01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2022-05-12 | 5 | 2022-05-12 | 0 |
| Cycle 2 | 2020-02-21 | 2 | 2020-02-21 | 2 |
| Cycle 3 | 2019-03-07 | 11 | 2019-03-07 | 2 |
CMS CCN 4454902026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Ave Maria Home
2805 Charles Bryan Rd · Bartlett, TN 38134 · Shelby County
Certified beds100CMS provider file
Recent citation rows22current CMS citation release
Penalty rows3current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
22 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2024-03-28 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-07-02 · complaint2022-05-12 · HEALTHF0640Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Correction field: Deficient, Provider has date of correction · 2022-06-102022-05-12 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2022-05-232022-05-12 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2022-05-232022-05-12 · HEALTHF0689Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2022-06-202022-05-12 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2022-06-032020-02-21 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2020-03-062020-02-21 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2020-03-062020-02-21 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2020-03-062020-02-21 · FIREK0524Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly.
Correction field: Deficient, Provider has date of correction · 2020-03-062019-03-07 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2019-04-152019-03-07 · HEALTHF0609Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2019-04-152019-03-07 · HEALTHF0610Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2019-04-152019-03-07 · HEALTHF0636Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Correction field: Deficient, Provider has date of correction · 2019-04-152019-03-07 · HEALTHF0732Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2019-04-152019-03-07 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2019-04-152019-03-07 · HEALTHF0770Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Provide timely, quality laboratory services/tests to meet the needs of residents.
Correction field: Deficient, Provider has date of correction · 2019-04-152019-03-07 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2019-04-152019-03-07 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2019-04-152019-03-07 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2019-04-152019-03-07 · FIREK0920Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2019-04-152019-03-07 · FIREK0923Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2019-04-1503 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-03-28 | Fine | $10,039 | 0 |
| 2024-03-28 | Fine | $17,882 | 0 |
| 2024-03-28 | Payment Denial | $0 | 94 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- JOHNSON, DANNYIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST34% · since 01/01/2019
- MCGRAW, WILLIAMIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST33% · since 01/01/2023
- O'TOOLE, JEANNIEIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST33% · since 01/01/2023
- JOHNSON, DANNYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2019
- MCGRAW, WILLIAMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2023
- O'TOOLE, JEANNIEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2023
- WILSON, EMMANUELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/26/2025
- HINES, ELBERTIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/13/2026
- WILSON, EMMANUELIndividual · ADP OF THE SNFNOT APPLICABLE · since 11/24/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours5.76per resident day
RN hours0.51per resident day
Weekend nurse hours5.13per resident day
Staff turnover—%CMS reported field
06 / LOCAL RECORDS
Open the Bartlett ledger →