Inspection Reports for
Midtown Center for Health and Rehabilitation
141 N McLean Blvd, Memphis, TN 38104, USA, TN, 38104
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 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
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 4, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, safety, and environmental conditions at Midtown Center for Health and Rehabilitation.
Findings
The facility failed to ensure accurate resident assessments for tobacco use, maintain a safe environment free from accident hazards such as unsecured oxygen tanks, and provide a clean, safe, and comfortable environment, particularly regarding the cleanliness of enteral feeding equipment for multiple residents.
Deficiencies (3)
F 0641: The facility failed to ensure residents #15 and #62 were accurately assessed for tobacco use on their MDS assessments despite being observed smoking in the designated area.
F 0689: Resident #15 was exposed to accident hazards due to an unsecured oxygen tank cylinder at the bedside, which could cause injury if it fell.
F 0921: The facility failed to maintain a safe, sanitary, and comfortable environment for residents receiving enteral tube feeding, as dried feeding substances and rust were observed on feeding pumps and poles for residents #4, #64, #65, #77, and #161.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Confirmed oxygen tank should be secured to prevent injury or harm | |
| MDS Director | Confirmed tobacco use should have been captured on MDS assessments for Residents #15 and #62 | |
| Director of Nurses (DON) | Confirmed enteral feeding poles and pumps needed cleaning and replacement | |
| Administrator | Confirmed enteral feeding poles should be clean and free of rust or dried substances |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication administration errors and infection control practices at the facility.
Complaint Details
The complaint investigation found substantiated medication errors and infection control deficiencies involving licensed practical nurses during medication administration.
Findings
The facility failed to follow physician orders during medication administration by administering the wrong medication to a resident. Additionally, several nurses failed to perform proper hand hygiene during medication administration, risking infection spread.
Deficiencies (2)
F 0684: The facility failed to follow physician orders for medication administration, resulting in a medication error where Albuterol Sulfate was administered instead of Arformoterol to Resident #48.
F 0880: The facility failed to ensure infection control practices, as 3 of 5 nurses did not perform hand hygiene during medication administration.
Report Facts
Residents affected: 1
Nurses observed: 5
Nurses failing hand hygiene: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Administered wrong medication and failed hand hygiene | |
| Licensed Practical Nurse (LPN) B | Failed hand hygiene during medication administration | |
| Licensed Practical Nurse (LPN) C | Failed hand hygiene during medication administration | |
| Assistant Director of Nursing (ADON) | Confirmed medication error | |
| Director of Nursing (DON) | Confirmed medication verification procedures and hand hygiene requirements |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 5, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse, wound care deficiencies, pressure ulcer care issues, and inadequate catheter care at Midtown Center for Health and Rehabilitation.
Complaint Details
The investigation was complaint-driven, focusing on allegations of resident-to-resident abuse, inadequate wound care, pressure ulcer management, and catheter care. The complaint was substantiated with findings of failure to investigate abuse allegations, delayed reporting, and deficient care practices.
Findings
The facility failed to thoroughly investigate allegations of resident-to-resident abuse and failed to submit timely 5-day follow-up reports. The facility also failed to provide appropriate wound care and pressure ulcer prevention and treatment, resulting in immediate jeopardy for several residents. Additionally, the facility failed to provide appropriate catheter care and did not follow physician orders for catheter bag changes, increasing the risk of urinary tract infections.
Deficiencies (4)
F 0610: The facility failed to thoroughly investigate alleged incidents of resident-to-resident abuse for 3 of 12 sampled residents and failed to submit timely 5-day follow-up reports for 2 of 5 residents reviewed for abuse.
F 0684: The facility failed to provide appropriate care and services for wounds (non-pressure ulcer/injury wounds) for 2 of 10 residents reviewed, including delayed antibiotic treatment and late wound classification changes.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevention, resulting in immediate jeopardy for 6 of 10 residents with pressure ulcers or injuries, including failure to follow care plans, delayed wound identification, and inadequate treatment.
F 0690: The facility failed to provide appropriate catheter care for 2 of 4 residents with indwelling catheters, including failure to change catheter bags as ordered, lack of documentation, and failure to follow physician orders, increasing the risk of urinary tract infections.
Report Facts
Residents reviewed for abuse: 12
Residents with abuse allegations not thoroughly investigated: 3
Residents with 5-day follow-up reports not timely submitted: 2
Residents reviewed for wounds: 10
Residents with wound care deficiencies: 2
Residents reviewed for pressure ulcers: 10
Residents with pressure ulcer care deficiencies: 6
Residents reviewed for catheter care: 4
Residents with catheter care deficiencies: 2
Date of survey completion: Sep 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Confirmed wound observations and antibiotic delay for Resident #123 |
| LPN A | Licensed Practical Nurse | Documented wound and care observations for Resident #27 |
| LPN N | Licensed Practical Nurse | Provided information on Resident #27's nail care and wound |
| CNA O | Certified Nursing Assistant | Provided information on Resident #27's care and hand rolls |
| LPN I | Licensed Practical Nurse | Confirmed catheter care for Resident #71 |
| DON | Director of Nursing | Confirmed catheter care policies and wound care documentation |
| Administrator | Confirmed policies and practices regarding catheter care and wound care | |
| Medical Director | Confirmed catheter change protocols and physician order adherence | |
| NP R | Nurse Practitioner | Discussed catheter change frequency and facility practices |
| NP Q | Nurse Practitioner | Discussed catheter change frequency and quality of care concerns |
| LPN M | Licensed Practical Nurse | Confirmed Resident #71's catheter care compliance and hospital transfer requests |
Inspection Report
Routine
Deficiencies: 13
Date: Sep 5, 2024
Visit Reason
Routine state inspection survey to assess compliance with healthcare regulations including resident care, safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide education on advance directives, timely reporting and investigation of abuse allegations, inadequate wound care and pressure ulcer management, failure to provide appropriate catheter and feeding tube care, improper medication storage and administration practices, and insufficient quality assurance oversight.
