Graceland Rehabilitation and Nursing Care Center
1250 Farrow Road, Memphis, TN 38116 · Shelby County · 240 certified beds · avg 168 residents/day · certified since Jul 1, 1994
SFF Candidate
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · May 13, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jun 12, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · May 1, 2024 · F-0725 · triggered by a complaint
The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Why it matters: Understaffing means longer waits for help, missed care, and higher risk of falls and other harm.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: May 28, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · May 1, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: May 28, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · May 1, 2024 · F-0835 · triggered by a complaint
The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents.
Why it matters: Poor administration often shows up as understaffing, supply shortages, and care problems across the whole facility.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: May 28, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · May 1, 2024 · F-0867 · triggered by a complaint
The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Why it matters: Without a working quality program, the same care problems tend to repeat instead of getting fixed.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: May 28, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · May 1, 2024 · F-0880 · triggered by a complaint
The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Aug 14, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · May 1, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: May 28, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · May 1, 2024 · F-0678 · triggered by a complaint
The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: May 28, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 1, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 23, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 1, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 2, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (33)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 13, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 13, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 13, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| May 13, 2025 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| May 13, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| May 13, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| May 13, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| May 13, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint |
| May 13, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 13, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jan 29, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Jan 29, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Jan 29, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| May 1, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| May 1, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| May 1, 2024 | ▲ K · Immediate jeopardy, repeated | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint |
| May 1, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint |
| May 1, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| May 1, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 1, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| May 1, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| May 1, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 1, 2024 | F · Potential for harm, facility-wide | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| May 1, 2024 | E · Potential for harm, repeated | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| May 1, 2024 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint |
| May 1, 2024 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint |
| May 1, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| May 1, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| May 1, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jul 11, 2019 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 11, 2019 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jul 11, 2019 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jul 11, 2019 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 4 | 0 | E |
| 2024 | 16 | 9 | K ▲ |
| 2025 | 13 | 1 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $342,603, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| May 13, 2025 | Fine | $39,293 |
| May 1, 2024 | Fine | $303,310 |
| May 1, 2024 | Payment Denial | 145 days from May 31, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Tennessee avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.89 | 3.62 | 3.95 | bottom 12% in Tennessee; bottom 10% in the U.S. |
| Registered Nurse hours | 0.28 | 0.57 | 0.69 | bottom 7% in Tennessee; bottom 7% in the U.S. |
| Weekend total nurse staffing | 2.57 | 3.15 | 3.50 | bottom 17% in Tennessee; bottom 11% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.14 | 0.39 | 0.48 | bottom 3% in Tennessee; bottom 5% in the U.S. |
| Total nursing staff turnover (%) | 51.6 | 48.9 | 45.8 | bottom 44% in Tennessee; bottom 33% in the U.S. |
| RN turnover (%) | 20.0 | 43.2 | 42.9 | top 11% in Tennessee; top 13% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.47, RN 0.33, weekend 3.10. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 4/5 · short-stay residents: 1/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Lichtschein, Raphael | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What were the findings behind this administration citation, and what has leadership changed since?"
- "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Parkway Health and Rehabilitation Center | 3.4 mi | Memphis, TN | ★★★☆☆ | 3/5 | |
| Diversicare of Southaven | 4.7 mi | Southaven, MS | ★☆☆☆☆ | 1/5 | |
| Delta Blues Health & Rehabilitation | 4.8 mi | Memphis, TN | ★★☆☆☆ | 2/5 | |
| Desoto Healthcare Center | 5.2 mi | Southaven, MS | ★★★☆☆ | 3/5 | |
| Allen Morgan Health and Rehabilitation Center | 6.3 mi | Memphis, TN | ★★★★★ | 5/5 | |
| Highlands Health and Rehabilitation Center | 6.3 mi | Memphis, TN | ★★☆☆☆ | 2/5 | |
| Landmark of Desoto | 6.4 mi | Horn Lake, MS | ★★☆☆☆ | 2/5 | |
| Midtown Center for Health and Rehabilitation | 6.7 mi | Memphis, TN | ★★☆☆☆ | 3/5 | |
| Majestic Gardens at Memphis Rehab & SNC | 6.7 mi | Memphis, TN | ★☆☆☆☆ | 1/5 | SFF |
| Shelby Oaks Post Acute | 8.2 mi | Memphis, TN | ★☆☆☆☆ | 1/5 | abuse |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 445331.