Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Memphis Jewish Home during CMS and state inspections, most recent first.
Failure to Follow Oxygen Order: A resident with COPD, chronic respiratory failure, and dependence on supplemental O2 had a physician order for 2 L via NC, but staff documentation and direct observations showed oxygen being administered at 2.5 L, 3 L, and 3.5 L on multiple occasions. The MAR reflected 2 L, while RT notes and staff interviews confirmed the resident was actually receiving higher flow rates than ordered.
Medication administration errors exceeded the allowed rate when an RN crushed a pantoprazole delayed-release tablet and administered diclofenac sodium topical gel without using the manufacturer dosing card. A resident with dysphagia, peptic ulcer, osteoarthritis, and severe cognitive impairment received pantoprazole mixed with pudding and topical diclofenac measured as 10 ml instead of the ordered 2 g, contributing to a 7.41% error rate.
Surveyors observed multiple infection control failures involving PPE, hand hygiene, and reusable equipment. An LPN and a treatment nurse failed to wear gowns during care for residents on EBP, a CNA failed to use required PPE and hand hygiene during Foley catheter care, another CNA entered a droplet isolation room without a gown while delivering a meal tray, and an LPN failed to clean reusable vital sign equipment and perform hand hygiene before and after resident contact.
A facility failed to resubmit a Level 2 PASRR for a resident after a new diagnosis of Psychotic Disorder and the initiation of antipsychotic medication. The resident, initially admitted with various diagnoses, was later prescribed Quetiapine following the new diagnosis. Despite these changes, the facility did not complete the required PASRR, as confirmed by the Resident Assessment Coordinator.
A facility failed to maintain a hazard-free environment when an unsecured disposable razor with exposed blades was found in a resident's bathroom. The resident, who had cognitive impairments and required assistance with daily activities, was at risk due to the facility's non-compliance with its policy on sharps disposal. The DON confirmed that razors should be secured and disposed of properly.
A facility failed to obtain a physician's order for an indwelling urinary catheter for a resident with Parkinson's, Dementia, and other conditions. The resident had the catheter upon arrival, but medical records lacked the necessary order, despite facility policy requiring it. Progress notes confirmed the catheter's presence and condition, and a physician later noted the resident was ready for its removal.
The facility failed to secure medications properly, as observed when an LPN left an inhaler unattended on a cart and an RN left a medication cart unlocked and unattended. The facility's policy requires medications to be locked or under direct observation during administration.
Failure to Follow Oxygen Order
Penalty
Summary
The facility failed to follow physician orders for oxygen administration for one resident with chronic obstructive pulmonary disease, chronic respiratory failure, dependence on supplemental oxygen, and hypoxemia. The resident was cognitively intact and had a care plan directing oxygen to be administered per MD orders. The physician’s order specified oxygen at 2 L via nasal cannula with oxygen saturation checks every shift when oxygen was in use, but the resident’s respiratory therapy progress notes documented oxygen therapy at 3 L via nasal cannula on multiple dates in January 2026. The Medication Administration Record documented oxygen therapy as being administered at 2 L via nasal cannula every shift throughout January and into February 2026, while direct observations showed the resident receiving oxygen at 3 L in the lobby and room on multiple occasions, 2.5 L on one observation, and 3.5 L on another. During interviews, an LPN stated the order was for 2 L and that the resident was usually administered 2 L, the unit manager stated the resident should be on 2 L but was observed at 3.5 L, RT staff stated they could not change the oxygen order and would change it to 2 L if the resident was receiving 3 L with an order for 2 L, and the DON stated oxygen should be administered at the rate prescribed by the physician.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure medication error rates remained below 5 percent for 1 of 9 nurses, RN B, after 2 errors were observed in 27 medication administration opportunities, resulting in a 7.41% error rate. Review of the Diclofenac Sodium Topical Gel 1% user guide showed the dosing card should be used to measure the correct dose, with 2.25 inches indicated for each upper body area, and FDA labeling for Protonix (pantoprazole) stated delayed-release tablets should be swallowed whole and not split, crushed, or chewed. The facility policy on administering medications required the right medication, dosage, time, and method to be verified before administration. Resident #97 had diagnoses including dysphagia, peptic ulcer, and primary osteoarthritis, and the quarterly MDS showed a BIMS score of 5, indicating severe cognitive impairment. During medication administration observation, RN B crushed pantoprazole delayed-release 40 mg and mixed it with pudding, then administered it by mouth along with sucralfate suspension. RN B also removed diclofenac sodium 1% gel from the tube and squeezed 10 ml into a medicine cup before applying it to the resident's left shoulder, rather than using the manufacturer's dosing card to measure the ordered 2 gram dose. In interview, RN B stated she usually put about 10 ml in the cup and acknowledged that this could result in a dose other than the prescribed amount; the DON stated the ordered topical dose would not be obtained by using 10 ml, and confirmed delayed-release medication should not be crushed.
