Inspection Reports for
Graceland Rehabilitation and Nursing Center
1250 Farrow Rd, Memphis, TN 38116, United States, TN, 38116
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
82% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
158 residents
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Routine
Census: 158
Deficiencies: 10
Date: May 13, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including medication consent, advance directives, psychotropic medication use, resident safety, infection control, food safety, and other care standards.
Findings
The facility was cited for multiple deficiencies including failure to obtain consent for psychotropic medications, failure to educate residents/families on advance directives, improper use and documentation of psychotropic medications, failure to timely report abuse investigations, failure to notify resident representatives of discharge, failure to follow physician orders for lab work, failure to prevent accidents resulting in resident injuries including an Immediate Jeopardy for a resident fall, improper medication storage, unsanitary food handling and storage practices, and failure to follow infection control protocols.
Deficiencies (10)
Failed to obtain consent for administration of psychotropic medications for 2 of 5 sampled residents.
Failed to provide education and written information to residents/families to formulate advance directives for 27 of 35 sampled residents.
Failed to ensure PRN psychotropic medications were limited to 14 days duration and failed to obtain physician's assessment or document rationale for continued use for 1 of 5 sampled residents.
Failed to report sufficient information describing results of investigations to the State Survey Agency within 5 working days for 1 of 2 sampled residents reviewed for injury of unknown origin.
Failed to notify resident's representative or family member of intent to discharge for 1 of 3 sampled residents.
Failed to follow physician's orders and obtain lab work for 2 of 5 sampled residents reviewed for unnecessary medication use.
Failed to ensure residents remained free from accident hazards resulting in Immediate Jeopardy for 1 resident fall with injury and substandard care for another resident fall.
Failed to ensure medications were properly stored and secured when medications were found unsecured and unattended in 1 of 78 resident rooms.
Failed to ensure food was stored, handled, prepared, and served under sanitary conditions including rust on equipment, unlabeled and undated food, unclean utensils, lack of thermometers, improper dish machine operation, and failure to use paper products.
Failed to ensure proper infection control practices were followed when 2 staff failed to wear PPE and perform hand hygiene, and failed to limit interactions of a contact isolation resident with others.
Report Facts
Residents receiving trays: 133
PRN Ativan administrations: 58
PRN Ativan administrations: 52
PRN Ativan administrations: 10
Fall duration before hospital transport: 388
Fall audit period: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in fall incident involving Resident #415 where CNA A was left alone with resident resulting in fall. |
| CNA B | Certified Nursing Assistant | Named in fall incident involving Resident #415 where CNA B left room to get supplies. |
| LPN G | Licensed Practical Nurse | Documented fall incident of Resident #415 and called responsible party. |
| LPN KK | Licensed Practical Nurse | Assessed Resident #515 after fall and documented pain. |
| Medical Director | Interviewed regarding fall protocols and medication orders. | |
| Social Service Director | Interviewed regarding psychotropic medication consents and discharge notification. | |
| Marketing Director | Interviewed regarding advance directives education process. | |
| Dietary FF | Dietary Staff | Observed taking food temperatures without changing alcohol pad between items and not informing staff about dish machine status. |
| Housekeeping CC | Housekeeping Staff | Observed entering isolation rooms without PPE and not performing hand hygiene. |
| LPN DD | Licensed Practical Nurse | Interviewed about contact isolation compliance for Resident #74. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 13, 2025
Visit Reason
The inspection was conducted due to complaints and incidents involving resident safety, including failure to report investigations timely and failure to notify representatives of discharge intent.
Complaint Details
The complaint investigation revealed failure to submit a final investigation report for an unwitnessed fall resulting in injury to Resident #515, and failure to notify the representative of discharge intent for Resident #316. The facility was found to have Immediate Jeopardy related to inadequate supervision and accident hazards causing injury to Residents #415 and #515.
Findings
The facility failed to timely report investigation results for a resident injury, failed to notify a resident's representative of discharge intent, and failed to ensure adequate supervision and accident hazard prevention resulting in falls with injury, including an Immediate Jeopardy for a resident who fell from bed due to insufficient assistance.
Deficiencies (3)
Failed to timely report results of investigations to the State Survey Agency within 5 working days for a resident injury of unknown origin.
Failed to notify resident's representative or family member of intent to discharge for a resident.
