Inspection Reports for
Majestic Gardens at Memphis Rehabilitation and Skilled Nursing Center
131 N Tucker St, Memphis, TN 38104, USA, TN, 38104
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
202% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Sep 11, 2025
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints, failure to timely report allegations of abuse, inadequate assistance with activities of daily living, medication administration errors, improper medication storage, and failure to properly disinfect reusable equipment.
Deficiencies (6)
F 0604: The facility failed to ensure residents were free from physical restraints; Resident #14 was restrained with a Geri chair tray without physician order or consent documentation.
F 0609: The facility failed to timely report allegations of staff-to-resident abuse for Residents #65 and #107 to appropriate authorities.
F 0677: The facility failed to provide adequate assistance with activities of daily living, including showering and personal hygiene, for Residents #2, #3, #89, and #148.
F 0755: The facility failed to ensure medications and treatments were administered accurately per physician orders for Residents #3, #41, #51, and #148.
F 0761: The facility failed to store medications securely; medications were found unsecured at bedside for Residents #11, #72, #122, and #148.
F 0880: The facility failed to disinfect reusable resident equipment; LPN A did not clean a blood pressure monitor between uses on Resident #151.
Report Facts
Residents reviewed for physical restraints: 1
Residents reviewed for abuse allegations: 3
Residents reviewed for ADL assistance: 5
Residents reviewed for medication administration: 32
Residents with medications found unsecured: 4
Nurses observed failing to disinfect equipment: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN J | Licensed Practical Nurse | Confirmed Resident #14 could not remove tray restraint |
| CNA C | Certified Nursing Assistant | Alleged in abuse incident with Resident #65 |
| LPN A | Licensed Practical Nurse | Failed to disinfect blood pressure monitor between uses |
| Director of Nursing | Director of Nursing | Confirmed restraint policies, medication errors, and infection control deficiencies |
| Administrator | Facility Administrator | Confirmed delays in reporting abuse allegations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to refund a discharged resident's personal funds within the required 30-day period.
Complaint Details
The complaint was substantiated. Resident #18's daughter confirmed the personal account refund was not received until over a month after discharge, and facility management acknowledged the delay.
Findings
The facility failed to provide care and services by not refunding Resident #18's personal funds within 30 days of discharge. The resident's personal account refund was delayed and only received by the responsible party over a month late.
Deficiencies (1)
F 0569: The facility failed to notify residents of certain balances and convey resident funds upon discharge, eviction, or death. Resident #18's personal funds were not refunded within 30 days of discharge as required by facility policy.
Report Facts
Days delayed for refund: 44
Residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Confirmed the account was not refunded within 30 days | |
| Administrator | Confirmed the account was not refunded within 30 days |
Inspection Report
Routine
Deficiencies: 11
Date: May 8, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements including resident rights, advance directives, environment safety, medication management, and care practices.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to provide advance directive information, inadequate housekeeping and maintenance, failure to notify ombudsman of emergency transfers, inaccurate resident assessments, failure to provide scheduled bathing, unsafe hot water temperatures posing immediate jeopardy, improper medication storage and administration, unsanitary food handling, and incomplete medical record documentation.
Deficiencies (11)
F 0550: Facility failed to treat residents with dignity and respect when staff entered rooms without knocking or announcing themselves during dining.
F 0578: Facility failed to provide information regarding residents' rights to formulate advance directives for 21 of 32 sampled residents.
F 0584: Facility failed to maintain a safe, clean, and homelike environment as evidenced by urine odors, dirty privacy curtains, standing water in sinks, and a loose handrail.
F 0623: Facility failed to notify the Ombudsman of emergency transfers for 1 of 1 sampled residents reviewed for hospitalization.
F 0641: Facility failed to ensure accurate resident assessments for cognitive status, falls, discharge disposition, and diagnoses for 5 of 32 sampled residents.
F 0677: Facility failed to provide scheduled bathing assistance for 2 of 3 sampled residents reviewed for activities of daily living care.
F 0689: Facility failed to maintain safe hot water temperatures, exposing residents to immediate jeopardy due to dangerously elevated water temperatures and failed to provide adequate supervision to prevent falls and injury for 2 sampled residents.
F 0690: Facility failed to provide appropriate care for an indwelling catheter for 1 sampled resident as ordered.
