and a BIMS score of 13, had a bottle of wound cleanser and a tube of moisture barrier ointment observed on the nightstand. Resident #149, who had diagnoses including cerebral infarct, vascular dementia, and depression and a BIMS score of 6, had a tube of antifungal ointment observed at the bedside. Staff confirmed that these medications and topical products should not have been left at the residents' bedsides unattended.
Failure to Disinfect Reusable Blood Pressure Monitor
Penalty
Summary
Provide and implement an infection prevention and control program. Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 4 nurses, Licensed Practical Nurse (LPN) A, failed to disinfect reusable resident equipment for 1 of 5 residents observed during medication administration. The facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, stated that resident-care equipment, including reusable items, will be cleaned and disinfected between residents and that reusable resident care equipment is decontaminated and/or sterilized between residents. Resident #151 was admitted with diagnoses including dementia, hypertension, and schizophrenia, and the admission MDS showed a BIMS score of 9, indicating moderate cognitive impairment. During observation in the resident's room, LPN A obtained the resident's blood pressure with an automatic wrist blood pressure monitor and failed to clean the monitor before or after use. The DON later confirmed that reusable equipment should be cleaned and disinfected between resident use.
Delay in Refunding Discharged Resident's Personal Funds
Penalty
Summary
The facility failed to provide timely conveyance of personal funds for one discharged resident. According to the facility's Resident Funds Policy and Procedure, residents' personal funds and a final accounting are to be conveyed within 30 days of discharge. Medical record review showed that a resident with diagnoses including psychotic disorder with delusions, dementia, and hypertension was discharged to another facility. Documentation and interviews confirmed that the resident's personal account refund was not mailed to the responsible party until well after the 30-day requirement had passed, with both the Business Office Manager and Administrator acknowledging the delay.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards, specifically by not maintaining safe hot water temperatures and not providing adequate supervision to prevent falls and injuries. Dangerous hot water temperatures ranging from 121°F to 142°F were found in multiple resident rooms and shower rooms, posing a risk of serious injury, harm, burns, or death to residents. The facility's maintenance staff lacked proper training and failed to monitor and adjust the hot water temperatures appropriately, leading to Immediate Jeopardy (IJ) for the residents' safety. Additionally, the facility's policies and procedures for water temperature safety were not followed, and there was a significant communication breakdown among the staff regarding the issue. The Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Maintenance Team Lead were all unaware of the correct water temperature ranges and failed to take immediate corrective actions when the dangerously high temperatures were discovered. The facility's failure to properly use a mechanical lift during the transfer of a resident resulted in actual harm, with one resident sustaining a lumbar compression fracture. Another resident fell and required an emergency room visit due to the facility's failure to implement one-on-one care. The facility's policies on fall prevention and management, as well as safe and proper resident handling, were not adequately followed, leading to these incidents. The facility's census was 131, and the Immediate Jeopardy for F-689 began on 4/29/2024 and was ongoing at the time of the report.
Failure to Inform Residents About Advance Directives
Penalty
Summary
The facility failed to provide information regarding a resident's right to formulate an Advance Directive for 21 of 32 sampled residents. The facility's policy, dated December 2023, mandates that upon admission, the facility will determine if the resident has executed an advance directive and, if not, will provide information regarding the formulation of an advance directive. However, the medical records of the sampled residents revealed no documentation indicating that the residents or their legal representatives were informed, offered, or provided written information regarding their right to formulate an Advance Directive upon admission. For instance, Resident #1, who was admitted with diagnoses including Abnormal Weight Loss, Cerebral Palsy, Major Depressive Disorder, and Diabetes, had a BIMS score of 14, indicating cognitive intactness. Despite this, there was no documentation in the medical record to show that the resident was informed about their right to formulate an Advance Directive. Similarly, Resident #3, with severe cognitive impairment and diagnoses such as Osteoporosis with Current Pathological Fracture and Traumatic Brain Injury, also lacked documentation of being informed about Advance Directives. The deficiency was consistent across multiple residents with varying degrees of cognitive impairment and different medical conditions. For example, Resident #14 with moderate cognitive impairment and diagnoses of Weight Loss and Epileptic Seizures, and Resident #21 with severe cognitive impairment and diagnoses of Fracture and Anxiety, both lacked documentation of being informed about Advance Directives. The Director of Nursing confirmed during an interview that all residents should have been offered or educated about Advance Directives upon admission, but the facility failed to do so for the sampled residents.
