Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mcrae Manor Nursing Home during CMS and state inspections, most recent first.
Improper Food Labeling and Unsanitary Kitchen Storage: Surveyors observed raw and cooked foods in the cooler without open, expiration, or use-by dates, and multiple pantry items stored in containers and zip lock bags without expiration dates. A thick layer of dust was also observed on the kitchen AC vent filter, with dust on the adjacent wall and ceiling. The DM confirmed the findings and stated it was her responsibility to ensure items are stored and labeled properly.
Dumpster Area Not Kept Sanitary: Surveyors observed that the area around three dumpsters was not maintained in a sanitary condition. The dumpster area had a shower bed behind it, wooden flats leaning against the fence, and scattered trash items such as used cups, empty juice containers, and an empty chip bag. The DM confirmed the area needed to be decluttered and cleaned and stated she was responsible for monitoring the area for cleanliness to prevent pests.
Unsafe and unclean room conditions were observed in multiple resident rooms, including dirty PTAC filters, a broken outlet cover with exposed low-voltage wiring on a bed hand control, a bed foot that stuck when raised, and a missing window handle that allowed cold air into a resident room. The DON and Administrator stated staff should report repair needs when identified, and the Maintenance Director confirmed several of the issues during rounds.
Incomplete care planning and failure to follow ordered enteral feeding interventions: The facility did not include dementia in one resident's care plan despite a diagnosis and medication order for dementia, and did not fully implement another resident's G-tube feeding orders. An LPN administered enteral feeding but used 40 mL and 60 mL water flushes instead of the ordered 100 mL before and after the formula, while the resident's care plan identified the resident as at risk for dehydration.
An LPN did not follow the physician-ordered G-tube flush volumes for a resident with severe cognitive impairment and a CVA-related feeding tube. During an observed bolus feeding, the LPN flushed with 40 mL of water before the formula and 60 mL after, instead of the ordered 100 mL before and after; the DON stated nurses are to follow physician orders and care plan interventions.
Expired medications and unsecured medication storage were observed in multiple areas. The wound care cart was left unlocked and unattended, the 300 south hall medication room contained expired magnesium citrate, and medication carts on the 100 hall and 200 north hall had expired items, including hemoccult developer, Opticell, IV tubing, albuterol unit dose vials without an open date, and expired saline flush syringes. An insulin syringe was also left on top of an unattended medication cart, and the DON confirmed these conditions were unacceptable.
The facility failed to conduct proper assessments and obtain informed consent for bed rail use for four residents. Observations and interviews revealed that residents were using bed rails without documented assessments or consent forms. The ADON confirmed that the facility did not consider side rails as restraints and did not require consent, leading to a deficiency in regulatory compliance.
The facility failed to maintain a safe environment in the 200 hall, where observations revealed two defective handrails. One handrail was loose, and another had broken brackets. The Maintenance Director confirmed the lack of a schedule or policy for checking handrails, and the Administrator acknowledged the absence of written procedures. No residents were reported to have fallen due to these deficiencies.
The facility failed to maintain cleanliness and proper storage for ice machines and expired food items, affecting 74 residents. Ice scoops were improperly stored, and the ice machine was dirty. Staff interviews revealed confusion about cleaning responsibilities, and expired drinks were found in storage.
The facility failed to uphold dignity for two residents. A CNA was observed standing while feeding a resident with severe cognitive impairment, contrary to the facility's Dignity Policy. Additionally, another resident with an indwelling urinary catheter had their catheter bag exposed without a privacy cover, visible from the hallway. The ADON confirmed that catheter bags should always be covered, and it is the responsibility of CNAs and nurses to ensure this.
A resident with dementia and anxiety disorder was found with unsecured nasal spray bottles in their room, which were not listed in their medical records. The facility's policy requires medications to be stored securely, but the Assistant Director of Nursing confirmed the oversight and removed the medications. The resident had not been assessed for self-administration, and the facility does not conduct such evaluations.
A resident with intact cognition and multiple medical diagnoses did not receive scheduled showers, as documented in the facility's policy. Observations revealed the resident had dry flaky skin and was unsure of her shower schedule. The Bath Sheets Shower book lacked documentation of showers since March, and staff interviews indicated inconsistent documentation practices, attributed to recent leadership changes.
The facility failed to prevent accident hazards for two residents. One resident's oxygen cylinder was improperly placed on the floor, contrary to policy, while another resident had access to harmful chemicals left unsecured in their room and hallway. Staff confirmed these practices, acknowledging the risks posed to residents, particularly those with cognitive impairments.
