Inspection Reports for Spring Gate Rehabilitation and Healthcare Center
3909 Covington Pike, Memphis, TN 38135, United States, TN, 38135
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
168% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Apr 30, 2025
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to follow care plans, medication administration errors, accident hazards, and inadequate documentation related to resident care and safety.
Findings
The facility failed to follow care plans for Activities of Daily Living (ADL) interventions, failed to administer medications as ordered, failed to provide a safe environment preventing accidents resulting in a resident's fall and death, and failed to document and report a dislodged tracheostomy during a CPR event.
Complaint Details
The complaint investigation revealed substantiated findings including failure to follow care plans, medication errors, inadequate supervision leading to a fatal fall, and failure to document a dislodged tracheostomy during CPR. The facility disputed the immediate jeopardy citation related to the fall.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to follow the care plan for ADL skills requiring 2-person assistance, resulting in a resident fall. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer Clonazepam medication as ordered for 3 doses. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide an environment free from accident hazards and adequate supervision, resulting in a resident fall from bed with fatal injuries. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to document and report that a resident's tracheostomy was dislodged during a CPR event. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication doses missed: 3
Observations planned: 10
QAPI meeting frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Named in failure to provide 2-person assistance leading to resident fall |
| RN D | Registered Nurse | Confirmed medication administration failure for Clonazepam |
| Director of Nursing | Director of Nursing (DON) | Confirmed care plan requirements and failures, and oversaw removal plan |
| RT A | Respiratory Therapist | Found resident unresponsive with dislodged tracheostomy and initiated CPR |
| RN C | Registered Nurse | Responded to resident fall and provided care |
| NP D | Nurse Practitioner | Assessed resident's inability to reposition or respond |
| LPN B | Licensed Practical Nurse | Involved in CPR event and reported lack of communication about tracheostomy status |
Inspection Report
Complaint Investigation
Deficiencies: 19
Oct 16, 2024
Visit Reason
The inspection was conducted based on complaint investigations related to resident rights, care, abuse allegations, infection control, and other regulatory compliance issues.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights, failure to conduct timely and thorough investigations of abuse allegations, failure to maintain a clean and safe environment, failure to provide appropriate care including medication administration, respiratory care, catheter care, and feeding tube care, failure to ensure accurate assessments and care planning, failure to conduct required physician visits, failure to maintain proper food sanitation, and failure to post accurate staffing information.
Complaint Details
Complaint investigation revealed multiple deficiencies related to resident rights, abuse reporting and investigation, infection control, medication administration, care planning, and environmental sanitation.
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to ensure residents' right to retain and use personal possessions. | — |
| Failed to ensure food preferences were acknowledged and honored. | — |
| Failed to provide information regarding advance directives to residents. | — |
| Failed to notify resident representative in advance of room change. | — |
| Failed to maintain a clean, safe, comfortable, and sanitary environment in multiple hallways and resident rooms. | — |
| Failed to timely report suspected abuse and neglect related to injury of unknown origin. | — |
| Failed to thoroughly investigate abuse allegations and report results to government agency within required timeframe. | — |
| Failed to ensure Minimum Data Set (MDS) assessments were complete and accurate. | — |
| Failed to assist residents with activities of daily living for personal grooming. | — |
| Failed to follow physician orders related to blood glucose monitoring, medication administration, and vital sign monitoring before antihypertensive medication. | — |
| Failed to provide appropriate care and secure indwelling catheters, resulting in pressure ulcer. | Actual harm |
| Failed to provide appropriate care and labeling for residents with feeding tubes and failed to provide PEG tube site care. | — |
| Failed to ensure medications were properly stored and secured; medications found unattended and undated. | — |
| Failed to follow policy for changing oxygen tubing and failed to follow physician orders for oxygen administration. | — |
| Failed to ensure physician visits were conducted according to facility policy. | — |
| Failed to post accurate and current nurse staffing information daily. | — |
| Failed to ensure food was stored, prepared, and served under sanitary conditions; multiple sanitation and food safety violations observed in kitchen and food storage areas. | — |
| Failed to ensure binding arbitration agreements were understood by residents or their representatives. | — |
| Failed to maintain an infection prevention and control program providing a safe, sanitary, and comfortable environment to prevent infections for residents, especially in tracheostomy/ventilator units. | — |
Report Facts
Days with inaccurate staffing posting: 5
Weeks of Daily Cleaning Schedules reviewed: 7
Sanitizer concentration: 10
Days blood glucose monitoring missed: 1
Medication doses missed: 9