Failed to ensure nursing home area was free from accident hazards and provide adequate supervision, resulting in falls with injury including a traumatic brain injury and a displaced femoral neck fracture.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Immediate Jeopardy duration: 63
Fall audit date: May 7, 2025
Fall incident delay: 388
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN G | Licensed Practical Nurse | Documented fall incident and assessment of Resident #415 |
| CNA A | Certified Nursing Assistant | Left alone with Resident #415 during fall incident |
| CNA B | Certified Nursing Assistant | Left room to get supplies during Resident #415 fall incident |
| Administrator | Interviewed regarding reporting and fall incident procedures | |
| Social Services Director | SSD | Confirmed responsibility for notifying representative of discharge |
| Director of Nursing | DON | Confirmed communication and supervision failures |
| Nurse Practitioner #1 | NP | Raised concerns about patient safety and fall education |
| MD | Medical Doctor | Provided expert opinion on fall preventability and nurse expectations |
| LPN KK | Licensed Practical Nurse | Assessed Resident #515 after fall and discussed transport delay |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jan 29, 2025
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, care planning, pressure ulcer prevention, and other regulatory requirements as part of the facility's annual survey.
Findings
The facility failed to provide reasonable accommodations for bathing due to inadequate hot water temperature affecting 5 of 10 sampled residents. Additionally, the facility failed to follow the comprehensive care plan for fall prevention for 1 resident and failed to accurately document skin assessments for 1 resident with wounds.
Deficiencies (3)
Failed to provide reasonable accommodations for bathing when hot water was below the minimum temperature for 5 of 10 sampled residents.
Failed to follow the comprehensive person-centered care plan for fall prevention for 1 of 3 residents reviewed.
Failed to accurately document weekly skin assessments for 1 of 3 residents with wounds reviewed.
Report Facts
Residents affected: 5
Residents affected: 1
Residents affected: 1
Wound measurements: 1.5
Wound measurements: 1
Wound measurements: 1
Wound measurements: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN F | Licensed Practical Nurse | Confirmed no assistance was given to CNA G during turning of Resident #4 at time of fall |
| CNA G | Certified Nursing Assistant | Involved in sliding Resident #4 to the floor and turning resident for care |
| Director of Nursing | Director of Nursing | Confirmed staff were not following Resident #4's care plan and reviewed skin assessment documentation for Resident #1 |
| LPN H | Licensed Practical Nurse | Reviewed Resident #1's weekly skin assessment documentation and stated the order was not put in correctly |
| Maintenance Director | Interviewed regarding water temperatures in resident rooms | |
| Administrator | Interviewed regarding awareness of water temperature issues |
Inspection Report
Immediate Jeopardy
Census: 171
Deficiencies: 12
Date: May 1, 2024
Visit Reason
Complaint investigation and follow-up survey related to medication administration, resident care, staffing, safety, and infection control at Graceland Rehabilitation and Nursing Care Center.
Complaint Details
Complaint investigation revealed multiple deficiencies including medication errors, staffing shortages, failure to provide timely assessments and care, failure to provide basic life support, failure to prevent accidents, and infection control breaches.
Findings
The facility failed to ensure residents were free from significant medication errors, failed to provide adequate staffing including licensed nurses on all shifts, failed to provide timely assessments and care for residents including post-fall monitoring, failed to provide basic life support immediately during emergencies, failed to maintain accurate medical records, failed to prevent accidents and ensure safe environment, and failed to implement effective infection prevention and control practices including proper cleaning of multi-use blood glucose meters. These failures resulted in actual harm and immediate jeopardy to residents.
Deficiencies (12)
Failed to assess and care plan for resident self-administration of medications.
Failed to provide supervision and monitoring after unwitnessed falls resulting in immediate jeopardy and harm.
Failed to ensure adequate and appropriate staffing including licensed nurses on all shifts, resulting in missed medication administration and assessments.
Failed to initiate and provide Basic Life Support (CPR) immediately for residents found unresponsive, and failed to ensure CPR certified staff were available.
Failed to provide appropriate pressure ulcer care and follow physician orders for wound treatment and suture removal.
Failed to prevent accidents and provide safe environment including proper use of mechanical lifts, resulting in resident fall with injury.
Failed to ensure nursing administered nutritional support and services as ordered for residents with feeding tubes.
Failed to maintain accurate and complete medical records for residents including documentation of elopement and falls.
Failed to ensure sufficient licensed nursing staff were available to provide care and services per physician orders and to meet residents' needs safely.
Failed to ensure residents were free from significant medication errors when medications were not administered as ordered by the physician.
