Inspection Reports for
Spring Gate Rehabilitation and Healthcare Center
3909 Covington Pike, Memphis, TN 38135, United States, TN, 38135
Back to Facility Profile5 CMS Surveys
Inspection Report — Apr 30, 2025
Enforcement
Date: Apr 30, 2025
Visit Reason
Statement of Deficiencies (CMS-2567) following a survey completed on 2025-04-30 documenting multiple deficiencies at Spring Gate Rehab & Healthcare Center, including care plan noncompliance, medication administration errors, an Immediate Jeopardy fall, and documentation failures.
Findings
The survey cited four deficiencies (F0656, F0684, F0689, F0842): failure to follow care plan for ADL/bed mobility, failure to administer ordered medication, an Immediate Jeopardy for accident hazards after a resident fell from bed and subsequently died, and failure to document a dislodged tracheostomy.
Citations (4)
F0656: The facility failed to implement and follow the resident's comprehensive care plan for Activities of Daily Living; staff did not provide required 2-person assistance for bed mobility and repositioning for Resident #3, resulting in a fall from bed.
F0684: The facility failed to administer Clonazepam 2 mg via PEG as ordered for Resident #3 on three occasions (including 4/17/2025 9:00 AM and 4/18/2025 9:00 AM and 9:00 PM), and RN D confirmed the doses were not given though the medication was available in the emergency drug cart.
F0689: The facility failed to provide an environment free from accident hazards and adequate supervision for Resident #3, a nonmobile 2-person assist resident, who fell from an elevated bed, sustained a head laceration, and was later pronounced deceased; this citation was issued as Immediate Jeopardy.
F0842: The facility failed to document and report that Resident #30's tracheostomy was dislodged prior to resuscitation; the Respiratory Therapist stated the trach was pulled out and replaced and CPR initiated, but the event was not recorded or communicated in the medical record.
Report Facts
Deficiencies cited: 4
Residents sampled for ADL/medication: 6
Residents sampled for falls/CPR review: 3
Inspection Report — Oct 16, 2024
Enforcement
Date: Oct 16, 2024
Visit Reason
CMS-2567 Statement of Deficiencies following a survey completed on 2024-10-16 documenting findings from policy review, record review, observations, and interviews.
Findings
Statement of Deficiencies documents multiple deficiencies across resident rights, environment cleanliness, abuse reporting and investigations, medication administration, falls with injury, enteral feeding/PEG care, physician visit frequency, staffing postings, medication storage, dental care access, and infection prevention and control identified during the 10/16/2024 survey.
Citations (14)
F 0550: Failed to honor a resident's request for a room change when Resident #118 requested a private room and the request was not followed up on by staff.
F 0557: Failed to ensure a resident's right to retain and use personal possessions when Resident #20 reported perfume missing and the loss was not documented on the facility's grievance/Quality Assistance form.
F 0580: Failed to notify a resident's representative in advance of a room change when Resident #305's family was not informed until after the resident was moved.
F 0584: Failed to maintain a clean, safe, comfortable, and sanitary environment across multiple halls and rooms, with observed dried food/biological build-up, dirty HVAC units and equipment, damaged walls, and inadequate housekeeping supplies and practices.
F 0609: Failed to timely report an injury of unknown origin for Resident #248; an X-ray showed a dislocation but there was no documentation the injury was reported within the facility's required timeframe.
F 0610: Failed to thoroughly investigate alleged abuse and to submit the facility's 5‑day follow-up reports within required timeframes for multiple incidents involving Residents #58, #248, #298, and #300.
F 0684: Failed to provide treatment and follow physician orders related to blood glucose monitoring, missed medication doses, and antihypertensive administration parameters for sampled residents (examples include Residents #12, #68, and residents on antihypertensives where vitals were not obtained or holds were ignored).
F 0689: Failed to ensure resident environment and supervision prevented accidents when Resident #77 (2-person assist) rolled out of bed, was moved by CNAs without nurse assessment, and sustained a right humerus fracture.
F 0693: Failed to ensure enteral feedings and flush solutions were properly labeled (name, date/time, rate, initials) for multiple residents and failed to provide PEG site care for Resident #498 until after admission.
F 0712: Failed to ensure physician face-to-face visits occurred per facility policy (physician seen within required intervals) for multiple residents including Residents #8, #38, #56, #57, #67, #71, #73, #104, and #305.
F 0732: Failed to post accurate and current nurse staffing information daily; posted Direct Care Staffing Hours were not updated on several observed dates.
F 0761: Failed to secure medications and label opened medications properly when medication cups with pills were left unattended in resident rooms (Residents #49 and #70) and an opened, undated vial of Tubersol was stored in a medication refrigerator.