Physician visits missing: 9
Residents with feeding tube labeling issues: 3
Residents with infection control issues: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA W | Certified Nursing Assistant | Admitted to returning Resident #77 to bed after fall without notifying nurse; terminated for failure to report incident. |
| CNA X | Certified Nursing Assistant | Assisted CNA W to get Resident #77 back in bed; did not notify nurse of fall; received written warning. |
| LPN O | Licensed Practical Nurse | Wrote progress notes regarding trauma to Resident #30's left labia related to catheter tubing. |
| Director of Nursing | Director of Nursing | Confirmed policies and deficiencies related to abuse reporting, medication administration, oxygen therapy, catheter care, and infection control. |
| Certified Dietary Manager | Certified Dietary Manager | Observed multiple sanitation violations in kitchen and food preparation areas. |
| Social Services Director | Social Services Director | Confirmed failure to conduct care conferences and dental consults, and issues with PASRR screening. |
| Admissions Director | Admissions Director | Described arbitration agreement process and acknowledged insufficient explanation to residents. |
Inspection Report
Routine
Deficiencies: 13
Oct 16, 2024
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, safety, infection control, medication administration, abuse reporting, physician visits, staffing, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights regarding room changes, failure to maintain a clean and safe environment, failure to timely report and investigate abuse allegations, failure to follow physician orders for medication administration, failure to ensure physician visits were conducted as required, failure to properly label and care for enteral feeding tubes, failure to secure medications properly, failure to maintain accurate nurse staffing postings, and failure to maintain an effective infection prevention and control program.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Level of Harm - Actual harm: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to honor a resident's right to request a room change for 1 of 6 residents (Resident #118). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents' right to retain and use personal possessions for 1 of 1 resident (Resident #20). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify resident representative in advance of a room change for 1 of 1 resident (Resident #305). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a clean, safe, comfortable, and sanitary environment on multiple hallways affecting many residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse and neglect related to injury of unknown origin within 2 hours for 1 of 3 residents (Resident #248). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to thoroughly investigate allegations of abuse and report results within 5 working days for 4 of 13 residents (Residents #58, #248, #298, #300). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician orders related to blood glucose monitoring, missed medication doses, and parameters for antihypertensive medication for 3 of 3 residents (Residents #12, #68, #73). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician visits were conducted according to facility policy for 9 of 11 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post accurate and current nurse staffing information for 5 of 15 days during the survey. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were properly stored and secured for 2 of 2 residents (Residents #49 and #70) and in medication storage areas. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide care and services for residents with PEG tubes including proper labeling of enteral feedings and flush solutions for 3 of 4 residents and failed to provide PEG site care for 1 of 4 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an infection prevention and control program providing a safe, sanitary, and comfortable environment to prevent infections for 24 of 38 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the resident environment remained free of accident hazards and provide adequate supervision to prevent accidents for 1 of 3 residents (Resident #77) resulting in a fracture. | Level of Harm - Actual harm |
Report Facts
Medication doses missed: 7
Days with inaccurate staffing posting: 5
Residents reviewed for infection control: 38
Residents reviewed for physician visits: 11
Residents reviewed for abuse investigation: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA W | Certified Nursing Assistant | Admitted to returning Resident #77 to bed without notifying nurse after fall; terminated for failure to follow policy |
| CNA X | Certified Nursing Assistant | Assisted CNA W to get Resident #77 back in bed; given written warning |
| Director of Nursing | Director of Nursing | Confirmed injury of unknown origin should be reported within 2 hours; confirmed medication and staffing deficiencies; confirmed abuse investigation requirements |
| Administrator | Administrator | Confirmed thorough abuse investigations require witness statements and timely reporting; confirmed physician visit frequency requirements |
| Social Service Director | Social Service Director | Confirmed failure to follow up on resident room change request; confirmed dental service referral process |
| Unit Manager B | Unit Manager | Confirmed blood glucose monitoring was not performed on 8/5/2024 |
| LPN D | Licensed Practical Nurse | Confirmed medications should not be left unattended; confirmed blood pressure should be recorded before antihypertensive administration |
| LPN C | Licensed Practical Nurse | Confirmed responsibility for cleaning feeding pumps and poles; acknowledged dried enteral feedings and dust on Resident #77's feeding pump |
