Inspection Reports for Memphis Jewish Home & Rehab
36 Bazeberry Rd, Cordova, TN 38018, TN, 38018
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, and screening processes at Memphis Jewish Home.
Findings
The facility was found deficient in multiple areas including failure to resubmit a PASRR after a new mental health diagnosis and antipsychotic medication, unsecured sharps in a resident bathroom, lack of physician's order for an indwelling urinary catheter, and unsecured medication storage and administration practices.
Deficiencies (4)
Failed to resubmit a PASRR after a resident had a new mental health diagnosis and new antipsychotic medication.
Unattended and unsecured disposable razor with blades exposed found in a resident bathroom.
Failed to have a physician's order for the use of an indwelling urinary catheter for a resident.
Medications were not properly stored and secured; medication cart was unlocked and unattended, and medications left unsecured on top of the medication cart.
Report Facts
Residents reviewed for PASRR: 1
Residents reviewed for accident hazards: 119
Residents reviewed for indwelling catheter use: 3
Medication storage areas observed: 15
Staff observed during medication administration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Left medications unsecured and unattended on top of a medication cart |
| RN B | Registered Nurse | Observed medication cart unlocked and unattended; confirmed medication cart should be locked |
| Resident Assessment Coordinator | Confirmed failure to complete Level 2 PASRR after resident was given mental illness diagnosis and antipsychotic medication | |
| Director of Nursing | Director of Nursing | Confirmed that razor should not be left unsecured in resident's bathroom and should be discarded in sharps container |
Inspection Report
Routine
Census: 131
Deficiencies: 7
Date: Mar 25, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, transfer documentation, resident assessments, medication administration, infection control, and food service sanitation.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity regarding urinary catheter privacy, lack of transfer documentation, incomplete resident assessments, inaccurate medication assessments, improper medication storage and administration, failure to maintain sanitary food service practices, and significant infection control breaches related to blood glucose meter cleaning and hand hygiene, resulting in immediate jeopardy to resident health.
Deficiencies (7)
Failure to provide and utilize indwelling urinary catheter privacy bags for 3 of 5 sampled residents.
Failure to have discharge and transfer documentation for 1 of 3 sampled residents reviewed for hospitalization.
Failure to complete required quarterly Minimum Data Set (MDS) assessments for 2 of 33 sampled residents.
Failure to accurately assess residents for antipsychotic medications for 1 of 33 sampled residents.
Failure to ensure medications were properly stored and secured; medication carts left unlocked and unattended; internal and external medications stored together.
Failure to ensure food was served under sanitary conditions; failure to sanitize thermometer and perform proper hand hygiene during meal service.
Failure to provide and implement an infection prevention and control program; multi-use blood glucose meters not cleaned and disinfected; failure of staff to perform hand hygiene, use barriers, dispose of contaminated sharps properly, and administer medications safely, resulting in Immediate Jeopardy.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Staff members: 4
Medication storage areas: 2
Staff members: 3
Residents affected: 31
Residents affected: 5
Nurses: 6
Residents affected: 8
Audit observations: 4
Audit observations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Confirmed urinary catheter bags should be covered; involved in multiple infection control breaches |
| Unit Manager #1 | Unit Manager | Confirmed urinary catheter bags should be covered; confirmed medication cart should not be left unlocked |
| MDS/Resident Care Coordinator #1 | MDS/Resident Care Coordinator | Confirmed quarterly MDS assessments were not done |
| MDS/Resident Care Coordinator #2 | MDS/Resident Care Coordinator | Confirmed antipsychotic medications were given and coding error on MDS |
| Director of Nursing | Director of Nursing | Confirmed multiple infection control and medication administration deficiencies; responsible for staff training and monitoring |
| Medical Director | Medical Director | Confirmed proper cleaning of blood glucose meters and hand hygiene requirements |
| Pharmacy Customer Reaction Specialist | Pharmacy Customer Reaction Specialist | Described medication pass oversight and staff education on infection control |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Observed administering medication with infection control breaches |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed administering medication with infection control breaches |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Observed improper handling of blood glucose meter and supplies |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Observed improper handling of blood glucose meter and supplies |
| Unit Manager #2 | Unit Manager | Observed improper medication administration and infection control breaches |
| Pantry Aide #1 | Pantry Aide | Observed failing to sanitize thermometer and improper glove use during meal service |
| Sous Chef #1 | Sous Chef | Observed failing to sanitize thermometer and improper glove use during meal service |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Observed failing to perform hand hygiene during meal tray delivery |
Inspection Report
Deficiencies: 3
Date: Jul 17, 2019
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding timely transmission and accuracy of Minimum Data Set (MDS) assessments, accuracy of resident assessments related to medications and hospice care, and infection prevention and control practices.
Findings
The facility failed to transmit MDS assessments timely for 3 of 32 sampled residents, failed to ensure accurate assessments for medications and hospice care for 2 of 32 residents, and failed to maintain proper infection prevention practices including hand hygiene and cleaning of medication syringes during medication administration for 2 of 7 sampled residents.
Deficiencies (3)
Failed to transmit MDS assessments timely for 3 of 32 sampled residents.
Failed to ensure assessments accurately reflected residents' status for medications and hospice care for 2 of 32 sampled residents.
Failed to implement infection prevention and control program; staff did not perform proper hand hygiene and did not clean medication syringes after use for 2 of 7 sampled residents.
Report Facts
Residents sampled: 32
Residents affected: 3
Residents affected: 2
Residents sampled: 7
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Assessments | Confirmed failure to retransmit assessments and inaccuracies in assessments | |
| LPN #1 | Licensed Practical Nurse | Failed to perform hand hygiene and clean medication syringe during medication administration |
| RN #1 | Registered Nurse | Failed to perform hand hygiene and clean medication syringe during medication administration |
| Director of Nursing | DON | Provided expectations for hand hygiene and cleaning medication syringes |
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