Ave Maria Home
2805 Charles Bryan Rd, Bartlett, TN 38134 · Shelby County · 100 certified beds · avg 93 residents/day · certified since Jan 1, 2009
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Mar 28, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 2, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (18)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 28, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 12, 2022 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 12, 2022 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| May 12, 2022 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| May 12, 2022 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| May 12, 2022 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Feb 21, 2020 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Feb 21, 2020 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Mar 7, 2019 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 7, 2019 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Mar 7, 2019 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Mar 7, 2019 | E · Potential for harm, repeated | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Mar 7, 2019 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Mar 7, 2019 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 7, 2019 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Mar 7, 2019 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Mar 7, 2019 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| Mar 7, 2019 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 10 | 0 | F |
| 2020 | 2 | 0 | D |
| 2022 | 5 | 0 | E |
| 2024 | 1 | 1 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $27,921, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Mar 28, 2024 | Fine | $10,039 |
| Mar 28, 2024 | Fine | $17,882 |
| Mar 28, 2024 | Payment Denial | 94 days from Mar 30, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Tennessee avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 6.23 | 3.62 | 3.95 | top 2% in Tennessee; top 3% in the U.S. |
| Registered Nurse hours | 0.55 | 0.57 | 0.69 | top 42% in Tennessee; bottom 45% in the U.S. |
| Weekend total nurse staffing | 5.55 | 3.15 | 3.50 | top 2% in Tennessee; top 3% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.32 | 0.39 | 0.48 | bottom 44% in Tennessee; bottom 36% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 48.9 | 45.8 | — |
| RN turnover (%) | 0.0 | 43.2 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.76, RN 0.51, weekend 5.13. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 1/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Johnson, Danny | Individual | 5% or Greater Indirect Ownership Interest | 34% | 01/01/2019 |
| McGraw, William | Individual | 5% or Greater Indirect Ownership Interest | 33% | 01/01/2023 |
| O'Toole, Jeannie | Individual | 5% or Greater Indirect Ownership Interest | 33% | 01/01/2023 |
| Hines, Elbert | Individual | ADP of the SNF | NOT APPLICABLE | 05/13/2026 |
| Johnson, Danny | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2019 |
| McGraw, William | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2023 |
| O'Toole, Jeannie | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2023 |
| Wilson, Emmanuel | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/26/2025 |
| Wilson, Emmanuel | Individual | ADP of the SNF | NOT APPLICABLE | 11/24/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure resident assessments are completed and submitted to the state on time?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "How do you coordinate and monitor care for residents who receive dialysis?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Signature Healthcare of Memphis | 0.0 mi | Memphis, TN | ★★★★★ | 5/5 | |
| Spring Gate Rehab & Healthcare Center | 4.8 mi | Memphis, TN | ★☆☆☆☆ | 1/5 | SFF |
| Shelby Oaks Post Acute | 5.4 mi | Memphis, TN | ★☆☆☆☆ | 1/5 | abuse |
| Allen Morgan Health and Rehabilitation Center | 5.6 mi | Memphis, TN | ★★★★★ | 5/5 | |
| Highlands Health and Rehabilitation Center | 5.6 mi | Memphis, TN | ★★☆☆☆ | 2/5 | |
| Midtown Center for Health and Rehabilitation | 5.8 mi | Memphis, TN | ★★☆☆☆ | 3/5 | |
| Majestic Gardens at Memphis Rehab & SNC | 5.8 mi | Memphis, TN | ★☆☆☆☆ | 1/5 | SFF |
| Harborview Post Acute | 6.0 mi | Memphis, TN | ★★★☆☆ | 2/5 | |
| The Kings Daughters and Sons | 7.6 mi | Bartlett, TN | ★★☆☆☆ | 2/5 | |
| Rainbow Rehab and Healthcare | 7.6 mi | Bartlett, TN | ★★☆☆☆ | 2/5 | |
| Signature Healthcare of Primacy | 8.5 mi | Memphis, TN | ★★★★★ | 4/5 | |
| Quince Nursing and Rehabilitation Center | 8.5 mi | Memphis, TN | ★★☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 445490.