F 0761: Facility failed to ensure medications were stored securely when medications were left unattended in resident rooms and medication carts were left unlocked and unattended.
F 0812: Facility failed to ensure food was stored, prepared, and served under sanitary conditions including use of bare hands, unlabeled and undated food items, and dirty equipment.
F 0842: Facility failed to maintain accurate and complete medical records for 1 sampled resident, including inaccurate neurological check documentation.
Report Facts
Residents reviewed for advance directives: 32
Residents with elevated hot water temperatures: 32
Facility census: 131
Residents receiving trays from kitchen: 124
Residents sampled for medication storage: 61
Medication carts observed unlocked: 2
Residents sampled for bathing assistance: 3
Residents sampled for assessment accuracy: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed failure to knock before entering rooms, failure to provide advance directive information, and acknowledged water temperature issues |
| Maintenance Team Lead | Maintenance Team Lead | Acknowledged lack of training on water temperature checks and failure to maintain safe water temperatures |
| Maintenance Technician | Maintenance Technician | Performed water temperature checks incorrectly and lacked formal training |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Confirmed food safety violations including unlabeled food and bare hand contact |
| Administrator | Facility Administrator | Acknowledged poor communication and delayed notification of immediate jeopardy related to water temperatures |
Inspection Report
Deficiencies: 12
Date: May 8, 2024
Visit Reason
The inspection was conducted to evaluate compliance with federal regulations related to resident rights, advance directives, housekeeping, notification of transfers, resident assessments, activities of daily living, accident prevention, medication storage, food safety, medical record accuracy, and equipment safety.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to provide advance directive information to many residents, inadequate housekeeping and maintenance leading to unsanitary conditions and safety hazards, failure to notify the Ombudsman of emergency transfers, inaccurate resident assessments, failure to provide scheduled bathing assistance, dangerously elevated hot water temperatures posing immediate jeopardy, improper catheter care, unsecured medication storage, unsafe food handling practices, inaccurate neurological documentation, and unsafe equipment conditions including capped off showers and a non-functioning elevator.
Deficiencies (12)
F 0550: The facility failed to treat residents with dignity and respect when staff failed to knock and announce themselves before entering resident rooms during dining.
F 0578: The facility failed to provide information regarding residents' rights to formulate advance directives for 21 of 32 sampled residents.
F 0584: The facility failed to provide effective housekeeping and maintenance services resulting in urine odors, dirty privacy curtains, standing water in sinks, and a loose handrail.
F 0623: The facility failed to notify the Ombudsman of emergency transfers for 1 of 1 sampled resident reviewed for hospitalization.
F 0641: The facility failed to accurately assess residents for cognitive status, falls, discharge disposition, and diagnoses for 5 of 32 sampled residents.
F 0677: The facility failed to ensure Activities of Daily Living assistance related to bathing was provided for 2 of 3 sampled residents reviewed for ADL care.
F 0689: The facility failed to maintain a safe environment and adequate supervision to prevent accidents and failed to control dangerously elevated hot water temperatures placing residents at immediate jeopardy.
F 0690: The facility failed to provide appropriate care and services for an indwelling catheter for 1 sampled resident.
F 0761: The facility failed to ensure medication was stored securely when medications were left unattended in resident rooms and medication carts were left unlocked and unattended.
F 0812: The facility failed to ensure food was stored, prepared, and served under sanitary conditions including use of bare hands, unlabeled and undated food items, and dirty equipment.
F 0842: The facility failed to maintain an accurate and complete medical record for 1 sampled resident, including inaccurate neurological check documentation.
F 0908: The facility failed to maintain equipment in safe operating condition for 4 shower room stalls that were capped off and for 1 elevator that was out of order for nearly a year.
