McRae Manor Nursing Home
160 South First Avenue, Mc Rae, GA 31055 · For profit - Limited Liability company · 133 certified beds · (229) 868-6473 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- lower-than-typical staff turnover (30% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,697 in federal fines (most recent 2024-07-12)
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.3% | 15.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.8% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.8% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.6% | 2.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 11.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 6.2% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 15.4% | 15.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 29.2% | 20.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.1% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.9% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 10.2% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 27.5% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 7.7% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 69.2% | 78.4% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.9% | 25.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.8% | 11.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.23 | 2.15 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.66 | 1.90 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 54.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 31 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.5%CMS range 7.2–16.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 54.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 51.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 29.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.0%CMS range 4.1–14.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.13 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 133 beds and averages 91.6 residents a day — about 69% occupied, or roughly 41 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.08 hrs/resident/day on weekends vs 3.72 on weekdays — 17% thinner on weekends. RN hours go from 0.59 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 30% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.
- Potential for harm · Fcited before2025-12-04 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interviews, the facility failed to ensure that food was properly labeled and dated and stored under sanitary conditions to prevent foodborne illness. The deficient practice has the potential to affect 79 of 86 residents receiving food from the kitchen.Findings include: A food storage policy was requested but was not made available to the surveyor.A tour with the Dietary Manager (DM) on 12/2/2025 at 9:21 am revealed the following concerns: -The cooler was observed with raw bacon, raw porkchops, cooked turkey, cooked cornbread, cooked dressing, cooked ham, and cooked pork, that were not labeled with open, expiration or use by dates.-The pantry was observed with open pasta noodles, macaroni noodles, corn bread meal/ batter, rice, vanilla wafers in containers and zip lock bags that were not labeled with expiration dates.-The air conditioner vent filter had a layer of thick dust, including the adjacent wall and ceiling in the kitchen. Interview with the DM during the kitchen tour on 12/2/2025 at 9:21 am confirmed all identified concerns. DM immediately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-12-04 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and policy titled Home Trash Management Policy and Procedure the facility failed to ensure trash and garbage refuse was maintained in a sanitary manner for three of three dumpsters observed. The deficient practice created the potential for harboring pests and insects.Findings Include:A record review of policy titled [NAME] Manor Home Trash Management Policy and Procedure revealed [NAME] Manor trash policies require staff to separate general waste from regulated medical waste (e.g., sharps, pharmaceuticals materials) and handle each stream according to specific regulations. General trash is disposed of like typical refuse, while regulated waste needs special containers, storage, and professional pickup services to prevent injury and environmental contamination. The specific rules for pickup frequency and handling vary by state and local regulations.Observation on 12/2/2025 at 10:44 am with the Dietary Manager (DM) revealed the trash and garbage dumpsters located outside adjacent to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and the facility policies titled Environmental Quality Policy and Procedure and Homelike Environment, the facility failed to ensure the residents' living area was safe, clean, comfortable, and homelike in 16 rooms (Rooms 104, 105, 107, 108, 109, 111, 112, 113, 208, 210, 211, 218, 226, 227, 229 and 303) on three of three halls (100 Hall, 200 Hall and 300 Hall) observed. Specifically, residents' rooms contained dirty air filters in self-contained heating and air system individual wall units (PTAC), cracked outlet cover, bed hand control wires exposed and window handle missing. This failure had the potential to affect patient comfort and safety. Findings include: 1. A review of the facility policy titled Homelike Environment revealed that the residents are provided with safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. An observation and interview with R63 in room [ROOM NUMBER] on 12/2/2025 at 12:17 pm…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-04 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and staff interviews, and policy titled, Care Planning, the facility failed to develop and/or