Spring Gate Rehab & Healthcare Center

3909 Covington Pike · Memphis, TN · 38135 · 9013771011

206 certified beds For profit - Limited Liability company Chain: Prestige Administrative Services

Why this verdict

  • Inspection record is far worse than the national median (deficiency count and severity).
  • Federal penalties on record: $128,974 in fines in the last 24 months.
  • Inspection results are getting worse cycle over cycle, not better.

The complete Safety Report — $19

Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.

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Red flags

1 immediate-jeopardy citation in prior inspection cycles

Serious past findings — check whether the underlying problems were fixed and stayed fixed.

2 actual-harm citations in the most recent cycle

Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.

$128,974 in federal fines in the last 24 months

2 fines — CMS fines are reserved for verified, serious non-compliance.

Score breakdown

Inspection record 30% of score 28
Serious harm & abuse 20% 82
Staffing 20% 77
Federal penalties 15% 27
Trend 10% 18
Context 5% 100

Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.

CMS ratings & staffing

Overall: 2 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 5 of 5

Total nurse hours / resident-day4.263.48 min · 4.1 strong
RN hours / resident-day0.820.55–0.75
Weekend hours / resident-day3.69≈ weekday level
Nursing turnover / year59%median 45%
Fines (3-yr window)2 · $128,974

Inspection citations (37 in the current record)

  • Immediate jeopardy · J April 30, 2025 · found via complaint

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Corrected May 22, 2025 · Quality of Life and Care

  • Potential for harm · D April 30, 2025 · found via complaint

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Corrected May 22, 2025 · Resident Assessment and Care Planning

  • Potential for harm · D April 30, 2025 · found via complaint

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Corrected May 22, 2025 · Quality of Life and Care

  • Potential for harm · D April 30, 2025 · found via complaint

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Corrected June 21, 2025 · Resident Assessment and Care Planning

  • Actual harm · G October 16, 2024

    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 November 14, 2024 · Quality of Life and Care

  • Actual harm · G October 16, 2024 · found via complaint

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Corrected January 3, 2025 · Quality of Life and Care

  • Potential for harm · D October 16, 2024

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

    Corrected November 14, 2024 · Resident Rights

  • Potential for harm · D October 16, 2024

    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 November 14, 2024 · Resident Rights

  • Potential for harm · D October 16, 2024

    Ensure each resident receives an accurate assessment.

    Corrected January 3, 2025 · Resident Assessment and Care Planning

  • Potential for harm · D October 16, 2024

    PASARR screening for Mental disorders or Intellectual Disabilities

    Corrected November 14, 2024 · Resident Assessment and Care Planning

  • Potential for harm · D October 16, 2024

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Corrected November 14, 2024 · Resident Assessment and Care Planning

  • Potential for harm · D October 16, 2024

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    Corrected January 3, 2025 · Quality of Life and Care

  • Potential for harm · D October 16, 2024

    Provide safe and appropriate respiratory care for a resident when needed.

    Corrected November 14, 2024 · Quality of Life and Care

  • Potential for harm · E October 16, 2024

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Corrected November 14, 2024 · Nutrition and Dietary

  • Potential for harm · D October 16, 2024

    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

    Corrected November 14, 2024 · Administration

  • Potential for harm · D October 16, 2024 · found via complaint

    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

    Corrected January 3, 2025 · Resident Rights

  • Potential for harm · D October 16, 2024 · found via complaint

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Corrected January 3, 2025 · Resident Rights

  • Potential for harm · F October 16, 2024 · found via complaint

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    Corrected January 3, 2025 · Resident Rights

  • Potential for harm · D October 16, 2024 · found via complaint

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Corrected November 14, 2024 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D October 16, 2024 · found via complaint

    Respond appropriately to all alleged violations.

    Corrected November 14, 2024 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D October 16, 2024 · found via complaint

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Corrected January 3, 2025 · Quality of Life and Care

  • Potential for harm · E October 16, 2024 · found via complaint

    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 January 3, 2025 · Quality of Life and Care

  • Potential for harm · E October 16, 2024 · found via complaint

    Ensure that the resident and his/her doctor meet face-to-face at all required visits.

    Corrected January 3, 2025 · Nursing and Physician Services

  • Potential for harm · D October 16, 2024 · found via complaint

    Post nurse staffing information every day.

    Corrected January 3, 2025 · Nursing and Physician Services

  • Potential for harm · D October 16, 2024 · found via complaint

    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 January 3, 2025 · Pharmacy Service

Showing the 25 most recent. The Safety Report includes every citation with full findings.

Federal penalties

DateTypeAmount / length
April 30, 2025Fine$50,749
October 16, 2024Fine$78,225
October 16, 2024Payment Denial50 days

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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 445220 · certified since May 2, 1989. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.