Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Waters Of Memphis A Rehabilitation & Nursing Ctr during CMS and state inspections, most recent first.
Administration failed to ensure nursing services were provided by qualified personnel when an unlicensed individual was hired and allowed to work as an RN and Unit Manager using another nurse’s license. Pre-employment documents for this staff member contained inconsistent SSNs and birth dates across the application, background check, W-4, and I-9, and the background report noted the SSN could not be validated. No abuse registry check or RN license verification was completed before hire, and a later license verification showed the last name on the RN license did not match the individual’s last name. The imposter, a walk-in applicant without a resume, worked multiple shifts providing nursing services before being separated as a voluntary termination, and facility staff did not question the documented discrepancies.
A resident with severe cognitive impairment and multiple medical conditions developed a right shoulder dislocation after a midline IV was placed. The facility's investigation into the injury was incomplete, lacking key staff statements and relying on unverified information, resulting in a failure to meet policy requirements for investigating injuries of unknown origin.
Imposter RN Hired and Allowed to Function Without Proper Verification
Penalty
Summary
Administration failed to ensure that nursing services were provided by qualified personnel when an unlicensed individual was hired and worked as an RN using another nurse’s Tennessee license. Facility policy titled “Abuse Program Policy” required pre-employment screening, including obtaining a copy of the state license for licensed positions and completing a criminal background check per state statute. The application for employment for the imposter nurse contained a scratched-out Social Security Number (SSN) with a different SSN written above that did not match the SSN on the I-9 form, and the birth date on the application also did not match the I-9. The background screening report showed an SSN and birth date that did not match the I-9 and included a note stating “UNABLE TO VALIDATE SSN.” A W-4 form contained an SSN that did not match the background check. The I-9 form listed the imposter’s legal first and last name, with a Social Security card and valid Tennessee driver’s license, but the birth date on the I-9 differed from the birth date on the background check. Review of the personnel file revealed no evidence that an abuse registry check was completed prior to hire, and there was no evidence that a license verification was done before the imposter nurse’s start date. Time cards showed the imposter worked multiple days in February and March as a Unit Manager. A later QuickConfirm license verification showed that the last name on the validated RN license did not match the imposter’s last name. Interviews with the DON, HR representative, and Administrator confirmed that the imposter was a walk-in applicant who did not provide a resume, that in-house HR was responsible for ordering background checks with corporate as backup, and that the imposter worked in the facility as a Unit Manager and was only separated as a voluntary termination for inability to uphold weekend schedule obligations. There was no evidence that the facility questioned the discrepancies in names, birth dates, or SSNs on the pre-employment documents, resulting in the employment of an unqualified person to render nursing services as an RN.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of an injury of unknown origin for a resident with significant cognitive impairment and multiple medical conditions, including dementia, contractures, and altered mental status. The resident was dependent on staff for activities of daily living and had a history of swelling in both upper and lower extremities. Documentation in the medical record indicated the resident had a midline IV placed in the right arm, and subsequently developed pain, swelling, and an anterior dislocation of the right shoulder, which was confirmed by radiology and led to a hospital transfer. The facility's abuse prevention policy required a thorough investigation of any incident or allegation involving abuse, neglect, or mistreatment, including gathering facts and completing a final report with a conclusion based on known facts. However, the investigation into the resident's injury was incomplete. The facility was unable to provide a written statement from the ADON, statements from nursing staff who provided care to the resident, or evidence of staff education following the injury. Only two statements from CNA staff were included, and the investigation relied heavily on a statement attributed to an RN who later denied having been interviewed about the incident. Interviews with facility staff, including the ADON, RN, and Medical Director, revealed uncertainty about the cause of the resident's shoulder dislocation. The Administrator acknowledged that a more extensive investigation would have provided a clearer picture of the events leading to the injury. The lack of comprehensive documentation, missing staff statements, and reliance on unverified accounts resulted in a failure to meet the facility's policy requirements for investigating injuries of unknown origin.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Signature Healthcare Of Primacy | 0 mi | ★★★★★ | 7 | 0 |
| Quince Nursing And Rehabilitation Center | 0 mi | ★★★★★ | 19 | 0 |
| Kirby Pines Manor | 2.8 mi | ★★★★★ | 0 | 0 |
| The Village At Germantown | 3.2 mi | ★★★★★ | 11 | 1 |
| Shelby Oaks Post Acute | 3.7 mi | ★★★★★ | 9 | 1 |
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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.