implement the care plan for two of seven residents (R) (R12 and R9) reviewed for care planning. This deficient practice has the potential to place R12 at risk of dehydration and clinical decline and R9 from reaching the highest practicable level of functioning. Findings include: 1. A review of the facility policy titled, Care Plan, dated 5/5/2023, revealed the initial admission care plan will be completed within 48 hours of admission to the facility. A comprehensive care plan will be completed for all residents by the 14th day after admission. A review of the face sheet for R9 revealed an initial admit date of 10/6/2025 and a readmit date of 10/22/2025. A review of the admission Minimal Data Set (MDS) for R9 dated 11/3/2025 revealed that Section C (Cognitive Patters) documented a Brief Interview for Mental Status (BIMS) score of 15 indicating little to no cognitive impairment. Section I (Active Diagnosis) revealed diagnoses but not all inclusive of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-04 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, record review and facility policy titled, Enteral Nutrition, the facility failed to follow physician orders regarding water flush for one of seven residents (R) (R12) that received enteral feedings via gastrostomy tube (G-tube) [tube inserted into the stomach for supplemental feeding]. This deficient practice had the potential to place R12 at increased risk for complications and adverse clinical outcomes. Findings Include:Review of the facility policy titled Enteral Nutrition, revised on 11/2018 documented: 11. The nurse confirms that orders for enteral nutrition are complete. Complete orders include g. instructions for flushing (solution, volume, frequency, timing, and 24-hour volume).A review of the admission Minimum Data Set (MDS) for R12 dated 9/29/2025 revealed that Section C (Cognitive Patters) documented a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. Section I (Active Diagnosis) revealed diagnoses but not all inclusive of anemia, atrial fibrillation, hypertension, and cerebrovascular…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-04 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and facility policy titled, Medication Storage in the Facility and Administering Medications, the facility failed to ensure one of three medication storage rooms did not have expired medications and one of one wound care cart was locked and secured when unattended by the nurse. In addition, three of five medication carts had expired medication, medication not stored or labeled correctly, and medications left on the cart for a discharged resident. The deficient practice had the potential to allow unauthorized staff, residents, and visitors access to medications, and place residents at risk of receiving expired medications.Findings Include:Review of the facility's policy titled, Medication Storage in the Facility effective date 4/1/2016 revealed, medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supplies are accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-07-12 · tag F0700 — widespreadTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to attempt appropriate alternatives, assess for risk of entrapment, review the risks versus benefits, and obtain informed consent prior to installing side rails for residents' beds for four of five Residents (R) (R60, R1, R14, and R66) reviewed for side rail/bedrail usage. Substandard Quality of Care was identified related to bedrails. Findings include: 1.Observation made on 7/9/2024 during the initial tour, starting at 1:00 pm revealed the presence of full side rails attached to the left and right side of R60's bed. R60 was observed lying in a bariatric bed with side rails up. Record review for R60 revealed the following diagnoses but not limited to [NAME] stenosis of lumbar region. The Annual Minimum Data Set (MDS) dated [DATE] assessed a Brief Interview Mental Status Score (BIMS) of 15 which indicates no cognitive impairment and total dependent for all Activity of Daily Living Skills (ADLs) except for eating. The Annual MDS dated [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-12 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and review of Job Description and Performance Standards - Maintenance Supervisor, the facility failed to provide a safe/clean/comfortable/homelike environment for one hallway (200 hall) of three hallways. Specifically, there was a handrail with loose posts and one handrail with broken brackets. Findings included: Review of Job Description and Performance Standards - Maintenance Supervisor revealed, purpose of this position is to develop and implement maintenance polices and procedures in an effective manner to safely meet residents' needs in compliance with federal, state and local requirement. Review of the primary functions of this position reflected the following: 4. Develop and implement repair and maintenance schedules for all areas of the facility and grounds. An observation on 7/9/2024 at 11:29 am revealed two defective handrails on 200 South between rooms [ROOM NUMBERS]. One handrail was pulling away from the wall due to loosened posts and one had broken brackets.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-12 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of policy titled Production, Storage and Dispensing of Ice, the facility failed to maintain the cleanliness of one of two ice machines, ensure proper storage of ice scoops for two of two ice machines, and failed to discard expired food items. These deficient practices had the potential to affect 74 out of 76 residents who received an oral diet. Findings include: Review of the policy titled, Production, Storage and Dispending of Ice (2021) revealed the following: 1. The ice dispenser will be cleaned and sanitized at least monthly, and/or as needed. Inside and outside of machine and the area around the machine will be cleaned. 