Deficiencies (13)
F 0578: The facility failed to provide education for Advance Directives to residents or their representatives for 33 of 34 sampled residents reviewed.
F 0609: The facility failed to timely report allegations of abuse for 4 of 12 residents and failed to thoroughly investigate alleged incidents of resident-to-resident abuse for 3 of 12 residents.
F 0610: The facility failed to respond appropriately to all alleged violations, including failure to submit timely 5-day follow-up reports for staff-to-resident abuse allegations for 2 residents.
F 0677: The facility failed to provide nail care for 1 of 4 residents reviewed for activities of daily living, resulting in actual harm when a resident's toenails adhered to skin causing pain.
F 0684: The facility failed to provide appropriate care and services for wounds for 2 of 10 residents reviewed for wounds, including delayed antibiotic treatment and failure to identify and treat wounds timely.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for 6 of 10 residents, resulting in immediate jeopardy due to multiple stage 3 and 4 pressure ulcers and inconsistent wound care.
F 0690: The facility failed to provide appropriate care for residents with indwelling catheters for 2 of 4 residents, including failure to change catheter bags as ordered and inadequate catheter care.
F 0693: The facility failed to ensure care and services for the use of a PEG feeding tube for 1 of 4 residents reviewed, including failure to perform PEG site care.
F 0726: The facility failed to ensure licensed practical nurses performing wound care had the competencies and skills necessary to provide care for pressure ulcers for 3 of 3 LPNs reviewed.
F 0761: The facility failed to ensure medications were stored appropriately when medication carts were left unlocked and unattended and medications were left unattended at residents' bedsides.
F 0812: The facility failed to ensure food was stored properly when unlabeled, undated, and expired items were found in nourishment refrigerators on two halls.
F 0867: The facility failed to implement an effective Quality Assurance Performance Improvement program to identify and correct quality deficiencies related to pressure ulcers and activities of daily living.
F 0880: The facility failed to ensure appropriate infection prevention and control practices during medication administration, including failure to perform hand hygiene, clean reusable equipment, and clean insulin pen seals.
Report Facts
Residents affected by Advance Directives deficiency: 33
Residents affected by abuse reporting deficiency: 4
Residents affected by wound care deficiency: 7
Residents affected by catheter care deficiency: 2
Residents affected by feeding tube care deficiency: 1
Residents affected by medication storage deficiency: 4
Residents affected by food storage deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Wound care nurse with incomplete wound dressing competency |
| LPN B | Licensed Practical Nurse | Wound care nurse with inconsistent wound staging |
| LPN C | Licensed Practical Nurse | Wound care nurse with delayed wound assessments and treatment documentation |
| LPN G | Licensed Practical Nurse | Failed to clean insulin pen seal and left medication cart unlocked |
| LPN H | Licensed Practical Nurse | Failed to clean reusable equipment and hand hygiene |
| LPN I | Licensed Practical Nurse | Failed to perform hand hygiene during medication administration |
| LPN L | Licensed Practical Nurse | Left medications unattended and failed hand hygiene |
| RN F | Registered Nurse | Left medications unattended and failed hand hygiene |
| Administrator | Facility Administrator | Confirmed lack of attendance at wound meetings and reliance on DON for wound oversight |
| DON | Director of Nursing | Oversight of wound care, confirmed knowledge gaps and PIP limitations |
| Medical Director | Medical Director | Unaware of stage 3 wounds, confirmed protocol for catheter care |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 16, 2023
Visit Reason
The inspection was conducted following a complaint investigation regarding the use of physical restraints and failure to provide necessary behavioral health care services for Resident #1.
Complaint Details
The complaint investigation was substantiated. Resident #1 was found to have been physically restrained by staff tying a sheet around him for convenience. The facility also failed to provide timely psychiatric services despite documented behavioral issues.
Findings
The facility failed to ensure Resident #1 was free from physical restraints, as staff tied a sheet around the resident for convenience. Additionally, the facility failed to provide timely psychiatric services despite documented behavioral health needs.
Deficiencies (2)
F 0604: The facility failed to ensure Resident #1 was free from physical restraints, as a sheet was tied around the resident's legs to prevent him from tearing his brief. This restraint was used for staff convenience and was not medically necessary.
F 0740: The facility failed to provide necessary behavioral health care services for Resident #1, who exhibited behaviors such as tearing and consuming pieces of his brief. Psychiatric services were ordered but not provided timely.
Report Facts
Brief Interview for Mental Status score: 2
Date of survey completion: May 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Admitted to tying a sheet around Resident #1 to prevent him from tearing his brief. |
| LPN #1 | Licensed Practical Nurse | Observed the restraint on Resident #1 and reported it to the Administrator. |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed observation of restraint and reported it to the Administrator. |
| Administrator | Administrator | Confirmed definition of restraint and acknowledged the restraint use on Resident #1. |
Report
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