Failure to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to provide effective housekeeping and maintenance services, resulting in a non-sanitary, non-orderly, and uncomfortable environment for residents. Observations revealed strong urine odors in multiple resident rooms and hallways, dirty privacy curtains, standing water in bathroom sinks and basins, and a loose handrail in the 100 Hall. Specific instances included yellow stains on fitted sheets, brown stains on privacy curtains, and clogged sinks with standing water containing black particles. These conditions persisted over several days, indicating a lack of timely and effective cleaning and maintenance interventions. Interviews with staff confirmed that the facility's cleaning and maintenance procedures were not being followed adequately. Staff I acknowledged that privacy curtains should be assessed and changed weekly but were found stained and unchanged over several days. CNA H admitted that the maintenance issue with a resident's sink had not been reported promptly, and Staff C confirmed that the sink issue had not been entered into the facility's reporting system. The Director of Nursing also confirmed that the loose handrail in the 100 Hall needed fixing but remained unrepaired for several days. The facility's policies on preventive maintenance and resident room cleaning were not effectively implemented, leading to unsanitary and unsafe conditions. Staff interviews revealed gaps in communication and follow-through on maintenance requests, contributing to the prolonged presence of odors, stains, and standing water. These deficiencies compromised the residents' right to a safe, clean, and comfortable environment, as mandated by the facility's policies and regulatory standards.
Failure to Maintain Sanitary Conditions in Food Storage, Preparation, and Service
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served under sanitary conditions. Staff were observed using bare hands to prepare food, and multiple food items in the kitchen were found to be unlabeled and undated. Specifically, there were opened and undated packages of coconut flakes, pancake waffles, corn nuggets, mangos, and various meats in the freezer. Additionally, sandwiches were found undated and unlabeled in a metal pan, and black eye peas in the refrigerator were dated beyond their discard date. The deep fryer contained dark brown grease and crumbs, indicating it had not been cleaned or the grease changed as required. Uncovered noodles were also observed sitting on a metal shelf in a Styrofoam container. These observations were confirmed by the Certified Dietary Manager (CDM), who acknowledged that the items should have been labeled, dated, and stored properly, and that the deep fryer grease should have been changed and the fryer cleaned as scheduled. Further observations revealed that a Cook/Dietary Aide used bare hands to handle bread rolls and slices of cheese, which were then left uncovered. The CDM confirmed that staff should not use bare hands to pick up food and should be wearing gloves when handling food. These actions and inactions by the staff led to the deficiency in maintaining sanitary conditions in food storage, preparation, and service, as per the facility's policies and professional standards for food safety.
Failure to Maintain Safe Operating Equipment
Penalty
Summary
The facility failed to maintain equipment in safe operating condition for four shower rooms and one elevator. Observations revealed that shower stalls in the 100, 200, 300, and 400 hall shower rooms were capped off due to issues with water coming out of both the sprayer and the shower head simultaneously, and the water not getting hot enough. The Maintenance Director confirmed these issues and stated that repairs would require accessing behind the walls. Additionally, the 200 hall elevator was found to be out of order with caution tape and an out-of-order sign, and it was confirmed by the Healthcare Consultant that the elevator had been non-functional for nearly a year.
Failure to Knock Before Entering Residents' Rooms
Penalty
Summary
The facility failed to treat all residents with dignity and respect when three staff members, including two CNAs and one LPN, did not knock or announce themselves before entering residents' rooms during dining. Specifically, CNA S entered Resident #2's room, CNA T entered Resident #15's room, and LPN U entered both Resident #26's and Resident #29's rooms without knocking or announcing their presence. This was observed during dining on Hall 300 and Hall 400. The Director of Nursing confirmed that staff should knock before entering a resident's room.
Failure to Notify Ombudsman of Emergency Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of an emergency transfer for a resident. The facility's policy required that a copy of the transfer notice be sent to the Ombudsman, potentially as a list of residents on a monthly basis. Resident #66, who had multiple diagnoses including Metabolic Encephalopathy, Dysphagia, Aphasia, Hemiplegia, Dementia, Congestive Heart Failure, Hypertension, and Contracture of the Left Hand, was admitted to the facility and later transferred to a hospital for evaluation after being found on the floor. The facility did not provide documentation that the Ombudsman was notified of this transfer. During an interview, a staff member confirmed that the Ombudsman Emergency Transfer List had not been completed or sent, and they were only informed of this requirement on the day of the interview.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to accurately assess residents for BIMS scores, falls, discharge disposition, and diagnoses for five residents. Resident #41 was admitted with multiple diagnoses, including Congenital Diaphragmatic Hernia and Alcohol and Cocaine Abuse, but the quarterly MDS did not include a required BIMS assessment. Resident #47, with diagnoses including Diabetes and Heart Failure, had multiple falls documented in progress notes and care plans, but the MDS assessments incorrectly indicated no falls prior to admission or reentry. The MDS Coordinator confirmed these assessments were coded incorrectly for falls. Resident #66, admitted with diagnoses such as Metabolic Encephalopathy and Hemiplegia, had a documented fall that was not reflected in the MDS. The MDS Coordinator acknowledged this oversight. Resident #86, with Muscle Wasting and Paraplegia, had an MDS that inaccurately marked Quadriplegia instead of Paraplegia. Lastly, Resident #128, discharged with diagnoses including Sepsis and Bipolar Disorder, had a discharge MDS indicating a BIMS of 15 and discharge to a hospital, while a physician's order indicated discharge home with family. The MDS Coordinator confirmed the resident was discharged home, not to a hospital.