Spring Gate Rehab & Healthcare Center
Memphis, Tennessee · CCN 445220
19 surveys since 2011, 15 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 128
- Surveys
- 19
- Harm or worse
- 15
- Immediate jeopardy
- 12
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 206
- Ownership
- For profit - Limited Liability company
- Chain
- PRESTIGE ADMINISTRATIVE SERVICES
- County
- Shelby
- Medicare-certified since
- 1989
CMS ratings
- Overall
- 1
- Health inspection
- 1
- Staffing
- 2
- Quality measures
- 4
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 77 for-profit facilities with 128 or more beds in Tennessee.
Last survey on record
Apr 30, 2025
558 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.95 | 3.56 |
| Registered-nurse hours per resident day | 0.83 | — |
| Annual nurse turnover | 67.5% | 48.6% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $128,974 across 2 penalties
- Payment denials
- 1
- Special focus
- SFF Candidate
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J12.7% | K— | L— |
| Actual harm | G25.4% | H— | I— |
| No harm, potential for more than minimal | D2773.0% | E513.5% | F25.4% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6843×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F6893×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F6562×
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- F6572×
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- F7612×
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.
In the surveyor’s words
From the most serious findings on record at Spring Gate Rehab & Healthcare Center, in the surveyor’s own words.
- Immediate jeopardy, isolatedF689Apr 30, 2025
Based on policy review, medical record review, facility investigation review, and interview, the facility failed to provide an environment that was free from accident hazards for 1 of 3 (Resident #3) sampled residents reviewed. Resident #3, a cognitively impaired resident with a tracheostomy (a plastic tube inserted into the throat to allow the person to breath), who was a 2 person assistance for bed mobility and dependent on staff for activities of daily living skills (ADLs) including bed mobility and transfers, fell from an elevated bed and sustained a laceration to her forehead and was later pronounced deceased in the Emergency Room. […]
- Immediate jeopardy, isolatedF689Sep 2, 2022
Based on policy review, facility investigation review, weather website review, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement for 1 of 8 sampled residents (Resident #1) reviewed for elopement/wandering behaviors. Resident #1, who had severely impaired cognition, exited the front door, walked approximately 396 feet on the sidewalk, went down a steep embankment, crossed a busy 4-lane highway, and was found at a bus stop approximately 0.1 mile from the facility. […]
- Immediate jeopardy, isolatedF695Sep 2, 2022
Based on Named State Medicaid Long Term Care Program requirements, policy review, medical record review, and interview, the facility failed to provide the necessary mechanical ventilator audible alarm, redundant external alarm system, response processes, and monitoring processes of continuous pulse oximetry (a process to measure the oxygen level in the blood) and end tidal carbon [MEDICATION(S)] (ETCO2) (the level of carbon [MEDICATION(S)] that is released at the end of an exhaled breath) or ETCO2 monitoring for 1 of 4 sampled residents (Resident #7) on mechanical ventilation. The facility's failure resulted in Immediate Jeopardy when Resident #7 was found unresponsive and no mechanical ventilator or pulse oximetry alarms sounded. […]
- Immediate jeopardy, isolatedF600Oct 14, 2021
Based on review of Lippincott Manual of Nursing Practice 10th Edition, Review of Manufacturing Guidelines, review of [CONDITION(S)] in the Older Adult:10 Common Causes & (and) What to Ask article, policy review, medical record review, observation, and interview, the facility neglected to provide the standard of care for vascular services safely to 1 of 2 sampled residents (Resident #1) reviewed with a Peripheral Midline Catheter (a special long Intravenous (IV) catheter that is placed into a large vein and requires safety mechanisms to prevent bleeding from the IV opening). The midline catheter has a clamp on the extension tubing between the catheter labeled junction and the catheter opening. The clamp should always be closed when the catheter is not in use. […]
- Immediate jeopardy, isolatedF694Oct 14, 2021
Based on review of Brunner & Suddarth's Textbook of Medical-Surgical Nursing 12th Edition, Merck Manual, [CONDITION(S)] in the Older Adult:10 Common Causes and (&) What to Ask article, policy review, medical record review, manufacturer guidelines for Midline Catheter device, observation, and interview, the facility failed to provide services safely to a resident with a Peripheral Midline Catheter (a special long Intravenous (IV) catheter that is placed into a large vein and requires safety mechanisms to prevent bleeding from the IV opening). The midline catheter has a clamp on the extension tubing between the catheter labeled junction and the catheter opening. The clamp should always be closed when the catheter is not in use. […]
Read 32 findings in full →The most serious and the most recent: 32 of 128 on record.
Every survey on record
FindingsAt actual harm or above
- Apr 30, 2025Complaint6 findings · 1 harm
- Oct 16, 2024Standard and complaint27 findings · 2 harm
- Nov 23, 2022Complaint3 findings
- Sep 2, 2022Complaint2 findings · 2 harm
- Oct 14, 2021Complaint4 findings · 4 harm
- Sep 24, 2021Standard5 findings
- Apr 9, 2021Complaint2 findings
- Oct 3, 2019Standard and complaint4 findings
Show the 11 earlier surveys
- Nov 1, 2018Standard3 findings
- Nov 15, 2017Standard3 findings
- Apr 27, 2017Complaint1 finding
- Sep 30, 2016Standard and complaint29 findings · 5 harm
- Sep 1, 2015Standard3 findings
- Jul 21, 2015Complaint7 findings
- Jul 10, 2014Standard and complaint5 findings
- Feb 19, 2013—1 finding
- Jul 12, 2012—6 findings
- Feb 15, 2012—1 finding
- Apr 13, 2011—16 findings · 1 harm
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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