Infection Control Failures With PPE, Hand Hygiene, and Equipment Cleaning
Penalty
Summary
The facility failed to ensure proper infection control practices were followed for residents on Transmission Based Precautions and Enhanced Barrier Precautions, and failed to ensure hand hygiene and reusable equipment cleaning were performed as observed by surveyors. The report states that 4 of 11 staff failed to wear required PPE for isolation precautions and EBP, failed to follow infection control standards for reusable equipment, and failed to perform hand hygiene for 4 of 14 sampled residents. Resident #6 had diagnoses including Adult Failure to Thrive, gastrostomy status, and pneumonia, and was assessed as moderately cognitively impaired. The resident also had an indwelling Foley catheter and PEG tube. During medication administration, an LPN entered the resident’s room and administered medications through the gastrostomy tube without donning a gown. Later, a treatment nurse provided catheter-related care and applied barrier cream while wearing gloves but without a gown, despite an EBP sign in the room indicating gown and gloves were required for high-contact resident care activities. The DON stated that EBP was used for residents with indwelling devices such as Foley catheters and PEG tubes and that a gown and gloves were required. Resident #116 had diagnoses including cerebral infarction, dysuria, and acute kidney failure, and had an indwelling Foley catheter. During catheter care, a CNA donned gloves, drained the catheter bag into a urinal, emptied the urinal into the toilet, and exited the room without wearing a gown. The CNA failed to place a barrier under the catheter and urinal, failed to disinfect the catheter valve after closing it, and failed to perform hand hygiene before and after handling the catheter bag and urinal and after removing gloves. Resident #175 remained on droplet isolation for COVID-19, yet a CNA entered the room with a meal tray and provided set-up assistance without donning a gown. Resident #179 had diagnoses including Parkinson’s disease, hypertension, and dysphagia; an LPN obtained vital signs using a portable machine and pulse oximeter but failed to perform hand hygiene before or after resident contact and failed to clean the reusable equipment before or after use. The DON acknowledged that reusable equipment should be wiped down and that staff should perform hand hygiene between glove changes.
Failure to Resubmit PASRR After New Diagnosis and Medication
Penalty
Summary
The facility failed to resubmit a Level 2 Pre-Admission Screening and Resident Review (PASRR) for a resident after a new mental health diagnosis and the initiation of antipsychotic medication. The resident, who was admitted with diagnoses including Dysphagia, Muscle Weakness, Dementia, and Anxiety, was later diagnosed with a Psychotic Disorder with hallucinations. This diagnosis was added on March 30, 2023. Subsequently, on May 31, 2024, a physician ordered Quetiapine, an antipsychotic medication, for the resident. The resident's quarterly Minimum Data Set indicated moderate cognitive impairment and confirmed the diagnosis of Psychotic Disorder and the use of antipsychotic medication. Despite these changes, the facility did not complete a Level 2 PASRR, as confirmed by the Resident Assessment Coordinator during an interview on November 22, 2024.
Unsecured Sharps in Resident Bathroom
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards when an unattended and unsecured disposable razor with exposed blades was observed in an occupied resident bathroom. The facility's policy on Bloodborne Pathogens/Contaminated Sharps, dated November 2021, mandates that sharps containers be provided to all staff for the disposal of potentially contaminated sharps. Resident #52, who was admitted with diagnoses including Parkinson's, Dementia, and Epilepsy, was moderately cognitively impaired and dependent on staff for assistance with activities of daily living. Observations on November 18, 2024, revealed the razor on the bathroom vanity, and the Director of Nursing confirmed that razors should not be left unsecured and should be discarded in a sharps container after use.
Lack of Physician's Order for Indwelling Catheter
Penalty
Summary
The facility failed to obtain a physician's order for the use of an indwelling urinary catheter for a resident. The facility's policy on the appropriate use of indwelling catheters requires that such devices be used only when clinically necessary and in accordance with physician orders. The resident, who was admitted with diagnoses including Parkinson's, Dementia, Retention of Urine, and Benign Prostatic Hyperplasia, was found to have an indwelling urinary catheter upon arrival at the facility. Despite this, the medical records from the period of 10/01/2024 to 11/22/2024 did not contain a physician's order for the catheter. Progress notes from 10/9/2024 to 10/14/2024 documented the presence and condition of the catheter, and a physician's note on 11/5/2024 indicated the resident was ready to have the catheter removed.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure proper storage and security of medications, as observed in two separate incidents. The first incident involved a Licensed Practical Nurse (LPN A) who left an Anoro inhaler unsecured and unattended on top of a medication cart in the hallway while administering medications to a resident. This occurred despite the facility's policy requiring medications to be under direct observation or locked during medication passes. The resident involved had a medical history of acute respiratory failure, chronic obstructive pulmonary disease, congestive heart failure, and hypertension, and was prescribed Anoro Ellipta to assist with breathing. In a second incident, a medication cart on the 300 Hall was found unlocked and unattended with a drawer open. A Registered Nurse (RN B) was in a resident's room, leaving the cart out of her vision. Upon inquiry, RN B confirmed that the medication cart should have been locked and that no drawer should be left open and unattended. These observations indicate a failure to adhere to the facility's medication storage policy, which mandates that all drugs and biologicals be stored in locked compartments.
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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) |
|---|---|---|---|---|
| Cordova Wellness And Rehabilitation Center | 0 mi | ★★★★★ | 6 | 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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.