Majestic Gardens At Memphis Rehab & Snc

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

41.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 44 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 32.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 61 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 169 beds and averages 151.3 residents a day — about 90% occupied, or roughly 18 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.36 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.00 hrs/resident/day on weekends vs 3.51 on weekdays — 15% thinner on weekends. RN hours go from 0.44 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 68% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

37 citations, most serious first. The 14 most serious are shown; the remaining 23 are one tap away and print in full.

• Immediate jeopardy · Kcited before2024-05-08 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, Director of Maintenance job description, facility investigation, manufacturer's manual recommendations, medical record review, observation, and interview, the facility failed to ensure the environment was free from accident hazards when dangerously elevated hot water temperatures were measured and when the facility failed to provide a safe environment and adequate supervision to prevent falls and injury for 2 of 5 (Resident #14 and #86) sampled residents reviewed for accidents. On 4/29/2024 and 5/7/2024, dangerous elevated hot water temperatures ranging from 121 degrees Fahrenheit (F) to 142 degrees Fahrenheit (F) were found in 32 of 169 (Resident Rooms #100, #101, #102, #103, #104, #105, #106, #107, #108, #109, #110, #115, #116, #203, #205, #212, #213, #215, #216, #306, #309, #316, #317, #318, #320, #325, #332, #400, #401, #406, #413, and #414) resident rooms checked for water temperatures. Hot water temperatures ranging from 121 degrees to 133 degrees F were found in 3 of the 4…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2023-08-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, video footage, hospital record review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure a safe environment to prevent serious injury and elopement 4 of 14 (Residents #1, #2, #6, and # 15) sampled residents for wheelchair/elevator and wandering/elopement accidents and incidents. On [DATE] Resident #1 exited the 200 hall elevator in a motorized wheelchair, the elevator floor was not level with the floor of the hallway when the elevator door opened, the resident fell out of the wheelchair sustaining bilateral leg fractures, and later died. Resident #2 fell to the floor in a wheelchair when exiting the unlevel elevator floor on [DATE], resulting in fractured leg, and Resident #6 fell from a wheelchair when exiting the unlevel elevator floor on [DATE], resulting in no injuries. Resident #15, a cognitively impaired resident with Dementia and a history of wandering and exit seeking behaviors, eloped from the facility for an…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-08-24 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on facility policy review, job description review, and interview, Administration failed to provide oversight that ensured a safe environment and adequate supervision to prevent serious injuries, failed to ensure a Quality Assurance Performance Improvement (QAPI) process of data collection, analysis, interventions, monitoring and follow up, and failed to ensure the highest practicable wellbeing of residents with wheelchair dependency, dementia and wandering behaviors. The facility Administration failed to ensure the 200 hall elevator functioned in a safe manner, failed to conduct a thorough investigation related to accident/hazards involving the malfunction of the 200 hall elevator, failed to take immediate actions to protect all residents from the 200 hall elevator malfunction, and failed to ensure a safe environment to prevent injuries for 4 of 14 (Residents #1, #2, #6, and # 15) sampled residents for wheelchair/elevator and wandering/elopement accidents and incidents. Residents #1, #2, and #6 experienced falls from their wheelchairs when exiting the 200 hall elevator when…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-08-24 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on policy review, job description review, review of Quality Assurance Performance Improvement (QAPI) minutes, and interview, the QAPI committee failed to ensure systems and processes were in place and consistently followed by staff that address quality issues related to a safe environment and adequate supervision to prevent serious injuries. The QAPI Committee failed to identify quality safety deficiencies and failed to implement and monitor effective safety interventions for 4 of 14 (Residents #1, #2, #6, and # 15) sampled residents for wheelchair/elevator and wandering/elopement accidents and incidents. On 5/22/2023, Resident #6 fell from a wheelchair when exiting the unlevel floor from the 200 hall elevator. On 6/2/2023, Resident #2 fell to the floor in a wheelchair when exiting the 200 hall elevator and sustained a fractured rib and fractured leg. On 7/22/2023, Resident #1 exited the 200 hall elevator in a motorized wheelchair, the elevator floor was not level with the floor of the hallway when the elevator door opened and the resident sustained bilateral leg fractures,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-11 · tag F0604 — failed to not use physical restraints improperly — isolated
  Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, record review, observations, and interviews, the facility failed to ensure residents were free from physical restraints for 1 of 1 (Resident #14) sampled residents reviewed for physical restraints. The findings include: Review of the undated facility policy titled, Use of Restraints, revealed .Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented.Physical Restraints.are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-11 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to ensure staff reported an allegation of staff to resident abuse to the appropriate agencies in a timely manner for 2 of 3 (Resident #65 and #107) sampled residents for allegations of abuse. The findings included: 1. Review of the facility policy titled, Facility Responsibility for Reporting Allegations, dated September 2022, revealed .All allegations/occurrences of all types of staff-to-resident abuse must be reported to the administrator and to other officials, including the State Survey Agency and adult protective services. 2. Review of medical records revealed Resident #65 was admitted on [DATE], with diagnoses including Cerebral infarction, Chronic Kidney Disease, and Diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #65 was cognitively intact. Review of the facility investigation dated 8/29/2025, revealed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-11 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided related to showering and personal hygiene care for 4 of 5 (Resident #2, #3, #89 and #148) sampled residents reviewed for ADLs. The findings include: 1. Review of the undated facility policy titled, Activities of Daily Living (ADLs), Supporting, revealed .Residents will be provided with care to carry out activities of daily living independently will receive the services necessary to maintain good .grooming and personal and oral hygiene .Appropriate care and services will be provided for the residents who are unable to carry out ADLs independently .including assistance with .hygiene (bathing, dressing, grooming and oral care) . 