2. Ice scoops will be stored outside the ice dispenser in a closed, clean container or in the ice machine in the scoop storage container provided by the manufacturer. Ice scoops will be cleaned and sanitized daily. During the initial tour of the kitchen on 7/9/2024 at 9:00 am with the Dietary Manager (DM) revealed in the dry storage room, 14 containers of four-ounce (4 oz) thickening lemon-flavored water drinks with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-12 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record reviews, and a review of the facility policy titled Dignity Policy, the facility failed to ensure dignity for two of 25 sampled residents (R) (R62, R29). Specifically, staff were observed standing while feeding R62 and there was no privacy bag used to cover the catheter drainage bag for R29. Findings include: Review of the facility policy titled Dignity Policy (last reviewed 5/5/2023) stated .It is the policy of the facility that staff must promote care for residents in a manner and in an environment that maintains or enhances each resident 's dignity and respect in full recognition of his or her individuality. This means staff must carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. 1. Record review of R62's medical record revealed the following diagnoses but not limited to vascular dementia with unspecified severity without behavioral disturbances, psychotic disturbance, and anxiety. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 8 citations
- Potential for harm · D2024-07-12 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled Administration Medication Policy and Procedures, the facility failed to ensure one of 23 sampled residents, (R) R23, did not have unsecured medications stored at the bedside. This deficient practice had the potential to allow unauthorized access of medications to other residents and visitors in the facility. Findings include: Record review of the facility's policy titled Administering Medications Policy and Procedures (not dated) stated return drugs to medication cart or medication room. Never leave any drug in a resident 's room. For residents who keep medication in their room check to ensure meds are stored properly out of reach of other residents. Record review of R23's medical record revealed the following diagnoses but not limited to dementia, hypertension, hypokalemia, and anxiety disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed an assessment for a Brief Interview Mental Status Score (BIMS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Activities of Daily Living the facility failed to ensure one resident, (R) R44, of 23 residents sampled were given showers as scheduled. This failure had the potential to cause R44 to be unclean and create an environment that could increase the potential for actual infections and cause the residents to feel self-conscious of appearance. Findings include: Review of the facility's policy titled, Activities of Daily Living (last revised March 2018), revealed residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. R44 admitted to the facility with diagnoses that included: Hemiplegia and Hemiparesis, cerebral infraction, personal history of transient ischemic attack and cerebral infarction without residual deficits, and seizures. Review of the most recent Quarterly Minimum Data Set…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interviews, and the facility policies titled Accidents and Incidents-Investigating and Reporting, Oxygen Delivery Policy, and Chemical Safety and Storage, the facility failed to ensure two of 23 sampled residents (R) ( R49 and R65) were free from accident hazards. Specifically, the facility failed to ensure R49 was free from exposure to free standing oxygen and R65 was free from exposure to harmful chemicals. Findings include: Review of facility policy titled Oxygen Delivery Policy (revised 2/28/2018) revealed 5. Oxygen cylinders must be in portable carrier or in wheelchair oxygen holders. Cylinders must not be placed on the floor. Review of facility policy titled Chemical Safety and Storage (undated) stated Proper storage of chemicals is necessary to ensure the resident environment remains as free of accident hazards as is possible. Guidelines: All chemicals should be labeled properly and in the correct containers and stored in the locked cabinet at all times.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and the facility policy titled Urinary Catheter, Maintenance of Indwelling Policy and Procedure , the facility failed to have a Physician order for one resident, (R) R62, of six residents with catheters. In addition, the indwelling urinary catheter order was omitted on the Medication Administration Record (MAR) to ensure monitoring instructions, and appropriate treatment services for the catheter. This deficient practice had the potential to put residents at risk for complications related to their urinary health with the possibility of urinary tract infections. Findings include Review of facility policy titled Urinary Catheters, Maintenance of Indwelling Policy and Procedure (undated) 1. A physician 's order and medical reason will be obtained for each resident receiving an indwelling catheter. The order will explain the size of catheter, size of balloon, and type of catheter to be used. It will also describe how often the catheter to be used. It will also…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-12 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview and review of the policy titled Medication