Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Memphis Convalescent Center during CMS and state inspections, most recent first.
Improper Food Storage and Labeling in Kitchen Freezer: The facility failed to store frozen food in accordance with food safety standards during a kitchen sanitation review. Surveyors found multiple items in the freezer that were unlabeled, undated, or improperly stored, including unidentified frozen food, ready-to-eat hamburger patties stored open to air, raw chicken, meat, pancakes, and expired sherbert with a loose lid. The DC, DA, and DM stated kitchen staff were responsible for labeling and dating food, and records showed the facility policy and FDA Food Code required food removed from original packaging to be identified and stored in covered or sealed containers.
MDS Did Not Accurately Reflect CPAP Use: A resident with COPD and sleep apnea had an active CPAP order, a care plan identifying CPAP/BiPAP use, and TAR documentation showing CPAP was provided during the MDS look-back period, but the quarterly MDS was not coded for non-invasive mechanical ventilation. The MDSC stated she misunderstood the RAI guidance and relied on the resident’s statement that she did not use CPAP, while the RRC confirmed the chart showed CPAP use.
No RN coverage was provided in the facility for one day during the reviewed period, meaning the facility did not use an RN for at least 8 consecutive hours a day, 7 days a week as required. The Corp RN said the DON had resigned shortly before and she was unaware of the vacancy, while the ADM said she was away for a doctor’s appointment and did not realize there was no RN coverage. Staff also stated that without an RN on duty, a major clinical issue might not receive the correct treatment.
An opened bottle of Novolog insulin was found on the medication cart past its 28-day use date. LVN D stated the insulin had been accessed and used, should have expired, and that an expired insulin could be ineffective and affect treatment. The facility’s insulin storage guidelines and expired medication policy required open-dated insulin to be labeled with the date opened and removed when outdated.
The facility failed to comply with food service safety standards, as observed in their kitchen operations. Freezer and refrigerator items were not properly labeled or dated, and expired pantry items were not removed. Staff interviews revealed inconsistent responsibility for food labeling and disposal, posing a risk of food-borne illness to residents. Facility policies and FDA guidelines for food labeling were not followed.
Three residents were inaccurately coded as receiving anticoagulant medication on their MDS assessments, despite only being prescribed aspirin. This error stemmed from a misunderstanding by the MDS LVN, who incorrectly believed aspirin should be coded as an anticoagulant. The DON acknowledged that such inaccuracies could negatively impact resident care, as care plans are based on MDS assessments.
The facility failed to provide a comprehensive activities program that met residents' needs and preferences. Observations showed that scheduled activities were not conducted, and residents did not receive individual activity calendars. Interviews revealed dissatisfaction with the repetitive and boring activities, lack of weekend programming, and absence of the Activity Director (AD) during weekends. The AD acknowledged leaving early without conducting a scheduled activity, leading to resident complaints. Facility policies emphasized supporting resident choice and providing engaging activities, which were not fulfilled.
The facility failed to notify the State Long-Term Care Ombudsman about a resident's discharge to home. The resident, who had severe cognitive impairment and multiple diagnoses, was discharged after demanding to go home. Both the DON and ADM admitted they did not notify the Ombudsman, with the DON unaware of the requirement and the ADM believing it was unnecessary. The facility's discharge policy did not include the requirement to contact the Ombudsman.
Improper Food Storage and Labeling in Kitchen Freezer
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during a kitchen sanitation review. Observation of the freezer revealed multiple items that were not properly labeled or dated, including a gallon bag of purple unidentified food, a bag of ready-to-eat hamburger patties stored open to air with ice crystals present, a large zip top bag of brown frozen liquid, a large bag of meat, a large zip top bag of raw chicken legs and wings, and a large clear bag of pancakes removed from the original packaging. A container of lime sherbert was also observed with visible freezer burn, a lid not secured tightly, and an expiration date of 09/09/2025. During interviews, the DC, DA, and DM each stated that kitchen staff were responsible for labeling and dating food and that expired or unlabeled food should be discarded because residents could get sick. Record review showed the facility’s food storage policy required open packages to be stored in closed containers or sealed bags and dated when opened, and that frozen food removed from original packaging should be dated when received or removed from packaging. The FDA Food Code excerpts reviewed also required working containers holding food removed from original packages to be identified with the common name of the food and food to be protected from cross contamination by storing it in packages, covered containers, or wrappings.