F 0791: Failed to ensure timely dental care when Resident #40 reported a broken tooth causing pain and was not placed on the dental consult list or provided follow-up.
F 0880: Failed to maintain an adequate infection prevention and control program and sanitary environment for numerous residents, with repeated observations of soiled equipment, enteral pump/feeding pole drips, dusty/dirty oxygen concentrator filters, clogged sinks, overflowing trash, and other environmental sanitation failures in high‑risk units.
Inspection Report — Oct 16, 2024
Enforcement
Date: Oct 16, 2024
Visit Reason
CMS Statement of Deficiencies (Form CMS-2567) documenting survey findings at Spring Gate Rehab & Healthcare Center; survey completed 2024-10-16 and printed 2026-03-16.
Findings
Survey identified numerous deficiencies across resident rights, clinical care, infection prevention, environmental sanitation, medication management, abuse reporting/investigation, and food services following the 10/16/2024 survey. Key findings included unsanitary conditions throughout multiple halls and rooms, failures to timely report and investigate alleged abuse, medication administration errors and omissions, inadequate enteral/PEG tube care and labeling, and incomplete clinical documentation/assessments.
Citations (23)
F0557: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions; facility failed to ensure Resident #20's right to retain possessions when perfume went missing and there was no documentation of a Quality Assistance (grievance) form.
F0561: Honor resident choice including food preferences; facility served Resident #70 pork and failed to follow meal-ticket preferences for finger foods on 9/23/2024.
F0578: Provide information about advance directives; facility failed to provide information/offer to formulate an advance directive for 10 of 32 sampled residents (list includes Residents #34, #57, #71, #72, #73, #79, #92, #104, #140, #498).
F0580: Notify resident representatives of room changes; facility failed to notify Resident #305's representative in advance of a room change.
F0584: Maintain a clean, safe, comfortable and homelike environment; observations 9/23/2024–10/2/2024 documented extensive dirt, dried bodily/feeding residues, dust, broken tiles, HVAC gaps and other sanitation failures across multiple halls and many resident rooms.
F0609: Timely report suspected abuse/neglect; facility failed to report an injury of unknown origin for Resident #248 within required timeframes after abnormal x-ray findings on 5/26/2023.
F0610: Respond appropriately to alleged violations and report investigation results; facility failed to thoroughly investigate and submit required 5-day follow-up results for alleged abuse incidents for Residents #58, #248, #298, and #300.
F0641: Ensure accurate assessments (MDS); facility failed to complete/record BIMS cognitive assessments for multiple residents (examples: Residents #6, #41, #84, #105) where BIMS was left as dashes.
F0645: PASRR rescreening when indicated; facility failed to resubmit a PASRR when Resident #56 had a new psychotropic medication order (Seroquel) on 5/6/2024.
F0657: Conduct and document care conferences; facility failed to conduct quarterly care conference meetings with Resident #20 or responsible party since January 2024.
F0677: Provide ADL assistance including grooming; facility failed to ensure Resident #80 received adequate hair care and personal grooming evidenced by matted hair on multiple observations.
F0684: Provide appropriate treatment and follow physician orders; facility failed to perform required blood glucose monitoring for Resident #12 and had multiple missed or untimely medication administrations and antihypertensive meds given outside ordered parameters for Residents #68 and #70.
F0689: Maintain a safe environment and supervision to prevent accidents; staff moved Resident #77 after a fall (8/9/2024) without notifying nurse, did not follow 2-person assist care plan, and the resident sustained a fracture to the right humerus.
F0690: Catheter care and prevention of device-related injury; Resident #30 was found lying on indwelling catheter tubing that was unsecured and developed a deep purple traumatic area to left labia related to tubing position.
F0693: Feeding tube care, labeling and use; enteral feed containers and flush bottles for Residents #58, #72, and #304 were not labeled with resident name/date/time/rate and Resident #498 had no documented PEG site care orders or care documented until 10/02/2024.
F0695: Respiratory care and oxygen use per orders; Resident #68 was observed on 9/23–9/26/2024 with oxygen set at 2.5 L/min despite physician order for 1 L/min and oxygen tubing had not been changed weekly per facility policy.
F0712: Physician face-to-face visits; facility failed to ensure attending physician visits occurred every other 60 days as required for multiple residents (examples: Residents #8, #38, #56, #57, #67, #71, #73, #104, #305).
F0732: Post daily nurse staffing information; posted staffing sheets were not updated or posted with the current date on multiple survey days (examples observed 9/23/2024, 9/25/2024, 10/1/2024, 10/15/2024, 10/16/2024).