Failed to administer the facility in a manner that provided oversight of care, sufficient staffing, and competent staff to provide care and services per physician orders.
Failed to provide and implement an infection prevention and control program including proper cleaning and disinfection of multi-use blood glucose meters and use of PPE.
Report Facts
Residents affected: 11
Residents affected: 25
Residents affected: 2
Residents affected: 1
Residents affected: 5
Census: 171
Staffing shortage days: 13
Medication administration missed days: 90
CNA staff in-service attendance: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN JJ | Licensed Practical Nurse | Failed to maintain CPR certification and failed to initiate CPR during resident code |
| CNA B | Certified Nursing Assistant | Found Resident #5 unresponsive and failed to initiate CPR immediately |
| CNA H | Certified Nursing Assistant | Found Resident #6 unresponsive and failed to initiate CPR immediately |
| LPN A | Licensed Practical Nurse | Failed to clean and disinfect blood glucometer and failed to don PPE during resident care |
| LPN B | Licensed Practical Nurse | Failed to clean and disinfect blood glucometer |
| CNA N | Certified Nursing Assistant | Failed to clean and disinfect mechanical lift after use |
| CNA M | Certified Nursing Assistant | Failed to clean and disinfect mechanical lift after use |
| LPN C | Licensed Practical Nurse | Inaccurate documentation of fall and medication administration |
| CNA K | Certified Nursing Assistant | Failed to report resident fall |
| LPN F | Licensed Practical Nurse | Failed to ensure proper transfer and care post fall |
| RN FF | Registered Nurse, Unit Manager | Aware of staffing shortages and missed medications on Crown Unit |
| Administrator | Facility Administrator | Responsible for facility oversight and staffing |
| COO | Chief Operating Officer | Responsible for facility operations and oversight |
| Interim DON | Interim Director of Nursing | Oversight of nursing services and infection control |
| FNP #1 | Family Nurse Practitioner | Provided clinical guidance on care and infection control |
| Housekeeping Supervisor | Housekeeping Supervisor | Unaware of proper lift pad disposal procedures |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 17, 2021
Visit Reason
The inspection was conducted as a routine annual survey of Graceland Rehabilitation and Nursing Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met all required standards at the time of the survey.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 11, 2019
Visit Reason
The inspection was conducted based on complaints regarding failure to maintain residents' dignity and privacy, failure to implement physician orders for splint devices, improper medication storage, and inadequate infection prevention and control practices.
Complaint Details
The complaint investigation found substantiated deficiencies related to resident dignity and privacy violations, failure to implement physician orders for splints, medication storage security lapses, and infection control failures including lack of isolation signage and poor hand hygiene.
Findings
The facility failed to maintain resident dignity and privacy when staff entered rooms without knocking and failed to provide privacy during toileting. The facility also failed to implement splint devices as ordered for residents with limited range of motion, failed to secure medication carts properly, and failed to follow infection control protocols including hand hygiene and isolation precautions.
Deficiencies (4)
Failure to honor resident's right to dignity and privacy; staff entered rooms without knocking and failed to provide privacy during toileting.
Failure to implement splint devices for residents with limited range of motion as ordered.
Failure to ensure medications were properly stored and secured; medication cart left unlocked and unattended.
Failure to implement infection prevention and control program; nurses failed hand hygiene during wound care and medication administration, and failure to post isolation signs for a resident requiring contact isolation.
Report Facts
Residents affected: 6
Residents affected: 2
Medication storage areas inspected: 14
Nurses observed: 8
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in findings for failure to knock before entering rooms and infection control violations |
| LPN #2 | Licensed Practical Nurse | Named in findings for failure to knock before entering rooms and infection control violations |
| LPN #3 | Licensed Practical Nurse | Named in medication cart security and isolation signage interview |
| LPN #4 | Licensed Practical Nurse | Named in findings for failure to knock before entering rooms |
| LPN #5 | Licensed Practical Nurse | Named in findings for failure to knock before entering rooms |
| LPN #6 | Licensed Practical Nurse | Named in infection control observations |
| CNA #1 | Certified Nursing Assistant | Named in findings for failure to knock before entering rooms |
| CNA #2 | Certified Nursing Assistant | Named in findings for failure to knock before entering rooms and interview on privacy |
| CNA #3 | Certified Nursing Assistant | Named in findings for failure to provide privacy during toileting |
| Director of Nursing | Director of Nursing | Interviewed regarding staff expectations for knocking and privacy, medication cart security, and splint application |
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