Memphis Convalescent Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure refrigerated and freezer items were properly stored, labeled, and dated. This failure could place residents at risk of food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 (Resident #5) of 12 residents reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #5 for the use of CPAP on her 09/01/25 quarterly MDS. This failure could result in residents not receiving correct care and services.

Inspectors wroteBased on interviews, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 (09/19/2025) of the last 90 days reviewed. The facility did not have an RN working in the facility for 1 (09/19/2025) of the last 90 days reviewed. This failure has the potential to affect the residents in the facility and place them at risk of not having staff with advanced care skills available to assist in their care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical service to include accurate dispensing and administering of biologicals for 1 of 7 insulins reviewed to meet the needs of each resident. The medication cart had an inulin bottle that was expired according to the date documented on the bottle of when it was opened. This failure could result in ineffective treatment resulting in exacerbation of residents' disease processes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure dented cans were not in circulation. 3. The facility failed to ensure pantry foods were properly stored, labeled, and dated. 4. The facility failed to ensure refrigerated foods were properly stored, labeled, and dated. 5. The facility failed to ensure expired foods were disposed of timely. These failures could place residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 3 (Resident #4, Resident #11, and Resident #22) of 12 residents reviewed for accuracy of assessments. 1. On Resident #4's MDS the facility inaccurately coded Resident #4 as receiving anticoagulant medication. 2. On Resident #11's MDS the facility inaccurately coded Resident #11 as receiving anticoagulant medication. 3. On Resident #22's MDS the facility inaccurately coded Resident #22 as receiving anticoagulant medication. These failures could place residents at risk of being inaccurately assessed and therefore not receiving necessary care. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of for 4 of 5 anonymous residents observed for 3 (August 4, 5, and 6 of 2024) of 3 days and reviewed for quality of life. The facility failed to ensure activities provided, met residents' needs or desires. The facility failed to ensure activities were being provided on the weekends. These failures could place residents at risk of boredom and a decline in their quality of life.

Inspectors wroteBased on Interview and Record Review, the facility failed to send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of six residents reviewed for transfer/discharge. The facility failed to send a discharge notice in writing to the facility's ombudsman as soon as practicable after Resident #1's discharge to home due to the facility not being able to meet Resident #1's needs. This failure could place residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to protect residents of verbal abuse and neglect for 1 (Resident #1) of 6 residents reviewed for abuse and neglect. 1) AD verbally abused Resident #1 by yelling at her in front of residents and family members during an activity. 2) ADM failed to protect Resident #1 from verbal abuse from AD when it was reported to her by other staff members An Immediate Jeopardy (IJ) was identified on 12/16/2023 at 2:30 PM. While the immediate jeopardy was removed on 12/17/2023 at 4:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to implement its' written policies and procedures that prohibit and prevent abuse and neglect for 1 of 6 residents (Resident #1) reviewed for abuse and neglect when: -The ADM was made aware of an allegation that AD was yelling during an activity and failed to follow policy and procedures of abuse and neglect. The facility's failure to ensure suspicions of abuse/neglect were investigated and reported to State could place all residents at risk for injuries, physical and mental decline, decrease in social gatherings, and delay of care. An Immediate Jeopardy (IJ) was identified on 12/16/2023 at 2:30 PM. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to conduct a thorough investigation of all allegations of abuse and neglect for 1 of 6 residents (Resident #1) reviewed for abuse and neglect when: -the facility reported an allegation of abuse reported by a family member and did not conduct a thorough investigation. The facility's failure to ensure allegations of abuse and neglect were thoroughly investigated could lead to continuous abuse, mental and physical decline, psychosocial harm. An Immediate Jeopardy (IJ) was identified on 12/16/2023 at 2:30 PM. While the immediate jeopardy was removed on 12/17/2023 at 4:00 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services in that: The staff did not complete hand hygiene while handling or distributing food or wear proper head coverings in the kitchen. This failure can place residents at risk of cross contamination, physical decline, and weight loss. Findings Included: An observation on 12/15/23 at 10:19 AM revealed DM not wearing a hair net in the kitchen. An observation on 12/15/23 at 12:07 PM showed DS I touched her face and not practicing hand hygiene before touching the hydration cart. An observation on 12/15/23 at 12:19 PM revealed RN A handing trays to staff without practicing hand hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to allow residents to organize without a staff member present, approve a staff member to aide, and demonstrate responses and rationales for changes made for 7 (#1, #4, #5, #7, #8, #9, #10, #11) of 7 residents who attended Resident Council meetings. The facility failed to include the approval of the Resident Council for decisions involving family members, approved staff, and frequency of meeting time. This failure restricted the privacy of these 8 residents and placed the residents at risk of not having the right to voice their concerns without staff being present or overhearing their concerns, conduct resident council meetings without interference, and approve changes made for the council meetings.

Inspectors wroteBased on observation, interview and record review, the facility failed to report an alleged violation of abuse or neglect immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or neglect or result in serious bodily injury, to officials in accordance with State law, including to the State Survey Agency for 2 (Resident #1 and Resident #6) of 6 residents reviewed for abuse/neglect. 1. The facility failed to report that Resident #1 had a laceration to the lower left leg which required 9 stitches. 2. The facility failed to report that Resident #1 was verbally abused by Activity Director. 3. The facility failed to report bruises to Resident #6's upper right arm, origin of injury could not be determined. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 3 (Resident #1, Resident #2, Resident #3) of 5 residents reviewed for dental care in that: Resident #1, Resident #2, and Resident #3 had various dental needs that had not been met per facility policy. This failure could place residents at risk of quality of life, nutritional decline, or infection.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored food was properly labeled and dated. The facility failed to store food at least 6 inches above the floor. This failure could place Residents at risk for foodborne illness. Findings Included: Observation of shelved/refrigerated foods on 7/16/2023 at 10:30am revealed the following: 1. Observation of freezer 1 on 7/16/23 at 10:30 am revealed onion rings with no label or date. 2. Observation of freezer 1 on 7/16/ 23 at 10:30 am revealed tater tots with no label or date. 3. Observation of freezer I on 7/16/23 at 10:33 am revealed chicken with no label or date. 4. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #130) of 12 residents reviewed for care planning. Resident #130's baseline care plan was inaccurate, in that it stated Resident #130 was taking antipsychotic medication and it did not state Resident #130 was taking antidepressant medication. This failure could place newly admitted residents at risk of having inaccurate or misleading baseline care plans.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 2 (Resident #13 and Resident #18) of 12 residents reviewed for care plan timing. 1. Resident #13 had a comprehensive assessment completed on 05/10/23 and her most recent care plan was developed on 05/31/23. 2. Resident #18 had a comprehensive assessment completed on 06/18/23 and her most recent care plan was developed on 05/23/23. These failures could place residents at risk of not receiving appropriate levels of care for needs identified in the comprehensive assessment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the person-centered care plan, and residents' goals and preferences for 1 (Resident #2) of 12 residents reviewed for respiratory care. The facility failed to ensure Resident #2 was provided O2 at 4 lpm continuously as ordered. This failure could place residents requiring O2 therapy at risk of hypoxia and not receiving prescribed care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #130) of 17 residents reviewed for infection control. Resident #130 was on transmission-based precautions for C. diff (an infection of the large intestine caused by bacteria, resulting in diarrhea and possible drop in blood pressure) and staff failed to use proper hand hygiene when they exited her room. This failure could place all residents of the facility at risk of contracting C. diff. an infectious disease.