MDS Did Not Accurately Reflect CPAP Use
Penalty
Summary
The facility failed to ensure Resident #5’s MDS accurately reflected her status for CPAP use on the 09/01/25 quarterly assessment. Resident #5 was a female resident with diagnoses including COPD and sleep apnea. Her care plan identified that she required CPAP/BiPAP for sleep apnea, and the active order summary showed CPAP therapy at bedtime. The TAR for the MDS look-back period showed she received CPAP therapy 11 times during the 14-day period, but Section O of the quarterly MDS was not marked for non-invasive mechanical ventilation. During interview, Resident #5 stated she had used CPAP until about 6 months earlier, then had trouble with the machine and mask, and the doctor said to start over while the facility tried to obtain prior sleep studies and schedule a new sleep study. The Administrator stated the resident was on CPAP therapy and had a history of refusing the mask, while the MDS Coordinator stated she did not mark CPAP because she believed the MDS did not require it on the comprehensive assessment and because the resident told her she never used CPAP. The RRC reviewed the chart and confirmed the resident was documented as receiving CPAP during the look-back period, though not every night.
No RN Coverage for Required Daily Hours
Penalty
Summary
The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week when no RN was working in the facility on 09/19/2025. Record review of the facility’s last 90 days of RN coverage showed that this was the only day in the reviewed period with no RN coverage. The deficiency was identified during review of RN coverage provided by the Corp RN. During interviews, the Corp RN stated that the DON had resigned two days earlier and that she was not aware there was a vacancy in coverage on 09/19/2025; she said she could have provided RN services that day if she had known. The ADM stated the DON had recently resigned and that she did not realize there was no RN coverage on that date because she had a doctor’s appointment and was not at work. The ADM also stated that administration personnel were responsible for ensuring licensed staff coverage. A confidential staff interview stated that without an RN on staff every day, a major clinical issue might not receive the correct treatment. A policy for RN coverage was requested but was not provided.
Expired Novolog Insulin Found on Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when an opened bottle of Novolog insulin was found on the medication cart past its use date. During observation of the facility’s only medication cart, the Novolog bottle was documented as opened on 8/07/25, which was 48 days before the survey review, even though the facility’s insulin storage guidelines state Novolog expires 28 days after opening. All other insulin medications in the cart were within the correct use date. During interview, LVN D stated the Novolog bottle had been accessed and used, should have expired in 28 days, and that the expired medication could result in a resident receiving medication that would not be effective and could affect treatment. LVN D also stated the night nurse had reported checking all insulins, but that was not accurate, and she would report the issue to the administrator. The Corporate RN later stated that all insulins should be marked with the date opened and that the expiration date depends on the type of insulin. The facility policy on expired medications with shortened expiration dates states that open-dated medications must be labeled with the date opened and that outdated or expired medications are to be removed from the medication cart.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. Specifically, the facility did not ensure that freezer items were properly stored, labeled, and dated, with items such as a bag of chicken breasts and a frozen ham lacking labels or dates. Similarly, the refrigerator contained several items, including cucumbers, cantaloupe, sour cream, bread loaves, cream cheese, bell pepper, limes, and a pitcher of red liquid, all without proper labeling or dating. Additionally, the pantry contained expired items such as lemon juice, taco shells, mini marshmallows, and brown gravy mix, along with a dented can of tropical fruit salad, which were not removed from circulation. Interviews with staff members revealed a lack of consistent responsibility for labeling, dating, and disposing of expired food. Staff members acknowledged the potential negative outcomes of serving expired or improperly stored food, including the risk of food-borne illness to residents. The facility's policies, dated 2012, outlined the requirements for food storage, labeling, and handling of dented cans, but these were not followed, as evidenced by the observations and staff interviews. The U.S. Food and Drug Administration's Food Code also mandates proper labeling of food, which was not adhered to in this case.