A facility failed to obtain a physician's order for a resident with an indwelling urinary catheter, leading to a lack of documented care instructions in the MAR. Observations showed the catheter tubing was coiled around the bed frame, potentially obstructing urine flow. Interviews confirmed the oversight, with the ADON acknowledging the need for monthly order updates and specific catheter care instructions.
A facility failed to ensure a stop date for a PRN antipsychotic medication, quetiapine, for a resident with Alzheimer's and severe agitation, exceeding the 14-day limit. The oversight was confirmed by an LPN and ADON, who contacted the Medical Director to address the issue, but the order remained unchanged pending the physician's response.
A resident with an indwelling urinary catheter was observed multiple times with the catheter drainage tubing dragging on the floor, contrary to the facility's infection control policy. The resident, who has a history of intellectual disability and other medical conditions, was seen in a wheelchair with the tubing on the floor. Facility staff confirmed the improper practice, acknowledging the need to keep catheter parts off the floor to prevent infection.
Improper Food Labeling and Unsanitary Kitchen Storage
Penalty
Summary
Food was not properly labeled, dated, or stored under sanitary conditions in the kitchen. During a tour with the Dietary Manager, surveyors observed raw bacon, raw pork chops, cooked turkey, cooked cornbread, cooked dressing, cooked ham, and cooked pork in the cooler without open, expiration, or use-by dates. In the pantry, open pasta noodles, macaroni noodles, corn bread meal/batter, rice, and vanilla wafers were stored in containers and zip lock bags without expiration dates. Surveyors also observed a thick layer of dust on the air conditioner vent filter, with dust on the adjacent wall and ceiling in the kitchen. The Dietary Manager confirmed the concerns during the tour and stated it was her responsibility to ensure all items received and cooked are stored and labeled properly.
Dumpster Area Not Kept Sanitary
Penalty
Summary
Dispose of garbage and refuse properly was cited after surveyors observed that the facility failed to maintain the trash and garbage dumpster area in a sanitary manner for three of three dumpsters. A record review of the facility’s Home Trash Management Policy and Procedure showed that general waste and regulated medical waste are to be separated and handled according to specific regulations. During an observation with the Dietary Manager, the area outside adjacent to the building where the three dumpsters were located contained a shower bed behind the dumpster, wooden flats leaning against the fence, and scattered trash articles including used cups, empty juice containers, and an empty chip bag. The Dietary Manager confirmed that the area around the dumpsters needed to be decluttered and cleaned and stated that she was responsible for monitoring the dumpster area for cleanliness to prevent pests.
Unsafe and Unclean Resident Room Conditions
Penalty
Summary
The facility failed to ensure residents' living areas were safe, clean, comfortable, and homelike in 16 rooms across the 100, 200, and 300 halls. Observations identified dirty air filters in self-contained heating and air wall units (PTAC) in Rooms 104, 105, 107, 108, 109, 111, 112, 113, 208, 210, 211, 218, 226, 227, 229, and 303. During walking rounds, the Maintenance Director confirmed that the filters in Rooms 211, 226, 227, 229, and 303 were dirty and needed to be cleaned, and stated he was going to do a complete sweep of the building and clean all filters. In Room [ROOM NUMBER], a resident was observed with exposed low-voltage wiring on the bed hand control, a foot of the bed that got stuck when raised, and a broken outlet cover. The resident stated the electrical outlet had been broken for 6 months and that staff and maintenance were aware of the bed and outlet issues. A later observation confirmed the exposed wiring and unrepaired outlet remained. The Maintenance Supervisor confirmed the wiring was exposed, the bed foot did not function correctly, and the outlet cover was broken. In another room, cold air was observed coming through an opening created by a missing window handle, and the Maintenance Director confirmed the room was cool and was not aware of the missing handle.
Incomplete care planning and failure to follow ordered enteral feeding interventions
Penalty
Summary
The facility failed to develop and/or implement complete care plans for two residents reviewed for care planning. For one resident, the admission MDS dated 11/3/2025 documented a BIMS score of 15 and diagnoses including diabetes mellitus, hyperlipidemia, and non-Alzheimer's dementia, and the physician ordered Donepezil 10 mg at bedtime for dementia. The resident's care plan dated 10/6/2025 did not include a care plan problem or interventions for dementia. The MDS Coordinator stated that all residents have a comprehensive care plan completed within 14 days of coming to the facility and that care plans are updated quarterly, and the DON stated that residents with a diagnosis of dementia should be care planned for that diagnosis. For another resident, the admission MDS dated 9/29/2025 documented a BIMS score of 00 and diagnoses including anemia, atrial fibrillation, hypertension, and cerebrovascular accident. The resident's care plan dated 9/23/2025 addressed a feeding tube for a diagnosis of nontraumatic cerebrovascular accident and stated the resident was at risk for dehydration due to having a G-tube, with orders to receive G-tube feedings and flushes as ordered. During an observation of the enteral feeding process, an LPN checked placement and residual, then flushed with 40 mL of water before administering one can of Jevity 1.5 and flushed with 60 mL after the feeding. The LPN confirmed she did not flush with the ordered 100 mL of water before and after the formula, and the DON stated nurses should follow the interventions on the care plan and the physician orders.
