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
Chain footprint
21 facilities
Chain averages 2 overall / 2 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
0.42
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.88
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.92
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.11
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,235
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.77
Composite VBP score used to determine payment impact.
Payment multiplier
0.9937
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.58
Baseline 22.25% · Performance 19.08% · Measure score 5.58 · Achievement 5.08 · Improvement 5.58
Healthcare-associated infections
5.64
Baseline 10.12% · Performance 6.98% · Measure score 5.64 · Achievement 2.87 · Improvement 5.64
Total nurse turnover
3.12
Baseline 69.07% · Performance 53.08% · Measure score 3.12 · Achievement 2.59 · Improvement 3.12
Adjusted total nurse staffing
1.98
Baseline 2.04 hours · Performance 2.97 hours · Measure score 1.98 · Achievement 0 · Improvement 1.98
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.61% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 14.47% · Lower 95% interval 7.45% |
| Discharge to community | 38.46% |
50.57%
12.1 pts worse
|
Worse than the National Rate · Eligible stays 73 · Observed rate 20.55% · Lower 95% interval 25.06% |
| Medicare spending per beneficiary | 1.31 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 62.62% |
95.27%
32.6 pts worse
|
Numerator 67 · Denominator 107 |
| Falls with major injury | 0.93% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 107 |
| Discharge self-care score | 40% |
53.69%
13.7 pts worse
|
Numerator 24 · Denominator 60 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 20 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 0.93% |
2.29%
1.4 pts better
|
Numerator 1 · Denominator 107 · Adjusted rate 0.63% |
| Healthcare-associated infections requiring hospitalization | 6.98% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 10.71% · Lower 95% interval 4.09% |
| Staff COVID-19 vaccination coverage | 0.65% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 154 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 38.33% |
56.45%
18.1 pts worse
|
Numerator 23 · Denominator 60 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 45 · Denominator 45 |
| Transfer of health information to patient | 90.91% |
96.28%
5.4 pts worse
|
Numerator 20 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 1.69% |
25.2%
23.5 pts worse
|
Numerator 1 · Denominator 59 |
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 · Adjusted 1.9 · Observed 2.4 · Expected 2.4 · Used in QM five-star |
| 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 · Adjusted 1.1 · Observed 1.2 · Expected 1.8 · Used in QM five-star |
| 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 · Q1 16.9% · Q2 13.1% · Q3 14.4% · Q4 26.4% · 4Q avg 17.6% |
| 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 · 4Q avg 26.0% |
| 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 · Q1 0.8% · Q2 0.0% · Q3 0.8% · Q4 0.8% · 4Q avg 0.6% · Used in QM five-star |
| 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 · Q1 10.1% · Q2 24.4% · Q3 23.5% · Q4 5.9% · 4Q avg 15.9% |
| 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 · Q1 13.4% · Q2 12.1% · Q3 15.4% · Q4 16.9% · 4Q avg 14.4% |
| 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 · Q1 21.9% · Q2 20.4% · Q3 20.8% · Q4 23.8% · 4Q avg 21.7% |
| 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 · Q1 17.0% · Q2 15.6% · Q3 19.3% · Q4 18.9% · 4Q avg 17.7% · 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 | 36.6% |
19.9%
16.7 pts worse
|
16.3%
20.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.6% · Q2 48.7% · Q3 20.7% · 4Q avg 36.6% · Used in QM five-star |
| 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 · Q1 31.7% · Q2 20.9% · Q3 10.3% · Q4 10.4% · 4Q avg 18.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.2% · Q3 1.3% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| 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 · Q1 0.8% · Q2 2.3% · Q3 2.4% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| 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 · Q1 13.2% · Q2 27.6% · Q3 15.1% · Q4 13.4% · 4Q avg 17.5% |
| 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 · Q1 6.5% · Q2 8.7% · Q3 6.4% · Q4 9.9% · 4Q avg 7.9% · Used in QM five-star |
| 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 · Q1 6.0% · Q2 5.2% · Q3 6.0% · Q4 9.6% · 4Q avg 6.9% |
| 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 · Adjusted 3.3% · Observed 3.9% · Expected 13.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 4.8% · Q3 5.9% · Q4 3.7% · 4Q avg 3.9% · Used in QM five-star |
| 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 · 4Q avg 2.5% |
| 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 · Adjusted 25.1% · Observed 33.3% · Expected 31.6% · Used in QM five-star |
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
Nearby options
Other facilities in reach
#1
Allen Morgan Health And Rehabilitation Center
Memphis, TN
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Shelby Oaks Post Acute
Memphis, TN
1-star overall rating with 1-star inspections with abuse icon flag with $126,318 in total fines with 13 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Majestic Gardens At Memphis Rehab & Snc
Memphis, TN
1-star overall rating with 1-star inspections with Special Focus status with $810,404 in total fines with 7 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
Jump out