Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

MAJESTIC GARDENS AT MEMPHIS REHAB & SNC

MEMPHIS, TN · 169 certified beds · Last Life Safety survey September 11, 2025

CMS Certification Number 445150 · first certified November 1982

Ownership

Operated by EPHRAM LAHASKY · For profit - Corporation

  • Ownership changed June 15, 2017 (change of ownership)to MAJESTIC GARDENS AT MEMPHIS REHABILITATION AND SKILLED NURSING CENTER from VANGUARD OF MEMPHIS, LLC
36
Citations on file
Rolling three-year window
5
Life Safety surveys
In the same window
12
Tags cited more than once
Across separate surveys
20
Inspection & testing records
Of the citations on file

Position within TN

36 citations — more than 99% of the 303 certified nursing homes in TN. Compared within TN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 18 citations; the earlier surveys in the window averaged 7.5. With 5 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens December 2026 — about 2 months from now. This facility’s last Life Safety survey was September 2025. Facilities in TN are typically surveyed 15–44 months after the last one (median 33), measured over 279 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

7 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

3 of the 36 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 36 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0584 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.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0908 Keep all essential equipment working safely.

How that compares

Citations on file over three years

Compared with the median facility in TN, and nationally. Surveyors differ markedly between states, so the TN figure is the meaningful one.

This facility36TN median8National median11
Citations on file over three years, compared
MeasureCitations
This facility36
Median facility in TN8
Median facility nationally11

Survey history

Citations at each Life Safety survey
52019-0712023-08122024-05122024-05182025-09
Citations at each Life Safety survey
Survey dateCitations
July 18, 20195
August 9, 20231
May 8, 202412
May 8, 202412
September 11, 202518

Most-cited tags

Most-cited tags at this facility
K-03453K-03533K-09203K-09182K-07122K-07612E-00392K-02112
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0345Have approved installation, maintenance and testing program for fire alarm systems.32025-09-11
K-0353Inspect, test, and maintain automatic sprinkler systems.32025-09-11
K-0920Ensure proper usage of power strips and extension cords.32025-09-11
K-0918Have generator or other power source capable of supplying service within 10 seconds.22025-09-11
K-0712Have simulated fire drills held at unexpected times.22025-09-11
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.22025-09-11
E-0039Conduct testing and exercise requirements.22025-09-11
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.22025-09-11

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 10
  • Gas, Vacuum, and Electrical Systems Deficiencies 7
  • Egress Deficiencies 7
  • Miscellaneous Deficiencies 6
  • Other 6
Citations by CMS category
CategoryCitations
Smoke Deficiencies10
Gas, Vacuum, and Electrical Systems Deficiencies7
Egress Deficiencies7
Miscellaneous Deficiencies6
Emergency Preparedness Deficiencies3
Services Deficiencies3

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

September 11, 2025 — 18 citations

Citations issued on September 11, 2025
TagWhat the surveyor checksStatus
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (October 11, 2025)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (October 11, 2025)
K-0222Add 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.Deficient, Provider has date of correction (October 11, 2025)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (October 11, 2025)
K-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (October 11, 2025)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (October 11, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 11, 2025)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (October 11, 2025)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (October 11, 2025)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (October 11, 2025)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (October 11, 2025)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (October 11, 2025)
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.Deficient, Provider has date of correction (October 11, 2025)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (October 11, 2025)
K-0781Have restrictions on the use of portable space heaters.Deficient, Provider has date of correction (October 11, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (October 11, 2025)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (October 11, 2025)
K-0929Ensure precautions for handling oxygen cylinders and equipment are correctly followed.Deficient, Provider has date of correction (October 11, 2025)

May 8, 2024 — 12 citations

Citations issued on May 8, 2024
TagWhat the surveyor checksStatus
E-0001Establish an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (June 1, 2024)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (June 15, 2024)
K-0222Add 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.Deficient, Provider has date of correction (June 1, 2024)
K-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (May 10, 2024)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (May 10, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (June 15, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (June 15, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (May 24, 2024)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (June 15, 2024)
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.Deficient, Provider has date of correction (May 31, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (May 31, 2024)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (May 20, 2024)

August 9, 2023 — 1 citation

Citations issued on August 9, 2023
TagWhat the surveyor checksStatus
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (August 10, 2023)

July 18, 2019 — 5 citations

Citations issued on July 18, 2019
TagWhat the surveyor checksStatus
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (August 18, 2019)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (August 2, 2019)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (August 2, 2019)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (August 2, 2019)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (August 2, 2019)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.