Report Facts
Residents reviewed for advance directives: 32
Residents with elevated hot water temperatures: 32
Facility census: 131
Residents receiving trays from kitchen: 124
Medication bottles in backup cart: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed staff should knock before entering rooms; confirmed failure to provide advance directive info; confirmed odor and maintenance issues; confirmed medication storage issues; confirmed inaccurate neuro check documentation |
| Maintenance Team Lead | Maintenance Team Lead | Reported lack of training on water temperature checks; confirmed elevated water temperatures; confirmed loose handrail; confirmed shower stalls capped off |
| Maintenance Technician | Maintenance Technician | Reported lack of training; admitted improper water temperature measurement; confirmed water heater settings |
| Regional Director of Maintenance | Regional Director of Maintenance (RDOM) | Acknowledged elevated water temperatures; confirmed lack of staff training; planned to educate maintenance staff |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Confirmed food safety violations including unlabeled food and bare hand contact |
| LPN B | Licensed Practical Nurse | Left medications unattended at bedside |
| LPN F | Licensed Practical Nurse | Confirmed backup medication cart was unlocked and unattended |
| Maintenance Director | Maintenance Director | Confirmed shower stalls capped off due to water temperature issues |
| Healthcare Consultant | Healthcare Consultant | Confirmed 200 hall elevator out of service for nearly a year |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Aug 24, 2023
Visit Reason
Investigation of multiple resident incidents including abuse allegations, injury of unknown origin, missing property, falls, and elopement at Majestic Gardens at Memphis Rehab & Snc.
Complaint Details
The investigation was complaint-driven, triggered by allegations of abuse, injury of unknown origin, missing property, falls, and elopement incidents involving multiple residents.
Findings
The facility failed to protect residents from misappropriation of property, timely report suspected abuse and injuries, thoroughly investigate allegations, provide appropriate care plans for falls and weight loss, ensure incontinent residents received proper care, follow physician orders for wound care, maintain a safe environment to prevent accidents including elevator malfunctions, and conduct effective quality assurance and performance improvement activities. Immediate jeopardy was identified related to elevator safety and resident elopement.
Deficiencies (9)
F0602: The facility failed to protect residents from misappropriation of property and delayed reporting and investigation of a missing cell phone and related items for Resident #6.
F0609: The facility failed to timely report suspected abuse and injury of unknown origin for Residents #10 and #11 within required timeframes.
F0610: The facility failed to thoroughly investigate an allegation of abuse (misappropriation) for Resident #6 and conducted an investigation based on incorrect incident dates.
F0657: The facility failed to develop and revise comprehensive care plans with appropriate fall prevention interventions for Residents #1, #7, #9, #10, #11, and #13.
F0677: The facility failed to provide adequate incontinent care for Residents #10, #11, #12, and #13, resulting in prolonged exposure to urine and feces and skin breakdown.
F0684: The facility failed to follow physician's orders for wound care for Residents #10, #12, and #13, including failure to apply ordered dressings and use unauthorized ointments.
F0689: The facility failed to ensure a safe environment to prevent serious injury and elopement for Residents #1, #2, #6, and #15, including failure to maintain elevator safety and supervise a cognitively impaired resident who eloped.
F0835: The facility administration failed to provide oversight to ensure resident safety, failed to conduct thorough investigations of incidents, failed to implement and monitor corrective actions, and failed to maintain a safe environment for residents with dementia and wandering behaviors.
F0867: The facility's Quality Assurance Performance Improvement (QAPI) program failed to identify and address quality deficiencies related to resident safety, failed to conduct root cause analyses, and failed to monitor effectiveness of corrective actions for incidents involving elevator malfunctions and resident elopement.
Report Facts
Fall incidents: 9
BIMS scores: 3
BIMS scores: 15
Elevator gap: 12
Incident dates: 3
Elopement date: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Reported missing cell phone for Resident #6 and assisted in investigation. | |
| Administrator | Interviewed multiple times regarding investigations, elevator incidents, and elopement. | |
| Director of Nursing | DON | Interviewed regarding investigations, QAPI, and corrective actions. |
| Maintenance Director | Interviewed regarding elevator maintenance and elopement incident. | |
| Medical Director | Notified of incidents but did not participate in investigations or QAPI meetings. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Mar 15, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding medication administration, wound care, resident supervision, and facility safety, including an elopement incident involving a cognitively impaired resident.
Complaint Details
The investigation was complaint-driven, triggered by concerns about medication administration, wound care, resident supervision, and safety, including an elopement incident of a cognitively impaired resident on 1/2/2023, which resulted in immediate jeopardy.
