Cycle 1
Health 2022-06-23 · Fire 2022-06-23
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cordova, TN
Cordova Wellness And Rehabilitation Center
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
955 Germantown Pkwy, Cordova, TN
(901) 754-1393
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
240
Certified beds
Average residents
164
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ahava Healthcare
Operator or chain grouping
Approved since
1989-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.32
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.55
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
3.59
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,098
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 24.67% · Performance 25.07% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 9.41% · Performance 10.38% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.63
Baseline 64.88% · Performance 52.94% · Measure score 2.63 · Achievement 2.63 · Improvement 2.48
Adjusted total nurse staffing
0.73
Baseline 3.21 hours · Performance 3.28 hours · Measure score 0.73 · Achievement 0.73 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.32% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 130 · Observed rate 17.69% · Lower 95% interval 8.31% |
| Discharge to community | 41.58% |
50.57%
9 pts worse
|
No Different than the National Rate · Eligible stays 152 · Observed rate 29.61% · Lower 95% interval 33.17% |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 99.45% |
95.27%
4.2 pts better
|
Numerator 180 · Denominator 181 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 181 |
| Discharge self-care score | 37.84% |
53.69%
15.8 pts worse
|
Numerator 28 · Denominator 74 |
| Discharge mobility score | 24.32% |
50.94%
26.6 pts worse
|
Numerator 18 · Denominator 74 |
| Pressure ulcers or injuries, new or worsened | 3.87% |
2.29%
1.6 pts worse
|
Numerator 7 · Denominator 181 · Adjusted rate 2.86% |
| Healthcare-associated infections requiring hospitalization | 10.38% |
7.12%
3.3 pts worse
|
Worse than the National Rate · Eligible stays 128 · Observed rate 16.41% · Lower 95% interval 7.4% |
| Staff COVID-19 vaccination coverage | 5.71% |
8.2%
2.5 pts worse
|
Numerator 10 · Denominator 175 |
| Staff flu vaccination coverage | 19.06% |
42%
22.9 pts worse
|
Numerator 53 · Denominator 278 |
| Discharge function score | 32.43% |
56.45%
24 pts worse
|
Numerator 24 · Denominator 74 |
| Transfer of health information to provider | 98.06% |
95.95%
2.1 pts better
|
Numerator 101 · Denominator 103 |
| Transfer of health information to patient | 94.87% |
96.28%
1.4 pts worse
|
Numerator 37 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 21% |
25.2%
4.2 pts worse
|
Numerator 21 · Denominator 100 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.6
0.7 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.6
0.8 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
89.9%
8.5 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 99.3% · Q3 98.5% · Q4 98.5% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
94.5%
2.2 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.6%
2.9 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.0% · Q4 1.5% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
11.8%
11.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
6.2%
5 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 1.6% · Q4 1.6% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.4% |
32.2%
7.8 pts better
|
19.6%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 19.7% · Q3 29.8% · Q4 25.4% · 4Q avg 24.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.1% |
18.1%
5 pts better
|
16.7%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 11.1% · Q3 12.6% · Q4 14.9% · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.4% |
19.9%
3.5 pts better
|
16.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 25.6% · Q3 23.5% · Q4 10.6% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.1% |
15.3%
5.2 pts better
|
14.9%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 12.6% · Q3 9.3% · Q4 6.3% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.4% · Q3 0.4% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.9%
1.7 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.2% |
20.2%
1 pts better
|
19.8%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 13.6% · Q3 21.4% · Q4 19.6% · 4Q avg 19.2% |
| Percentage of long-stay residents with pressure ulcers | 9.2% |
5.4%
3.8 pts worse
|
5.1%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 11.9% · Q3 8.0% · Q4 7.3% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.5% |
79.6%
6.9 pts better
|
81.7%
4.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.8% · Q2 83.3% · Q3 84.9% · Q4 94.7% · 4Q avg 86.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
11.2%
4.9 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 18.0% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.6%
1.2 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 0.0% · Q4 0.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.4% |
79.8%
0.6 pts better
|
79.7%
0.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.3% |
22.2%
10.1 pts worse
|
23.9%
8.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.3% · Observed 38.1% · Expected 28.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-09 · Fire 2019-10-09
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2018-11-08 · Fire 2018-11-08
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-06-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-07-15
E · Potential for more than minimal harm
2019-10-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-10-25
D · Potential for more than minimal harm
2019-10-09
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-10-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-10-15
D · Potential for more than minimal harm
2019-10-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-10-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-20
D · Potential for more than minimal harm
2018-11-08
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2018-11-26
D · Potential for more than minimal harm
2018-11-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-11-26
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-06-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-15
E · Potential for more than minimal harm
2022-06-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-07-15
E · Potential for more than minimal harm
2022-06-23
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-07-15
E · Potential for more than minimal harm
2022-06-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-23
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-07-15
D · Potential for more than minimal harm
2022-06-23
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-07-15
E · Potential for more than minimal harm
2018-11-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-11-28
D · Potential for more than minimal harm
2018-11-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-11-28
D · Potential for more than minimal harm
2018-11-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-11-28
Penalties and ownership
What sits behind the stars
Ownership
Cordova Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Niederman, Anshel
5% Or Greater Indirect Ownership Interest · Individual
Bdv Inv Holdco, LLC
5% Or Greater Indirect Ownership Interest · Organization
Ecm Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Labin, Shiya
5% Or Greater Indirect Ownership Interest · Individual
Neuman, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
Dubert, Donni
Operational/Managerial Control · Individual
Nash, Dana
Operational/Managerial Control · Individual
Niederman, Anshel
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Applingwood Post Acute
Cordova, TN
2-star overall rating with 2-star inspections with $98,460 in total fines with 9 recent health deficiencies
#2
Memphis Jewish Home
Cordova, TN
2-star overall rating with 2-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
The Village At Germantown
Germantown, TN
2-star overall rating with 1-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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