Cycle 1
Health 2022-08-11 · Fire 2022-08-11
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Memphis, TN
Highlands Health And Rehabilitation Center
2-star overall rating with 2-star inspections with $305,320 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
3549 Norriswood, Memphis, TN
(901) 325-7820
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
180
Certified beds
Average residents
157
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Champion Care
Operator or chain grouping
Approved since
1984-06-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing
LPN hours / resident day
0.95
Licensed practical nurse staffing
Aide hours / resident day
1.88
Nurse aide staffing
Weekend hours
2.92
Weekend nurse staffing
RN turnover
31%
Annual RN turnover
Total nurse turnover
50%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 17.6% |
89.9%
72.3 pts worse
|
93.4%
75.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 26.0% |
94.5%
68.5 pts worse
|
95.5%
69.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
3.6%
3 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 15.9% |
11.8%
4.1 pts worse
|
11.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 14.4% |
6.2%
8.2 pts worse
|
5.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.7% |
32.2%
10.5 pts better
|
19.6%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 17.7% |
18.1%
0.4 pts better
|
16.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 36.6% |
19.9%
16.7 pts worse
|
16.3%
20.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.2% |
15.3%
2.9 pts worse
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.9%
0.5 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.5% |
20.2%
2.7 pts better
|
19.8%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
5.4%
2.5 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 6.9% |
79.6%
72.7 pts worse
|
81.7%
74.8 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.3% |
11.2%
7.9 pts better
|
12.0%
8.7 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.9% |
1.6%
2.3 pts worse
|
1.6%
2.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 2.5% |
79.8%
77.3 pts worse
|
79.7%
77.2 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.1% |
22.2%
2.9 pts worse
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-22 · Fire 2019-10-22
3 health deficiencies
Top issue: Infection Control (1 deficiency)
13 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2018-12-06 · Fire 2018-12-06
14 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-08-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-09-19
D · Potential for more than minimal harm
2022-08-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-19
D · Potential for more than minimal harm
2022-08-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-08-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-08-08
D · Potential for more than minimal harm
2019-10-22
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2019-11-15
D · Potential for more than minimal harm
2019-10-22
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-12-24
D · Potential for more than minimal harm
2019-10-22
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2019-12-24
D · Potential for more than minimal harm
2019-10-22
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2019-11-13
D · Potential for more than minimal harm
2019-10-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-15
D · Potential for more than minimal harm
2019-10-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-11-15
D · Potential for more than minimal harm
2019-10-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-12-24
D · Potential for more than minimal harm
2019-10-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-12-24
D · Potential for more than minimal harm
2019-10-22
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2019-11-15
D · Potential for more than minimal harm
2019-10-22
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-12-24
D · Potential for more than minimal harm
2019-10-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-11-15
D · Potential for more than minimal harm
2019-10-22
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2019-11-15
D · Potential for more than minimal harm
2019-10-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-15
D · Potential for more than minimal harm
2018-12-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-01-06
D · Potential for more than minimal harm
2018-12-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-12-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-17
J · Immediate jeopardy
2023-05-05
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 2023-06-27
E · Potential for more than minimal harm
2023-05-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-27
D · Potential for more than minimal harm
2023-05-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-06-27
D · Potential for more than minimal harm
2023-05-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-27
D · Potential for more than minimal harm
2023-05-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-06-27
D · Potential for more than minimal harm
2023-05-05
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2023-06-27
D · Potential for more than minimal harm
2023-05-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-06-27
E · Potential for more than minimal harm
2023-03-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-28
D · Potential for more than minimal harm
2023-03-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-28
E · Potential for more than minimal harm
2022-08-11
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 2022-08-24
E · Potential for more than minimal harm
2022-08-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-08-11
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 2022-08-24
D · Potential for more than minimal harm
2022-08-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-08-11
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-08-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-30
D · Potential for more than minimal harm
2019-10-22
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-12-05
D · Potential for more than minimal harm
2019-10-22
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2019-12-05
D · Potential for more than minimal harm
2019-10-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-05
E · Potential for more than minimal harm
2018-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-01-06
D · Potential for more than minimal harm
2018-12-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-01-06
D · Potential for more than minimal harm
2018-12-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-01-06
D · Potential for more than minimal harm
2018-12-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-01-06
D · Potential for more than minimal harm
2018-12-06
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2019-01-06
Penalties and ownership
What sits behind the stars
$305,320
2023-05-05
Fine
Fine · fine $305,320
Fine
$0
2023-05-05
Payment Denial
Payment Denial · denial start 2023-06-09 · 18 days
18 day denial
Ownership
The Bay At Highlands Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Bl Capital Group Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Champion Care LLC
Operational/Managerial Control · Organization
Landa, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
Legacy SNF Opco Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Legacy SNF Opco Holdings Trust
5% Or Greater Indirect Ownership Interest · Organization
Paul, Charlotte
W-2 Managing Employee · Individual
Ruvel, Menachem
5% Or Greater Indirect Ownership Interest · Individual
Ruvel, Menachem
Operational/Managerial Control · Individual
Ruvel, Menachem
Corporate Officer · Individual
Tn2 Opco Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Weinberg, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Weinberg, Yisroel
Operational/Managerial Control · Individual
Weinberg, Yisroel
Corporate Officer · Individual
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