Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Kirby Pines Manor during CMS and state inspections, most recent first.
The facility did not track specific organisms in its infection control program, as required by policy. The IP/DON confirmed that organism tracking was not performed, and infection control documents lacked this information. This failure affected all residents by limiting the facility's ability to identify, report, and control infections.
A resident with end-stage renal disease requiring hemodialysis did not receive consistent monitoring of their dialysis fistula as ordered by the physician, with documentation missing for most days over a month. Staff were unable to provide records of required communication with the dialysis center, and the care plan was not updated to reflect current orders. Interviews revealed staff were not consistently performing or documenting the required assessments.
Failure to Track Infectious Organisms in Infection Control Program
Penalty
Summary
The facility failed to establish and implement an effective infection prevention and control program as required by its own policies and procedures. Specifically, the Infection Preventionist/Director of Nursing (IP/DON) did not track the specific organisms being treated within the facility, nor did she monitor for outbreaks or cross-contamination. Policy documents reviewed indicated that surveillance should include identification of epidemiologically significant organisms, collection of data such as resident name, room number, unit, date of onset, infection site, and pathogens. However, infection control monitoring documents for several months did not include documentation of the organisms being tracked. During an interview, the IP/DON confirmed that she does not track organisms in the infection control program and was unable to provide documentation that such tracking was occurring. This lack of organism tracking and monitoring for outbreaks had the potential to affect all seven residents in the facility, as it hindered the facility's ability to identify, report, investigate, and control infections and communicable diseases as outlined in their policies.
Failure to Follow Physician Orders and Document Dialysis Fistula Care
Penalty
Summary
The facility failed to follow physician orders and established policies regarding the care and monitoring of a dialysis fistula for a resident with end-stage renal disease who was dependent on hemodialysis. Specifically, staff did not consistently document daily monitoring of the fistula for thrill as ordered by the physician and outlined in the care plan. Documentation showed that the required assessment was only recorded on five occasions over a 33-day period, leaving 28 days without evidence of compliance. Additionally, the Medication Administration Record and Treatment Administration Record for the relevant months did not contain documentation of the required monitoring. The facility also failed to maintain and provide records of communication between the facility and the dialysis center, despite staff stating that a cover sheet with vital signs and other information was sent with the resident. Interviews with staff revealed a lack of awareness and adherence to the care plan requirements, with one LPN stating that they did not check the thrill as required. The Director of Nursing confirmed that the care plan should have been updated to reflect current physician orders and was unable to provide documentation of communication with the dialysis center.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 172 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Memphis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Signature Healthcare Of Primacy | 2.8 mi | ★★★★★ | 7 | 0 |
| Quince Nursing And Rehabilitation Center | 2.8 mi | ★★★★★ | 19 | 0 |
| Waters Of Memphis A Rehabilitation & Nursing Ctr | 2.8 mi | ★★★★★ | 1 | 0 |
| The Village At Germantown | 4.1 mi | ★★★★★ | 11 | 1 |
| Delta Blues Health & Rehabilitation | 4.4 mi | ★★★★★ | 7 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.