Cycle 1
Health 2021-12-01 · Fire 2021-12-01
4 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Memphis, TN
Signature Healthcare Of Primacy
4-star overall rating with 4-star inspections with 4 recent health deficiencies
6025 Primacy Parkway, Memphis, TN
(901) 767-1040
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
97
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1981-06-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
71 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.64
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.67
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.79
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.43
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,129
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.48
Baseline 23.79% · Performance 20.43% · Measure score 4.48 · Achievement 2.17 · Improvement 4.48
Healthcare-associated infections
1.18
Baseline 9.59% · Performance 8.82% · Measure score 1.18 · Achievement 0 · Improvement 1.18
Total nurse turnover
0.98
Baseline 51.58% · Performance 59.66% · Measure score 0.98 · Achievement 0.98 · Improvement 0
Adjusted total nurse staffing
0.53
Baseline 3.79 hours · Performance 3.23 hours · Measure score 0.53 · Achievement 0.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.18% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 230 · Observed rate 14.78% · Lower 95% interval 9.25% |
| Discharge to community | 54.95% |
50.57%
4.4 pts better
|
No Different than the National Rate · Eligible stays 239 · Observed rate 43.1% · Lower 95% interval 46.48% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 68.5% |
95.27%
26.8 pts worse
|
Numerator 87 · Denominator 127 |
| Falls with major injury | 0.79% |
0.77%
About the same
|
Numerator 1 · Denominator 126 |
| Discharge self-care score | 44.78% |
53.69%
8.9 pts worse
|
Numerator 30 · Denominator 67 |
| Discharge mobility score | 46.27% |
50.94%
4.7 pts worse
|
Numerator 31 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 3.2% |
2.29%
0.9 pts worse
|
Numerator 4 · Denominator 125 · Adjusted rate 2.29% |
| Healthcare-associated infections requiring hospitalization | 8.82% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 153 · Observed rate 12.42% · Lower 95% interval 6.27% |
| Staff COVID-19 vaccination coverage | 5.88% |
8.2%
2.3 pts worse
|
Numerator 8 · Denominator 136 |
| Staff flu vaccination coverage | 1.43% |
42%
40.6 pts worse
|
Numerator 3 · Denominator 210 |
| Discharge function score | 52.24% |
56.45%
4.2 pts worse
|
Numerator 35 · Denominator 67 |
| Transfer of health information to provider | 84.91% |
95.95%
11 pts worse
|
Numerator 45 · Denominator 53 |
| Transfer of health information to patient | 72.58% |
96.28%
23.7 pts worse
|
Numerator 45 · Denominator 62 |
| Resident COVID-19 vaccinations up to date | 9.09% |
25.2%
16.1 pts worse
|
Numerator 6 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.6
1 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 3.5 · Expected 2.5 · 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 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 63.1% |
89.9%
26.8 pts worse
|
93.4%
30.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.8% · Q2 81.4% · Q3 56.8% · Q4 46.2% · 4Q avg 63.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 54.9% |
94.5%
39.6 pts worse
|
95.5%
40.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 54.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.6%
3.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
11.8%
8.7 pts better
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.6% · Q3 5.3% · Q4 2.1% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 7.2% |
6.2%
1 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.3% · Q3 14.0% · Q4 8.0% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
32.2%
13.8 pts better
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 16.3% · Q3 20.5% · Q4 15.7% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.4% |
18.1%
9.7 pts better
|
16.7%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 12.1% · Q3 10.8% · Q4 4.8% · 4Q avg 8.4% · 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 | 26.8% |
19.9%
6.9 pts worse
|
16.3%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
15.3%
3.7 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 18.9% · Q3 21.1% · Q4 11.1% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.9%
1.4 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.3% |
20.2%
4.9 pts better
|
19.8%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 11.0% · Q3 10.3% · Q4 16.5% · 4Q avg 15.3% |
| Percentage of long-stay residents with pressure ulcers | 12.7% |
5.4%
7.3 pts worse
|
5.1%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 16.4% · Q3 7.5% · Q4 12.8% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.3% |
79.6%
25.3 pts worse
|
81.7%
27.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 69.8% · Q2 60.8% · Q3 49.1% · Q4 40.6% · 4Q avg 54.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
11.2%
3.8 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 7.8% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.6%
0.1 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.7% · Q3 1.6% · Q4 2.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 52.5% |
79.8%
27.3 pts worse
|
79.7%
27.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 52.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
22.2%
1.9 pts worse
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 27.3% · Expected 27.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-22 · Fire 2019-10-22
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-12-19 · Fire 2018-12-19
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2021-12-01
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 2022-02-01
D · Potential for more than minimal harm
2021-12-01
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-02-01
D · Potential for more than minimal harm
2021-12-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-02-01
D · Potential for more than minimal harm
2021-12-01
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 2022-02-01
E · Potential for more than minimal harm
2018-12-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-01-19
E · Potential for more than minimal harm
2018-12-19
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 2019-01-19
E · Potential for more than minimal harm
2018-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-01-19
D · Potential for more than minimal harm
2018-12-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-01-19
D · Potential for more than minimal harm
2018-12-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-01-19
D · Potential for more than minimal harm
2018-12-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-01-19
Penalties and ownership
What sits behind the stars
Ownership
Shc LP Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Asbr Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Harrison, John
Corporate Officer · Individual
Jjla LLC
5% Or Greater Indirect Ownership Interest · Organization
Lpsnf LLC
5% Or Greater Indirect Ownership Interest · Organization
Scott, Charla
W-2 Managing Employee · Individual
Smedra, Ira
5% Or Greater Indirect Ownership Interest · Individual
Steier Iii, Elmer
5% Or Greater Indirect Ownership Interest · Individual
Wheaten LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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#2
Waters Of Memphis A Rehabilitation & Nursing Ctr
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2-star overall rating with 2-star inspections with $5,293 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Kirby Pines Manor
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5-star overall rating with 5-star inspections with 2 recent health deficiencies
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