Failure to Follow Ordered G-Tube Flush Volumes
Penalty
Summary
R12, a resident with severe cognitive impairment (BIMS score of 00) and diagnoses including anemia, atrial fibrillation, hypertension, and cerebrovascular accident, had a feeding tube in place for nutrition related to the CVA. The care plan directed staff to provide feeding and flushes as ordered, and the physician order dated 10/28/2025 specified Jevity 1.5 cal/fiber one can via G-tube six times daily with 100 cc of water before and after feeding. During an observed enteral feeding on 12/3/2025, an LPN checked tube placement and residual, then flushed the tube with 40 mL of water before administering one can of Jevity 1.5 and 60 mL of water afterward. In a concurrent interview, the LPN confirmed she did not flush with the ordered 100 mL of water before and after the formula. The DON later stated that nurses are to follow physician orders and care plan interventions.
Medication Storage and Cart Security Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently stored and labeled in accordance with facility policy and accepted professional principles. During observation, the wound care cart was found unlocked and unattended, and the WCN confirmed it was unlocked both times it was observed. The DON also confirmed that the wound cart should be locked when not in use. In the medication room on the 300 south hall, three bottles of magnesium citrate were found expired on 10/13/2025, and the DON confirmed the items were expired. The Central Supplier stated she stocks the medication rooms, checks expiration dates, and moves older items to the front, but expired stock is given to the Unit Manager. Additional observations found expired and improperly stored items on medication carts. The 100 hall medication cart contained two containers of hemoccult developer, one package of Opticell, and three sets of IV tubing that were all expired, and the RN confirmed the items were expired. The 200 north hall medication cart contained albuterol unit dose vials without an open date and saline flush syringes that expired on 12/1/2025, and the LPN confirmed the items were expired. An insulin syringe was also observed on top of the 100 hall medication cart while it was unattended, and the RN confirmed it should not have been left there. The DON confirmed it was unacceptable to have expired medications, medications with missing open dates, and medications left unattended on medication carts, and stated nurses should check the carts daily, every shift.
Deficiency in Bed Rail Assessment and Consent
Penalty
Summary
The facility failed to adhere to regulatory requirements regarding the use of bed rails for residents, as evidenced by the lack of appropriate assessments, informed consent, and consideration of alternatives. Observations and interviews revealed that four residents were using bed rails without documented assessments or consent forms. The Assistant Director of Nursing (ADON) confirmed that the facility did not conduct side rail assessments, as they did not consider them restraints, and no consent was obtained from residents. Resident 60 was observed using full side rails on a bariatric bed without any documented assessment or consent. Despite having no cognitive impairment, as indicated by a Brief Interview Mental Status Score (BIMS) of 15, the resident was fully dependent on staff for activities of daily living, except for eating. The resident reported using the bed rails for support during repositioning and care. Similarly, Resident 1, who also had intact cognition, requested full bed rails but lacked a documented assessment. The resident expressed satisfaction with the bed rails and indicated they were necessary for daily use. Resident 14, who was nonverbal but alert, was observed with bed rails up on both sides of the bed, yet no assessment was completed. Lastly, Resident 66, with a BIMS score of 14, used half bed rails for repositioning during care, but again, no assessment was documented. The facility's failure to conduct proper assessments and obtain informed consent for bed rail use was confirmed during interviews with staff, including the ADON and Maintenance Director.
Defective Handrails in Facility Hallway
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in one of its hallways, specifically the 200 hall. Observations on consecutive days revealed two defective handrails between certain rooms on the 200 South section. One handrail was pulling away from the wall due to loosened posts, and another had broken brackets. These deficiencies were confirmed during a walkthrough with the Administrator and Maintenance Director, who began repairs immediately. Interviews with the Maintenance Director revealed that there was no existing schedule or policy for checking the handrails, and maintenance was typically performed based on work tickets. The Administrator also confirmed the lack of written procedures for monitoring the handrails, although she expected the Maintenance Director to do so. Despite the deficiencies, there was no evidence that any residents had experienced a fall due to the loose and broken handrails.