F0761: Medication storage and security; medications were found unattended/unsecured at resident bedside (Residents #49 and #70) and an opened undated vial (Tubersol) was found in medication refrigerator.
F0791: Dental services access; facility failed to ensure Resident #40 received follow-up dental evaluation after reporting a broken tooth and eating/drinking difficulties.
F0812: Food safety and kitchen sanitation; extensive sanitation failures observed in kitchen (leaking sinks, standing water, dirty/soiled pots and pans, mold/contaminants in ice machine, failure to sanitize three-compartment sink, missing/undated food items) and staff failed to follow sanitizer/hand-hygiene procedures on tray line.
F0847: Binding arbitration explanation; facility did not ensure binding arbitration agreement was explained in a form and manner the resident or representative understood (Resident #140's POA reported it was emailed and not explained).
F0880: Infection prevention and control program / environmental cleaning; widespread failures in cleaning and disinfection practices and environmental sanitation across multiple halls and rooms (numerous observations of dried bodily/enteral residues, dust, soiled HVAC vents, contaminated feeding poles) increasing infection risk for high-acuity residents (many examples and residents affected listed).
Inspection Report — Sep 24, 2021
Enforcement
Date: Sep 24, 2021
Visit Reason
Statement of Deficiencies (CMS-2567) following a nursing home survey completed on 2021-09-24 that cites multiple F-tags for care and infection control deficiencies.
Findings
Multiple deficiencies were cited including failure to assess a resident for self-administration of nebulizer treatment (Resident #34), failure to invite a resident to care plan meetings (Resident #87), missed medication administration documentation (Resident #80), inaccurate wound assessments for Residents #68 and #112, and numerous infection control breaches including improper tracheostomy technique, failure to don required PPE for droplet precautions, and incomplete COVID-19 staff screening.
Citations (5)
F0554: Allow residents to self-administer drugs if determined clinically appropriate; the facility failed to assess Resident #34 for self-administration of a nebulizer treatment and the resident was observed receiving an unattended nebulizer treatment.
F0657: Develop the complete care plan within 7 days of the comprehensive assessment; the facility failed to document that Resident #87 was invited to participate in care planning for meetings done in May and August 2021.
F0684: Provide appropriate treatment and care according to orders; the facility's September 2021 MAR did not reflect that Resident #80 received the ordered IV Cubicin at bedtime on 9/20/2021 and 9/21/2021.
F0686: Provide appropriate pressure ulcer care and prevent new ulcers; the facility failed to accurately assess and document pressure injuries for Residents #68 and #112, with facility wound measurements inconsistent with physician manual measurements and the computerized camera found inaccurate.
F0880: Provide and implement an infection prevention and control program; staff failed to use sterile technique during tracheostomy care, an RN entered a droplet-precaution room without an N95, and several staff failed to complete COVID-19 screening logs on multiple days.
Report Facts
Deficiency tags cited: 5
Staff failed screening - staff count: 4
Days of missed COVID-19 screening: 13
Transmission-based precaution duration (days): 14
Inspection Report — Oct 3, 2019
Enforcement
Date: Oct 3, 2019
Visit Reason
CMS Statement of Deficiencies (Form CMS-2567) documenting survey findings for Spring Gate Rehab & Healthcare Center following a survey completed on 2019-10-03.
Findings
The Statement of Deficiencies cites multiple F-tags alleging failures in care planning and transfers, accident hazards/fall prevention, medication storage security, and food sanitation. The document describes specific incidents involving Resident #6 and Resident #149 and observations in medication storage and the kitchen.
Citations (4)
F 0656: Care plan intervention for mechanical lift transfers was not implemented for Resident #6, who required two-person mechanical lift per care plan and experienced a fall during a one-person lift. The care plan and incident reports document the transfer requirement and the fall.
F 0689: The facility failed to ensure the environment was free from accident hazards for Resident #6 and Resident #149, including a one-person mechanical lift transfer that resulted in a fall and an air mattress overlay that slid off causing Resident #149 to fall. Interviews and observations attributed the incidents to improper staff actions and mattress attachment.
F 0761: Medications were not properly secured when surveyors observed an unlocked and unattended medication cart on the 500 Hall medication area. The facility policy requires medication storage remain locked when not in use.
F 0812: Food service sanitation deficiencies were observed including wet-nesting of dishware and kitchen staff without hair/beard restraints, which the facility acknowledged was not appropriate and could contaminate food. The condition was reported to potentially affect residents receiving meal trays from the kitchen.
Report Facts
Resident sample - Resident #6: 1
Residents sampled for falls: 2
Medication storage areas: 1
Residents potentially affected: 170
Total residents receiving meal trays: 175
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