Provider Name: MAJESTIC GARDENS AT MEMPHIS REHAB & SNC
Address: 131 N TUCKER, MEMPHIS, TN 38104
Phone: (901) 726-5600
County: Shelby (780)
Ownership Type: For profit - Partnership
Certified Beds: 169
Average Residents Per Day: 143. ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: MAJESTIC OPERATIONS LLC
First Approved Date: November 1, 1982
Affiliated Entity: EPHRAM LAHASKY (205)
Retirement Community: N, Special Focus Status: SFF Candidate
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 2 ()
Health Inspection Rating: 1 ()
QM Rating: 5 ()
Long Stay QM Rating: 5 ()
Short Stay QM Rating: 5 ()
Staffing Rating: 2 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.13058, LPN Staff Hours Per Day: 0.9760, RN Staff Hours Per Day: 0.4215, Licensed Staff Hours Per Day: 1.3976
Total Nurse Staff Hours Per Day, per resident: 3.52823
Weekend Nurse Staff Hours: 2.97895, Weekend RN Staff Hours: 0.2304
PT Staff Hours Per Day, per resident: 0.0225
Nurse Staff Turnover: 65.4, Nurse Turnover Note:
RN Turnover: 30.0, RN Turnover Note:
Admin Left Number: 0, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 1.9305, Case Mix LPN Hours Per Day: 0.7666, Case Mix RN Hours Per Day: 0.3842
Adjusted Nurse Aide Hours Per Day, per resident: 2.24831, Adjusted LPN Hours Per Day: 0.9396, Adjusted RN Hours Per Day: 0.4133
Total Adjusted Nurse Hours Per Day, per resident: 3.60905
Adjusted Weekend Nurse Hours Per Day, per resident: 3.04719
Health Survey Dates and Scores: Cycle 1: 2019-07-18 (Score: 508), Cycle 2: 2018-09-25 (Score: 1023), Cycle 3: 2017-08-24 (Score: 108)
Total Weighted Health Score: 613.00
Reported Incidents: 5, Substantiated Complaints: 48
Infection Control Citations: 1
Fines and Penalties: Number of Fines: 17, Total Fines in Dollars: 902724.03, Payment Denials Number: 2, Total Penalties Number: 19
Location and GPS: 131 N TUCKER,MEMPHIS,TN,38104 (35.1407, -89.996)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Protect each resident from the wrongful use of the resident's belongings or money.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-01-30
Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-01-30
Type: Health, Deficiency: Respond appropriately to all alleged violations.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-01-30
Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-01-30
Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-09-18
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-09-18
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: K - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-01-30
Type: Health, Deficiency: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-09-18
Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2024-01-30
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-26
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-26
Type: Health, Deficiency: Provide enough food/fluids to maintain a resident's health.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-26
Type: Health, Deficiency: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-26
Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-04-26
Type: Health, Deficiency: Ensure each resident receives an accurate assessment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-07-19
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-07-19
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-07-19
Type: Health, Deficiency: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-07-23
Type: Health, Deficiency: Ensure medication error rates are not 5 percent or greater.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-08-16
Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-07-19
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-08-09
Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-07-24
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-07-19
Type: Health, Deficiency: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity: L - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-07-22
Type: Health, Deficiency: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity: L - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-07-22
Type: Health, Deficiency: Provide enough food/fluids to maintain a resident's health.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-07-22
Type: Health, Deficiency: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity: L - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-07-22
Type: Health, Deficiency: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Severity: L - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-07-22
Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity: L - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-07-22
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-18
Type: Health, Deficiency: Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-18
Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-04-18
Type: Health, Deficiency: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-10
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-10
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-10
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-10
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-10
Type: Health, Deficiency: Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-05-17
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-05-24
Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-29
Type: Health, Deficiency: Respond appropriately to all alleged violations.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-03-29
Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-08-30
Type: Health, Deficiency: Provide care by qualified persons according to each resident's written plan of care.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-09-10
Type: Health, Deficiency: Provide necessary care and services to maintain or improve the highest well being of each resident .
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-08-25
Type: Health, Deficiency: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-08-25
Type: Health, Deficiency: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-08-24
Type: Health, Deficiency: Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-09-05
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-08-25
Type: Health, Deficiency: Ensure residents maintain acceptable nutritional status.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-08-30
Type: Health, Deficiency: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-09-10
Type: Health, Deficiency: Hire a qualified dietician.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-09-20
Type: Health, Deficiency: Store, cook, and serve food in a safe and clean way.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-08-25
Type: Health, Deficiency: Dispose of garbage and refuse properly.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-08-25
Type: Health, Deficiency: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-08-25
Type: Health, Deficiency: Have a program that investigates, controls and keeps infection from spreading.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-08-25
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0345, Version: New
Description: Have approved installation, maintenance and testing program for fire alarm systems.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-08-10
Type: Fire Safety, Tag: 0039, Version: New
Description: Conduct testing and exercise requirements.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-08-18
Type: Fire Safety, Tag: 0324, Version: New
Description: Provide properly protected cooking facilities.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-08-02
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-08-02
Type: Fire Safety, Tag: 0521, Version: New
Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-08-02
Type: Fire Safety, Tag: 0920, Version: New
Description: Ensure proper usage of power strips and extension cords.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-08-02
Type: Fire Safety, Tag: 0004, Version: New
Description: Develop and maintain an Emergency Preparedness Program (EP).
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-07-12
Type: Fire Safety, Tag: 0001, Version: New
Description: Establish an Emergency Preparedness Program (EP).
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-10
Type: Fire Safety, Tag: 0291, Version: New
Description: Install emergency lighting that can last at least 1 1/2 hours.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-10
Type: Fire Safety, Tag: 0293, Version: New
Description: Have properly located and lighted "Exit" signs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-10
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-10
Type: Fire Safety, Tag: 0781, Version: New
Description: Have restrictions on the use of portable space heaters.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-10
Type: Fire Safety, Tag: 0920, Version: New
Description: Ensure proper usage of power strips and extension cords.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-10
Type: Fire Safety, Tag: 0211, Version: New
Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-09-20
Type: Fire Safety, Tag: 0281, Version: New
Description: Install proper backup exit lighting.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-09-18
Type: Fire Safety, Tag: 0291, Version: New
Description: Install emergency lighting that can last at least 1 1/2 hours.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-08-30
Type: Fire Safety, Tag: 0293, Version: New
Description: Have properly located and lighted "Exit" signs.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-08-25
Type: Fire Safety, Tag: 0345, Version: New
Description: Have approved installation, maintenance and testing program for fire alarm systems.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-08-25
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-09-15
Type: Fire Safety, Tag: 0914, Version: New
Description: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-09-20
Type: Fire Safety, Tag: 0920, Version: New
Description: Ensure proper usage of power strips and extension cords.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-08-25