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that assistance with Activities of Daily Living (ADL) related to bathing was provided for two residents. Resident #1, who has diagnoses including Spastic Quadriplegic Cerebral Palsy, Chronic Kidney Disease, Diabetes, Hypertension, and Depression, was scheduled to receive showers twice weekly. However, the facility's Skin Check sheets revealed that Resident #1 did not receive showers on three scheduled dates in April 2024. Interviews with staff confirmed that the resident should have received showers twice weekly and that the Skin Check sheets were not completed for the missed dates. Similarly, Resident #80, who has diagnoses including Peripheral Vascular Disease, Pressure Ulcers, Heart Failure, Diabetes, and Adult Failure to Thrive, was also scheduled to receive showers twice weekly. The Skin Check sheets for March and April 2024 showed that Resident #80 missed several scheduled baths. Interviews with the Director of Nursing (DON) confirmed that the resident should have received showers on the specified days and that the Skin Check sheets were incomplete. The DON acknowledged the lack of documentation and confirmed the scheduled shower days for Resident #80.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care and services for an indwelling catheter for a resident with multiple diagnoses, including obstructive uropathy. The facility's policy on Foley catheter care, revised in June 2023, aims to prevent urinary tract infections by ensuring proper catheter maintenance. However, a review of the medical record revealed that the resident's catheter was not changed as ordered on April 14, 2024. This was confirmed by the Director of Nursing during an interview on May 6, 2024. The resident, who was cognitively intact with a BIMS score of 15, had an indwelling catheter and was admitted with several medical conditions, including osteomyelitis, obstructive uropathy, hemiplegia, cerebral infarction, hypertension, and arteriosclerotic heart disease. The care plan specified that the catheter should be changed monthly and as needed, but this was not documented in the April 2024 Medication Administration Record. An observation on May 1, 2024, showed the resident resting in bed with the catheter in place, but the required catheter change had not been performed as per the physician's orders.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medication was stored securely in several instances. In one case, medication was left unattended in a resident's room. Specifically, two white pills were observed on the overbed table of a resident who was lying in bed and asked for water to take her medicine. The LPN responsible for administering the medication confirmed that she left the medications at the bedside because she got busy and did not return to administer them. Additionally, two medication carts were found unlocked, unattended, and out of staff's line of sight. The Back up medication cart, which contained various over-the-counter medications, was left unlocked at the 100 hall Nurse's station. The 100 hall medication cart was also found unlocked and unattended in the 200 hall. During interviews, the DON confirmed that medication carts should not be left unlocked and unattended. The DON also explained that one nurse was responsible for residents on both the 100 and 200 halls, leading to the decision to separate medications into two carts. The LPNs involved acknowledged that they should not have left medications unattended. These actions and inactions led to the deficiency in ensuring the secure storage of medications in the facility.
Inaccurate Documentation of Neurological Check
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident, identified as Resident #66. The resident's medical record contained an inaccurate neurological check. According to the facility's policy, neurological assessments must be documented with the exact time they are performed. However, a neuro check for Resident #66 was documented at 12:45 PM on 2/21/2024, despite the resident being transported to the emergency room and not present in the facility at that time. This discrepancy was confirmed through a review of the medical record and the prehospital patient record from the fire department, which indicated that the resident left the facility at 6:25 AM and returned at 12:55 PM on the same day. The Director of Nursing acknowledged the error during an interview, stating that the resident would have been on his way to the hospital at the time the neuro check was documented. Resident #66 was admitted to the facility with multiple diagnoses, including Metabolic Encephalopathy, Dysphagia, Aphasia, Hemiplegia, Cognitive Communication Deficit, Dementia, Congestive Heart Failure, Hypertension, History of Falling, and Contracture of the Left Hand. The resident had a severe cognitive impairment, as indicated by a BIMS score of 7. On 2/21/2024, the resident was found on the floor with an open area over the left brow, prompting the need for neurological checks. The inaccurate documentation of the neuro check at 12:45 PM, when the resident was not in the facility, highlights the failure to maintain accurate medical records as per the facility's policies.
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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 Memphis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Midtown Center For Health And Rehabilitation | 0 mi | ★★★★★ | 11 | 0 |
| Harborview Post Acute | 2.9 mi | ★★★★★ | 1 | 0 |
| Regional One Health Subacute Care | 3 mi | — | 0 | 0 |
| Allen Morgan Health And Rehabilitation Center | 3.3 mi | ★★★★★ | 2 | 0 |
| Highlands Health And Rehabilitation Center | 3.3 mi | ★★★★★ | 2 | 1 |
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