| Certified Nursing Assistant P | Certified Nursing Assistant | Reported black smear on Resident #116's bedframe and Resident #34's side rail; stated resident rooms should be clean |
| CNA V | Certified Nursing Assistant | Turned and repositioned Resident #77 alone; did not report fall incident |
Inspection Report
Annual Inspection
Deficiencies: 7
Sep 24, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, care planning, pressure ulcer management, infection prevention and control, and COVID-19 protocols at Spring Gate Rehab & Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to assess resident self-administration of medication, failure to invite residents to care planning, failure to administer prescribed medications, inaccurate pressure ulcer assessments, improper infection control practices during tracheostomy care, failure to don appropriate PPE in isolation rooms, and incomplete COVID-19 staff screening logs.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to assess 1 of 1 sampled resident for self-administration of medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were invited to participate in care planning for 1 of 22 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer prescribed medication for 1 of 6 sampled residents reviewed for Physician's Orders and medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately assess pressure injuries for 2 of 5 sampled residents reviewed for pressure injuries. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure infection control guidelines were followed during tracheostomy care for 2 of 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to don appropriate Personal Protective Equipment before entering a resident's room in droplet precautions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete COVID-19 screening logs on multiple days for 4 of 174 staff members. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiencies cited: 7
Staff members failed COVID-19 screening: 4
Days of incomplete COVID-19 screening: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Confirmed residents should not be left unattended during nebulizer treatment |
| Director of Nursing | DON | Confirmed medication orders should be followed and no blanks on MAR; confirmed wounds not assessed accurately |
| Social Services Director | Acknowledged resident was not invited to care planning meetings | |
| Wound Care Nurse | Confirmed computerized wound measurements inaccurate and manual measurements preferred | |
| Regional Nurse Consultant | Confirmed wound assessments are not accurate | |
| Wound Care Physician #1 | Stated computerized wound measurement system is inconsistent and not reliable | |
| Wound Care Physician #2 | Stated computerized wound measurement system is totally inaccurate and wounds are larger than documented | |
| Wound Care Physician #3 | Stated manual wound measurements are more accurate than computerized system | |
| Respiratory Therapist #1 | RT | Failed to use sterile technique and hand hygiene during tracheostomy care |
| Respiratory Therapist #2 | RT | Failed to maintain sterile technique and hand hygiene during tracheostomy care |
| Registered Nurse #1 | RN | Failed to don N95 mask before entering droplet precaution room |
| Unit Manager #1 | Confirmed staff should wear N95 mask in droplet precaution rooms | |
| Regional RT Manager | Confirmed staff should perform sterile technique during tracheostomy care | |
| Administrator | Confirmed all staff should be screened for COVID-19 upon entering facility |
Inspection Report
Complaint Investigation
Deficiencies: 4
Oct 3, 2019
Visit Reason
The inspection was conducted based on complaint investigations related to failure in implementing care plan interventions for mechanical lift transfers, accident hazards, medication storage, and food safety in the facility.
Findings
The facility failed to ensure mechanical lift transfers were conducted by two persons as required by the care plan, resulting in a resident fall without injury. Additionally, the facility did not maintain a safe environment free from accident hazards for residents, failed to properly secure medications, and did not follow sanitary food handling procedures including wet nesting of dishware and lack of hair/beard restraints for kitchen staff.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to follow care plan interventions for mechanical lifts, maintain a safe environment free of accident hazards, properly store medications, and ensure sanitary food handling practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure mechanical lift transfers were conducted by two persons as required by the care plan, resulting in a resident fall. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the nursing home area was free from accident hazards and provided adequate supervision to prevent accidents for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were properly stored and secured in medication storage areas. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was stored, prepared, and served under sanitary conditions, including wet nesting of dishware and kitchen staff without hair and beard restraints. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 2
Medication storage areas inspected: 13
Residents potentially affected: 170
Total residents: 175
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about Resident #6's fall and mechanical lift transfer |
| Director of Nursing | Director of Nursing | Interviewed about Resident #6's fall, mechanical lift transfer, and medication cart security |
| CNA #1 | Certified Nursing Assistant | Interviewed about Resident #6's fall and mechanical lift transfer |
| LPN #2 | Licensed Practical Nurse | Interviewed about Resident #149's fall due to air mattress not secured |
| Kitchen Manager | Kitchen Manager | Interviewed about food safety deficiencies including wet nesting and hair/beard restraints |
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