Findings
The facility failed to provide ordered medications and wound care treatments for multiple residents, failed to ensure adequate supervision and safety for residents with dementia and wandering behaviors, resulting in an elopement incident placing a resident in immediate jeopardy. The facility also failed to maintain accurate wandering risk assessments and implement effective quality assurance and performance improvement activities.
Deficiencies (5)
F684: The facility failed to provide medications and wound treatments as ordered by the physician for 4 of 6 sampled residents, with multiple instances of missed medication doses and wound care treatments.
F689: The facility failed to ensure a safe environment and adequate supervision to prevent accidents, resulting in immediate jeopardy when a cognitively impaired resident eloped and was found unsupervised outside the building.
F692: The facility failed to follow its hydration policy and manage residents' hydration needs and preferences for 7 of 10 sampled residents, with observations of residents lacking access to fluids and staff unaware of hydration provisions.
F835: The facility administration failed to use resources effectively and efficiently, failing to provide oversight to ensure safe care for residents with dementia and wandering behaviors, and failed to implement corrective actions after a resident eloped.
F867: The Quality Assurance Performance Improvement (QAPI) committee failed to provide oversight and implement effective policies and procedures to prevent resident elopements and ensure a safe environment, resulting in ongoing immediate jeopardy.
Report Facts
Resident elopement distance: 1000
Wandering risk screen completion rate: 63.4
Facility census: 131
Residents with incomplete wandering risk screens: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Found Resident #1 after elopement and provided interview about the incident. |
| CNA #3 | Certified Nursing Assistant | Observed Resident #1 exit seeking prior to elopement. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding elopement incident, audits, and QAPI activities. |
| Administrator | Facility Administrator | Interviewed regarding elopement incident, facility oversight, and QAPI. |
Inspection Report
Annual Inspection
Census: 139
Deficiencies: 9
Date: Jul 18, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found deficient in multiple areas including failure to complete timely Minimum Data Set assessments, incomplete care plans, unsafe storage of chemicals and medications, medication administration errors, unsanitary kitchen conditions, inaccurate resident weight recordings, and inadequate infection control practices.
Deficiencies (9)
F0641: The facility failed to complete a quarterly Minimum Data Set assessment timely for 1 of 35 sampled residents.
F0656: The facility failed to develop a comprehensive care plan for 1 of 31 sampled residents reviewed.
F0689: The facility failed to ensure the environment was free of accident hazards when unsecured chemicals were found in a shower room.
F0698: The facility failed to provide appropriate dialysis care and complete dialysis communication records for 1 resident.
F0759: The facility failed to ensure medication error rates were less than 5 percent, with 4 errors observed out of 36 opportunities.
F0761: The facility failed to ensure medications and chemicals were stored separately, medications were dated when opened, not expired, and medication carts were secured and attended.
F0812: The facility failed to ensure food was stored, prepared, and served under sanitary conditions, with multiple sanitation issues observed in the kitchen.
F0842: The facility failed to ensure weights were accurately obtained and recorded for 1 of 4 sampled residents reviewed for nutritional risk.
F0880: The facility failed to implement infection prevention and control practices, including lack of isolation signage and improper hand hygiene during PEG tube care.
Report Facts
Medication error rate: 11.11
Resident census: 139
Residents receiving kitchen trays: 125
Weight discrepancy: 27.2
Weight discrepancy: 24.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in medication error finding for incorrect Symbicort inhaler dose |
| LPN #3 | Licensed Practical Nurse | Named in medication error finding for incorrect Gentamicin dose |
| LPN #8 | Licensed Practical Nurse | Named in medication error finding for incorrect Lisinopril dose and infection control hand hygiene failure |
| RN #1 | Registered Nurse | Named in medication error finding for incorrect Aspirin dose |
| MDS Coordinator #1 | Interviewed regarding incomplete quarterly MDS assessment | |
| MDS Coordinator #2 | Interviewed regarding overdue comprehensive care plan | |
| Director of Nursing | Director of Nursing | Interviewed regarding dialysis communication records, medication errors, and infection control expectations |
| Administrator | Administrator | Interviewed regarding chemical storage, kitchen sanitation responsibility, and MDS assessment timeliness |
| Registered Dietitian | Registered Dietitian | Interviewed regarding kitchen sanitation and absence of Certified Dietary Manager |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding responsibility for resident weight recording accuracy |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding chemical storage in shower room |
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