Inaccurate MDS Coding for Anticoagulant Medication
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, specifically in the coding of anticoagulant medication on their Minimum Data Set (MDS) assessments. Resident #4, a female with dementia, chronic atrial fibrillation, and high blood pressure, was inaccurately coded as receiving anticoagulant medication, despite no active or discontinued orders for such medication. Instead, she was prescribed aspirin, which should not be coded as an anticoagulant according to the Resident Assessment Instrument (RAI) guidelines. Similarly, Resident #11, a female with cerebral infarction, high blood pressure, and dementia, was also inaccurately coded as receiving anticoagulant medication. Her records showed an order for aspirin, but no anticoagulant medication was prescribed. Resident #22, with high blood pressure, peripheral vascular disease, and colon cancer, was similarly misrepresented in her MDS assessment. Her records indicated an order for aspirin, but no anticoagulant medication was present. Interviews with facility staff revealed a misunderstanding in coding practices. The MDS Licensed Vocational Nurse (LVN) responsible for completing the assessments believed aspirin should be coded as an anticoagulant, based on incorrect information from an unspecified source. This misunderstanding was clarified during the survey, as the RAI manual explicitly states that aspirin should not be coded as an anticoagulant. The Director of Nursing (DON) acknowledged that inaccurate MDS assessments could negatively impact resident care, as care plans are based on these assessments.
Deficiency in Resident Activities Program
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the needs and preferences of residents, as observed over three days in August 2024. The activities calendar for the month showed repetitive scheduling, with the same activities planned each week, and a lack of variety in the offerings. Observations revealed that scheduled activities, such as chronicle/devotions and dominoes, were not conducted as planned. Additionally, residents did not receive individual activity calendars in their rooms, and they had to rely on a single calendar posted outside the dining room. Interviews with residents indicated dissatisfaction with the activities program, noting that activities were not conducted on weekends and that the Activity Director (AD) was not present to facilitate them. Residents expressed that they found the activities boring and repetitive, and their suggestions for new games were not implemented. The AD confirmed that she did not work on weekends and was unsure who was responsible for running activities during that time. The AD also acknowledged that she had left early on a Friday without conducting the scheduled activity, which led to a resident complaint. The facility's grievance log and resident council minutes further highlighted issues with the activities program, with several complaints about the lack of engaging activities and the absence of weekend programming. The AD, who had recently received her certification, was aware of the residents' complaints but had not yet implemented changes. The facility's policies on resident rights and activity programming emphasized the importance of supporting resident choice and providing activities that meet their interests and needs, which were not being fulfilled as per the observations and interviews conducted.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman for a resident who was discharged to home. The resident, a male with severe cognitive impairment and multiple diagnoses including dementia, schizoaffective disorder, and bipolar type, was readmitted to the facility from a behavioral hospital after assaulting another resident. The facility staff had informed the resident's family member that they would not be able to keep the resident if another incident occurred, and the family member agreed to take him home if that happened. On the day of discharge, the resident returned from a 72-hour pass with his family member, was angry, and demanded to go home. The DON and ADM had a meeting with the resident and his family member, who agreed to discharge him and take him home. During interviews, both the DON and ADM admitted that they did not notify the Ombudsman about the discharge. The DON stated she was unaware of the requirement to notify the Ombudsman, while the ADM believed it was unnecessary because the discharge was not against the resident's will. The facility's discharge planning policy did not mention the requirement to contact the State Ombudsman's office. This oversight could potentially deprive residents of their rights to advocacy services, discharge/transfer options, and appeal processes.
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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) |
|---|---|---|---|---|
| Wellington Care Center | 20.2 mi | ★★★★★ | 9 | 1 |
| Clarendon Nursing Home | 23.6 mi | ★★★★★ | 5 | 0 |
| Avir At Childress | 28.6 mi | ★★★★★ | 4 | 0 |
| Mclean Care Center | 34.7 mi | ★★★★★ | 1 | 1 |
| Colonial Manor Ii | 36 mi | ★★★★★ | 2 | 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.