Cycle 1
Health 2024-07-12 · Fire 2024-07-12
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Mc Rae, GA
Mcrae Manor Nursing Home
2-star overall rating with 2-star inspections with $40,512 in total fines with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
160 South First Avenue, Mc Rae, GA
(229) 868-6473
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
133
Certified beds
Average residents
84
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Peach Health Group
Operator or chain grouping
Approved since
1989-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.49 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.93 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.57 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,791
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.32
Performance 20.36% · Measure score 2.32 · Achievement 2.32 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 7.99% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
2.26
Baseline 4.16 hours · Performance 3.72 hours · Measure score 2.26 · Achievement 2.26 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.47% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 7.89% · Lower 95% interval 7.2% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.18% |
95.27%
2.9 pts better
|
Numerator 54 · Denominator 55 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 55 |
| Discharge self-care score | 58.82% |
53.69%
5.1 pts better
|
Numerator 20 · Denominator 34 |
| Discharge mobility score | 20.59% |
50.94%
30.3 pts worse
|
Numerator 7 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 1.82% |
2.29%
0.5 pts better
|
Numerator 1 · Denominator 55 · Adjusted rate 1.17% |
| Healthcare-associated infections requiring hospitalization | 7.99% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 11.54% · Lower 95% interval 4.12% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 102 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 47.06% |
56.45%
9.4 pts worse
|
Numerator 16 · Denominator 34 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.2
About the same
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.4 |
2.0
2.4 pts worse
|
1.8
2.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.4 · Observed 4.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
91.2%
7.1 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.2% · Q4 96.2% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.1% |
95.0%
0.1 pts better
|
95.5%
0.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.2%
1.1 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.8% · Q3 4.2% · Q4 6.2% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
9.6%
9.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
5.9%
0.8 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 6.2% · Q3 7.2% · Q4 1.4% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.0% |
20.7%
11.3 pts worse
|
19.6%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.5% · Q2 31.0% · Q3 32.9% · Q4 28.6% · 4Q avg 32.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.0% |
21.4%
4.6 pts worse
|
16.7%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 22.0% · Q3 23.1% · Q4 27.3% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.3% |
17.9%
5.6 pts better
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 16.6% · Q3 9.9% · Q4 17.1% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
16.2%
1.1 pts worse
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 15.6% · Q3 17.2% · Q4 25.7% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.5% |
1.1%
3.4 pts worse
|
1.0%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 10.3% · Q3 4.4% · Q4 0.9% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
2.5%
0.4 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 3.0% · Q3 2.8% · Q4 1.3% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.2% |
16.1%
7.9 pts better
|
19.8%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 8.4% · Q3 11.7% · Q4 10.2% · 4Q avg 8.2% |
| Percentage of long-stay residents with pressure ulcers | 7.2% |
6.2%
1 pts worse
|
5.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 6.0% · Q3 6.8% · Q4 8.3% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.7% |
80.4%
7.7 pts worse
|
81.7%
9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.2% · Q2 70.8% · Q3 80.0% · Q4 62.5% · 4Q avg 72.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
12.2%
6.2 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.9% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.5% |
2.2%
5.3 pts worse
|
1.6%
5.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.2% |
78.2%
9 pts worse
|
79.7%
10.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.1% |
24.2%
7.1 pts better
|
23.9%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 17.6% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-10 · Fire 2022-11-10
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
9 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2019-10-10 · Fire 2019-10-10
4 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-21
F · Potential for more than minimal harm
2024-07-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-08-21
F · Potential for more than minimal harm
2024-07-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-21
E · Potential for more than minimal harm
2024-07-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-08-21
E · Potential for more than minimal harm
2024-07-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-21
E · Potential for more than minimal harm
2024-07-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-08-21
E · Potential for more than minimal harm
2024-07-12
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-08-21
E · Potential for more than minimal harm
2024-07-12
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-07-12
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-07-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-07-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-21
E · Potential for more than minimal harm
2022-11-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-25
E · Potential for more than minimal harm
2022-11-10
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-12-25
E · Potential for more than minimal harm
2022-11-10
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-12-25
E · Potential for more than minimal harm
2022-11-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-12-25
E · Potential for more than minimal harm
2022-11-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-25
E · Potential for more than minimal harm
2022-11-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-25
E · Potential for more than minimal harm
2022-11-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-25
E · Potential for more than minimal harm
2022-11-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-25
E · Potential for more than minimal harm
2022-11-10
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-12-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-07-12
F700 · Quality of Life and Care Deficiencies
Health
Try 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.
Corrected 2024-08-21
E · Potential for more than minimal harm
2024-07-12
F584 · Resident Rights Deficiencies
Health
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 2024-08-21
E · Potential for more than minimal harm
2024-07-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-07-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-07-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-07-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-07-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-07-12
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-07-12
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2024-08-21
D · Potential for more than minimal harm
2024-07-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-21
D · Potential for more than minimal harm
2022-11-10
F584 · Resident Rights Deficiencies
Health
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 2022-12-25
D · Potential for more than minimal harm
2022-11-10
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2022-12-25
D · Potential for more than minimal harm
2019-10-10
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2019-11-24
D · Potential for more than minimal harm
2019-10-10
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2019-11-24
D · Potential for more than minimal harm
2019-10-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-11-24
D · Potential for more than minimal harm
2019-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-24
Penalties and ownership
What sits behind the stars
$8,697
2024-07-12
Fine
Fine · fine $8,697
Fine
$4,545
2023-05-23
Fine
Fine · fine $4,545
Fine
$4,545
2023-05-15
Fine
Fine · fine $4,545
Fine
$4,545
2023-05-08
Fine
Fine · fine $4,545
Fine
$13,635
2023-04-17
Fine
Fine · fine $13,635
Fine
$4,545
2023-03-20
Fine
Fine · fine $4,545
Fine
Ownership
Forrister, Karen
5% Or Greater Direct Ownership Interest · Individual
Lemcke, David
5% Or Greater Direct Ownership Interest · Individual
Forrister, Karen
Operational/Managerial Control · Individual
Forrister, Karen
Corporate Officer · Individual
Lemcke, David
Corporate Officer · Individual
Peach Health Group LLC
Operational/Managerial Control · Organization
Siddall, Brian
Contracted Managing Employee · Individual
Tanner, Gail
Operational/Managerial Control · Individual
Tanner, Gail
W-2 Managing Employee · Individual
Nearby options
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Lumber City Care Center LLC
Lumber City, GA
3-star overall rating with 3-star inspections with 8 recent health deficiencies
#2
Glenwood Health and Rehabilitation
Glenwood, GA
1-star overall rating with 2-star inspections with $7,901 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Heart Of Georgia Nursing Home
Eastman, GA
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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