Deficiencies in Ice Machine Maintenance and Food Storage
Penalty
Summary
The facility failed to maintain cleanliness and proper storage practices for ice machines and expired food items, potentially affecting 74 out of 76 residents on an oral diet. Observations revealed that the ice machine in the dining room had an ice scoop resting in the ice, contrary to the facility's policy, which requires the scoop to be stored in a designated container. Additionally, the ice machine in the nourishment prep room was found with a dirty frame and an ice scoop resting in the ice. Interviews with staff, including the Dietary Manager, Certified Nursing Assistant, and Dietary Aid, confirmed the improper storage of ice scoops and uncertainty about the responsibility for cleaning the ice machine. The facility's policy mandates monthly cleaning of ice dispensers and daily cleaning of ice scoops, but these practices were not followed. The Dietary Manager confirmed expired thickening lemon-flavored water drinks in the dry storage room, indicating a lapse in monitoring expiration dates. The Maintenance Director stated that the ice machine should be deep cleaned every six months, but there was confusion about daily cleaning responsibilities. The Dietary Manager and staff were unsure who was responsible for maintaining the ice machine's cleanliness, highlighting a lack of clarity in roles and responsibilities regarding equipment maintenance.
Dignity Concerns: Improper Feeding and Lack of Privacy
Penalty
Summary
The facility failed to ensure dignity for two residents, as observed during a survey. For one resident with severe cognitive impairment, a CNA was observed standing while assisting the resident with eating, which is against the facility's Dignity Policy. The CNA admitted to being unaware that standing while feeding a resident was inappropriate and had not received training to sit at eye level with residents during meals. The ADON and LPN confirmed that this practice was a dignity concern and could pose a choking hazard. Another resident, who had an intact cognitive status and an indwelling urinary catheter, was observed without a privacy bag covering the catheter drainage bag, which was visible from the hallway. The ADON confirmed that the facility's policy requires catheter bags to be covered with privacy bags, and it is the responsibility of CNAs and nurses to ensure compliance. The lack of privacy bag was confirmed by an LPN during the survey.
Unsecured Medications Found in Resident's Room
Penalty
Summary
The facility failed to ensure that a resident, identified as R23, did not have unsecured medications stored at the bedside, which could potentially allow unauthorized access to medications by other residents and visitors. The facility's policy on administering medications clearly states that drugs should be returned to the medication cart or room and never left in a resident's room. However, during an observation, two bottles of Equate Nasal Spray were found in R23's room, one on a dresser and another on a bookshelf, both within visual view. R23, who has diagnoses including dementia and anxiety disorder, was observed in bed at the time. The resident's medical records did not list an order for nasal spray, indicating that these medications were not prescribed or documented for R23. Interviews with the Administrator and the Assistant Director of Nursing (ADON) confirmed the presence of the medications in the resident's room, and the ADON removed them. The ADON was unaware of the origin of the nasal spray and acknowledged that medications left unsecured posed a risk to other residents. It was also confirmed that R23 had not been assessed for self-administration of medications, and the facility does not conduct self-administration evaluations. This oversight highlights a lapse in adherence to the facility's medication administration policy, as no residents in the facility had been assessed to self-administer medications.
Failure to Provide Scheduled Showers for a Resident
Penalty
Summary
The facility failed to ensure that Resident R44 received showers as scheduled, which is a deficiency in providing necessary assistance for activities of daily living. The facility's policy on Activities of Daily Living, last revised in March 2018, mandates that residents who cannot independently perform daily activities should receive services to maintain personal hygiene. However, R44, who has diagnoses including Hemiplegia, Hemiparesis, and a history of cerebral infarction, was observed with dry flaky skin and a dried substance around her mouth, indicating a lack of proper hygiene care. The resident, who has intact cognition as per the most recent Quarterly Minimum Data Set, expressed uncertainty about her shower schedule and stated she had not received a shower in a long time. The facility's documentation practices were found lacking, as the Bath Sheets Shower book did not reflect any recorded showers or baths for R44 since March 2024. Interviews with staff, including a CNA and the Assistant Director of Nursing, revealed that CNAs are not required to document showers unless a resident refuses, in which case the nurse is notified. The ADON acknowledged that bath sheets are not consistently placed in the bath book and attributed the lack of documentation to recent leadership changes. This lack of documentation and adherence to policy resulted in the failure to provide R44 with the necessary hygiene care.
