Cycle 1
Health 2024-11-22 · Fire 2024-11-22
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cordova, TN
Memphis Jewish Home
2-star overall rating with 2-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
36 Bazeberry Road, Cordova, TN
(901) 758-0036
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
131
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-07-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.05
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.60
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
3.22
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
5.88
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
2.66
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
5.17
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.72
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
0.89
CMS adjusted RN staffing hours
Adjusted total hours
4.97
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,910
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.50% · Performance 23.87% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.16
Baseline 6.37% · Performance 6.59% · Measure score 4.16 · Achievement 4.16 · Improvement 0
Total nurse turnover
1.13
Baseline 65.62% · Performance 59.04% · Measure score 1.13 · Achievement 1.13 · Improvement 1.11
Adjusted total nurse staffing
2.18
Baseline 5.37 hours · Performance 3.70 hours · Measure score 2.18 · Achievement 2.18 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.94% |
10.72%
4.2 pts worse
|
Worse than the National Rate · Eligible stays 1061 · Observed rate 14.04% · Lower 95% interval 12.93% |
| Discharge to community | 56.2% |
50.57%
5.6 pts better
|
Better than the National Rate · Eligible stays 1054 · Observed rate 51.23% · Lower 95% interval 52.45% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.49% |
95.27%
3.2 pts better
|
Numerator 652 · Denominator 662 |
| Falls with major injury | 0.3% |
0.77%
0.5 pts better
|
Numerator 2 · Denominator 662 |
| Discharge self-care score | 51.06% |
53.69%
2.6 pts worse
|
Numerator 264 · Denominator 517 |
| Discharge mobility score | 48.94% |
50.94%
2 pts worse
|
Numerator 253 · Denominator 517 |
| Pressure ulcers or injuries, new or worsened | 1.96% |
2.29%
0.3 pts better
|
Numerator 13 · Denominator 662 · Adjusted rate 1.96% |
| Healthcare-associated infections requiring hospitalization | 6.59% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 647 · Observed rate 6.18% · Lower 95% interval 5.04% |
| Staff COVID-19 vaccination coverage | 1.24% |
8.2%
7 pts worse
|
Numerator 3 · Denominator 241 |
| Staff flu vaccination coverage | 58.15% |
42%
16.1 pts better
|
Numerator 182 · Denominator 313 |
| Discharge function score | 67.89% |
56.45%
11.4 pts better
|
Numerator 351 · Denominator 517 |
| Transfer of health information to provider | 98.27% |
95.95%
2.3 pts better
|
Numerator 227 · Denominator 231 |
| Transfer of health information to patient | 98.65% |
96.28%
2.4 pts better
|
Numerator 365 · Denominator 370 |
| Resident COVID-19 vaccinations up to date | 7.32% |
25.2%
17.9 pts worse
|
Numerator 24 · Denominator 328 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.6
0.9 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
89.9%
7.4 pts better
|
93.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 95.9% · Q4 93.5% · 4Q avg 97.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
94.5%
4.2 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.6%
0.2 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.1% · Q3 2.7% · Q4 2.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
11.8%
11.4 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
6.2%
2.7 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 1.5% · Q3 3.3% · Q4 4.5% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.3% |
32.2%
7.1 pts worse
|
19.6%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.2% · Q2 36.1% · Q3 44.9% · Q4 41.1% · 4Q avg 39.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.7% |
18.1%
4.6 pts worse
|
16.7%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 27.1% · Q3 19.2% · Q4 16.7% · 4Q avg 22.7% · 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 need for help with daily activities has increased | 38.1% |
15.3%
22.8 pts worse
|
14.9%
23.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 59.3% · Q2 38.5% · Q3 27.6% · Q4 38.6% · 4Q avg 38.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.9% |
0.9%
4 pts worse
|
1.0%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.6% · Q3 5.3% · Q4 7.5% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.4% |
1.9%
2.5 pts worse
|
1.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 1.5% · Q3 4.7% · Q4 4.2% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.4% |
20.2%
1.2 pts worse
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 19.1% · Q3 14.6% · Q4 25.6% · 4Q avg 21.4% |
| Percentage of long-stay residents with pressure ulcers | 9.7% |
5.4%
4.3 pts worse
|
5.1%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 9.2% · Q3 6.7% · Q4 8.6% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
79.6%
19.7 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 99.4% · Q3 99.8% · Q4 99.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
11.2%
1.7 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 8.7% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.6%
1.2 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.3% · Q3 2.4% · Q4 1.7% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.2% |
79.8%
12.4 pts better
|
79.7%
12.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
22.2%
6.3 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 25.2% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-25 · Fire 2022-03-25
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-07-17 · Fire 2019-07-17
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-22
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 2024-12-13
D · Potential for more than minimal harm
2024-11-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-22
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-12-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-22
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-22
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 2024-12-13
D · Potential for more than minimal harm
2024-11-22
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 2024-12-13
D · Potential for more than minimal harm
2024-11-22
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 2024-12-13
K · Immediate jeopardy
2022-03-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-17
E · Potential for more than minimal harm
2022-03-25
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 2022-04-17
E · Potential for more than minimal harm
2022-03-25
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 2022-04-17
E · Potential for more than minimal harm
2022-03-25
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 2022-04-17
D · Potential for more than minimal harm
2022-03-25
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2022-04-17
D · Potential for more than minimal harm
2022-03-25
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-04-17
D · Potential for more than minimal harm
2022-03-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-04-17
D · Potential for more than minimal harm
2019-07-17
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2019-08-12
D · Potential for more than minimal harm
2019-07-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-08-12
D · Potential for more than minimal harm
2019-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-12
Penalties and ownership
What sits behind the stars
Ownership
Meadows, Bobby
Operational/Managerial Control · 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
Cordova Wellness And Rehabilitation Center
Cordova, TN
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 3 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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