Monitoring and Management, the facility failed to ensure a stop date for the use of a PRN (as needed) antipsychotic medication (quetiapine) was not over 14 days for one of five residents, (R) R65, reviewed for unnecessary medications. Findings include: Record review of the facility policy titled Medication Monitoring and Management (dated 3/30/2023) stated PRN (as needed) orders for Psychotropic and Antipsychotic Medications. In certain situations, psychotropic medications may be prescribed on a PRN basis, such as while the dose is adjusted, to address acute or intermittent symptoms or in an emergency, PRN orders for antipsychotic medications Time Limitations -14 days. Record review of R65's medical record revealed the following diagnoses but not limited to chronic obstructive pulmonary disease, Alzheimer 's Disease, unspecified dementia with severe agitations, chronic obstructive pulmonary disease, atrial fibrillation, major…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and review of the facility policy titled Maintenance of Indwelling Urinary Catheters, the facility failed to properly perform infection control practices to prevent the possible spread of infections by allowing an indwelling urinary catheter bag to drag on the floor for one of six residents, (R) (R7), with catheters. Findings include: Review of the facilities, undated, Maintenance of Indwelling Urinary Catheters, documented maintaining indwelling catheters promotes good hygiene and reduces the potential for infection. A physician's order and medical reason will be obtained for each resident receiving an indwelling catheter. The record review for R7 revealed diagnosis that included intellectual disability (a delay in the acquisition of skills needed for independent living and social functioning), lap diverting colostomy (used to treat an intestinal injury or a chronic condition) status post peritoneal (a membrane that lines the inside of your abdomen and pelvis) debridement (medical removal of dead, damaged, or infected tissue), and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-10 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews the facility failed to ensure a clean, comfortable, and homelike environment in three resident's bathrooms (shared bathrooms 208/210, 209/211, and 213/215), one resident room (room [ROOM NUMBER]), and in the 200-hall shower room on one of three halls. Finding include: During facility observations held on 11/8/22 at 9:00 a.m. and 11/9/22 at 9:01 a.m. revealed the following: 1. In room [ROOM NUMBER]/210 shared bathroom-The bottom of the toilet, floor and baseboards had dark brown grime buildup and the sink had a rust type stain in toilet bowl. 2.In room [ROOM NUMBER]/211 the shared bathroom-The bathroom sink had yellow/brown grime stains in bowl of sink and dried unpainted caulk patches on the ceiling around the sprinkler. 3. In room [ROOM NUMBER] room it was very cluttered with wheelchairs and an extra bed, the bathroom was cluttered with wheelchairs and equipment. The room is a 4-bedroom ward with only one resident in the room. 4. In room [ROOM NUMBER]/215 the shared…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-11-10 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews and review of the facility policy titled Medication Monitoring and Management the facility failed to ensure that psychotropic medications including an antipsychotic was not ordered as needed (PRN) for more than 14 days unless clinically indicated for one (1) of five (5) residents ((R) R#30) reviewed for unnecessary medications. Findings include: Review of the facility policy titled Medication Monitoring and Management effective 4/1/2016 6) PRN orders include an indication for use. a. If the PRN medication is used to modify behavior, the indication for use is clearly defined in objective terms, what specific symptom is being addressed. b. The resident is monitored for the effectiveness of the medication or possible adverse consequence. the results are documented in the medical record. R#30 was admitted to the facility on [DATE] with diagnoses that included but not limited to transient ischemic attack, hypothyroid, and dementia. Review of R#30's admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,697 in federal fines across 1 penalty.
- $8,697 — penalty dated 2024-07-12
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SIDDALL, BRIAN | Individual | CONTRACTED MANAGING EMPLOYEE | since 07/01/2024 |
| TANNER, GAIL | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/10/2025 |
| FORRISTER, KAREN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2024 |
| LEMCKE, DAVID | Individual | CORPORATE OFFICER | since 07/01/2024 |
| PEACH HEALTH GROUP LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 07/01/2024 |
| WALLACE, BILLY | Individual | TRUSTEE OF THE SNF | since 07/01/2024 |
| MCRAE MANOR NURSING HOME INC | Organization | ADP OF THE SNF | since 12/06/2024 |
| T BUFORD COOK TUW SR | Organization | ADP OF THE SNF | since 12/06/2024 |
| WALLACE FAMILY IRREVOCABLE TRUST | Organization | ADP OF THE SNF | since 12/05/2024 |
| CONLEY, GERALD | Individual | ADP OF THE SNF | since 01/10/2025 |
| CONLEY, KIM | Individual | ADP OF THE SNF | since 12/24/2024 |
| CONLEY, REX | Individual | ADP OF THE SNF | since 12/24/2024 |
| COOK, SHEILA | Individual | ADP OF THE SNF | since 12/24/2024 |
| LOWERY, IRIS | Individual | ADP OF THE SNF | since 12/06/2024 |
CMS files one row per role, so the 18 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $454K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in GA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115494. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-04, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.