Failure to Prevent Accident Hazards for Residents
Penalty
Summary
The facility failed to ensure that two residents were free from accident hazards, as observed during a survey. Resident 49, who has chronic obstructive pulmonary disease, hypertension, and atrial fibrillation, was found with an oxygen cylinder placed on the floor next to his wheelchair in a dining area. This was contrary to the facility's Oxygen Delivery Policy, which mandates that oxygen cylinders must be in a portable carrier or wheelchair holder and not placed on the floor. The resident reported that a staff member had removed the oxygen from the wheelchair holder and placed it on the floor, a routine practice before smoke breaks. Housekeeping staff confirmed observing the oxygen on the floor but were unaware of the associated risks. Another deficiency was noted with Resident 65, who has Alzheimer's disease, glaucoma, unspecified dementia with severe agitation, and other conditions. Harmful chemicals, including Micro Kill bleach, were found in the resident's bathroom and on a PPE cart outside the room. The facility's Chemical Safety and Storage policy requires chemicals to be stored in locked cabinets and not left in resident areas. The Housekeeper Supervisor and ADON confirmed the presence of these chemicals and acknowledged that leaving them accessible posed a risk to residents, especially those with cognitive impairments and a history of wandering. The ADON, who also serves as the Infection Control Preventionist, confirmed that the facility's policy does not allow for chemicals to be left outside resident doorways. The chemicals should be stored securely, either on the nurses' cart or in a designated secure place. The presence of these chemicals in accessible areas was attributed to a possible oversight by a Certified Nursing Assistant, and the facility acknowledged the risk of harmful ingestion by residents due to this oversight.
Failure to Obtain Physician's Order for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to obtain a physician's order for a resident, R62, who had an indwelling urinary catheter. This oversight was identified during a survey, revealing that the order for the catheter, including its size, balloon size, type, and change frequency, was not documented. Additionally, the Medication Administration Record (MAR) for several months did not include any instructions for the care and monitoring of the indwelling urinary catheter. This lack of documentation and oversight had the potential to compromise the resident's urinary health and increase the risk of urinary tract infections. Observations during the survey showed that the catheter tubing was coiled around the bed frame, which could obstruct urine flow. Interviews with the LPN and ADON confirmed that no order was in place until it was identified during the survey. The ADON acknowledged that the order should have been carried over each month and that the nursing staff were responsible for monitoring all orders. The absence of a specific order for catheter care and monitoring was noted, despite a general statement about urinary output being present in the February MAR.
Failure to Ensure Stop Date for PRN Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a stop date for the use of a PRN antipsychotic medication, quetiapine, was not over 14 days for a resident reviewed for unnecessary medications. The facility's policy on Medication Monitoring and Management specifies that PRN orders for antipsychotic medications should have a time limitation of 14 days. However, the medical record of a resident with multiple diagnoses, including Alzheimer's Disease and severe agitation, showed a PRN order for quetiapine with a start date of 3/6/2024, and the medication was last administered on 7/1/2024, exceeding the 14-day limit. During an interview, both a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON) confirmed the oversight in ensuring a stop date for the quetiapine order. The LPN reported contacting the Medical Director after being instructed by the ADON to address the issue. The ADON noticed the PRN medication order during a review of the resident's record and instructed the nurse to contact the Medical Director, but the order had not been changed at the time of the interview due to awaiting the physician's response.
Infection Control Deficiency: Catheter Bag Dragging on Floor
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by the observation of an indwelling urinary catheter bag dragging on the floor for a resident. The facility's policy on the maintenance of indwelling urinary catheters emphasizes the importance of maintaining good hygiene to reduce infection risks. However, during multiple observations on the same day, the resident was seen with the catheter drainage tubing on the floor while sitting in a wheelchair and propelling herself through the halls. The resident involved had a medical history that included intellectual disability, a colostomy, peritoneal debridement, and vulva cancer. The resident's cognitive assessment indicated mildly impaired cognition. Interviews with the Assistant Director of Nursing and the Unit Manager confirmed the improper positioning of the catheter tubing and acknowledged that it should not touch the floor to prevent infection.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mc Rae
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woods At Lumber City Of Journey Llc, The | 12.7 mi | ★★★★★ | 8 | 0 |
| Glenwood Health And Rehabilitation | 15.7 mi | ★★★★★ | 22 | 0 |
| Heart Of Georgia Nursing Home | 18.4 mi | ★★★★★ | 7 | 0 |
| Eastman Trails Of Journey Llc | 19.4 mi | ★★★★★ | 11 | 0 |
| Hazelhurst Court Care And Rehabilitation Center | 22.1 mi | ★★★★★ | 14 | 3 |
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