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Hemiparesis and Morbid Obesity. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed a Brief…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-11 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to ensure staff were dispensing and accurately administering medications and treatments per Physician's Orders for 4 of 32 (Residents #3 #41, #51, and #148) residents reviewed. The findings include: 1. Review of the facility policy titled, Medication Administration, dated 7/2023, revealed .Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications.Medications are administered in accordance with written orders of the attending physician.The resident's MAR/EHR [Medication Administration Record/Electronic Health Record] is initialed by the person administering the medication, in the space provided under the date and on the line for that specific medication dose administration time. 2. Review of the medical record revealed…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-11 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to store medication in accordance with facility policy when medication was found unsecured at the beside for 4 of 32 (Resident #11, # 72, #122, and #148) residents. The findings include: 1. Review of the facility policy titled, Medication Storage, dated 4/2025, revealed .The facility is responsible for maintaining proper storage.All medication will be stored according to state and federal laws and regulations.Oral (solid) medication-stored in medication carts except those requiring refrigeration.All medication with routes other than PO (oral) must be stored in separate compartments in medication cart, medication room cabinets, or refrigerator. 2. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Arthritis, Chronic Pancreatitis, Anemia, and Hypertension. Review of the quarterly Minimal Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-09-11 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 (Resident #151) residents observed during medication administration. The findings include: Review of the undated facility policy titled, Cleaning and Disinfection of Resident -Care Items and Equipment, revealed .Resident-care equipment, including reusable items.will be cleaned and disinfected.Reusable items are cleaned and disinfected or sterilized between residents.Reusable resident care equipment is decontaminated and/or sterilized between residents. Review of medical record revealed Resident #151 was admitted to the facility on [DATE], with diagnoses including Dementia, Hypertension, and Schizophrenia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS)…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-20 · tag F0569 — isolated
  Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation and interview, the facility failed to provide care and services when 1 of 3 (Resident #18) discharged sample residents reviewed did not receive a personal refund within 30 days of discharge. The findings include: Review of the facility's policy titled Resident Funds Policy and Procedure, dated 2025, revealed .To ensure that.residents have access to, and are able to manage, their personal funds.Conveyance upon discharge, eviction, or death.Upon discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility shall convey within 30 days, the resident's funds, and a final accounting of those funds, to the resident, his or her legal representative. Review of the medical record revealed Resident #18 was admitted on [DATE], with diagnoses including Psychotic Disorder with Delusions, Dementia, and Hypertension. Resident #18 was discharged to another facility on 12/13/2025. Review of the facility's Patient Fund Request…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-05-08 · tag F0578 — failed to honor advance directives / code status — pattern
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to formulate an Advanced Directive for 21 of 32 sampled residents (Resident #1, #3, #14, #21, #26, #31, #33, #41, #47, #55, #65, #66, #70, #71, #75, #87, #88, #102, #106, #112, and #115) reviewed for Advanced Directives. The findings include: 1. Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, dated 12/2023, revealed .It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive and will provide Advance Directive information if requested . 2. Review of the medical record revealed Resident #1 was admitted to the facility on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-05-08 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, and interview, the facility failed to provide effective housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable environment as evidenced by the odor of urine in Resident's rooms, the 200 and 300 hallways, dirty privacy curtains, standing water in resident's bathroom sinks and in basins, and a loose handrail observed in the 100 Hall. The findings include: 1. Review of the facility's policy, titled, Preventive Maintenance Program, with a revision date of 9/2023, revealed, . A Preventive Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environmental for residents, staff, and the public .The Maintenance Director is responsible is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a sage and operable manner . Review of the facility's procedure titled, Resident Room Cleaning and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-05-08 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by staff using bare hands to prepare food, unlabeled, undated food items, and dirty equipment. The facility had a census of 131 with 124 of those residents receiving a tray from the Kitchen. The findings include: 1. Review of the facility's policy Food Preparation and Service, dated 10/2017, revealed .Food and nutrition services employees shall prepare and serve food in a manner that complies with safe handling practices .Bare hand contact with food is prohibited. Gloves must be worn when handling food directly . Review of the facility's policy Food Receiving and Storage, dated 10/2017, revealed .Foods shall be received and stored in a manner that complies with safe food handling practices .All foods stored in the refrigerator or freezer will be covered, labeled and dated ['use by date] . opened containers must be dated Review of the facility's policy Food Safety Requirements, dated 12/2023, revealed .Food will be stored,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$810,404 in federal fines across 9 penalties. 2 Medicare payment denials on record.

• $285,904 — penalty dated 2024-05-08
• $4,893 — penalty dated 2024-01-08
• $13,635 — penalty dated 2023-12-11
• $4,545 — penalty dated 2023-11-20
• $4,545 — penalty dated 2023-11-13
• $4,545 — penalty dated 2023-11-06
• $4,545 — penalty dated 2023-10-30
• $11,538 — penalty dated 2023-10-10
• $476,254 — penalty dated 2023-08-24
• Medicare payment denial — starting 2024-05-11 for 129 days
• Medicare payment denial — starting 2023-09-23 for 129 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to EPHRAM LAHASKY — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 26 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.3M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TN