Kirby Pines Manor
Memphis, Tennessee · CCN 445189
10 surveys since 2011, and no finding has been recorded at harm level.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 48
- Surveys
- 10
- Harm or worse
- 0
- Immediate jeopardy
- 0
No finding on record has been cited at harm level or above.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 120
- Ownership
- Non profit - Corporation
- Chain
- Independent
- County
- Shelby
- Medicare-certified since
- 1986
CMS ratings
- Overall
- 5
- Health inspection
- 5
- Staffing
- 4
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Not shown for this facility: too few citations in window (n=2, floor 20).
Last survey on record
Jun 3, 2025
524 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.67 | 4.35 |
| Registered-nurse hours per resident day | 1.81 | — |
| Annual nurse turnover | 54.5% | 49.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D150.0% | E150.0% | F— |
| No harm, potential for minimal | A— | B— | C— |
In the surveyor’s words
From the most serious findings on record at Kirby Pines Manor, in the surveyor’s own words.
- No harm, potential for more than minimal, patternF880Jun 3, 2025
Based on policy review, review of the facility's Infection Control Program documents, and interview, the facility failed to establish and implement a program to identify, report, investigate and control infections and communicable diseases when the Infection Preventionist (IP)/Director of Nursing (DON) failed to track organisms being treated in the facility and monitor for outbreaks and cross contamination. This had the potential to affect 7 of 7 residents in the facility. The findings include: 1. […]
- No harm, potential for more than minimal, isolatedF698Jun 3, 2025
Based on policy review, medical record review, and interview, the facility failed to follow physician orders for the care and services of a dialysis fistula (a plastic device inserted into a vein or artery to deliver treatment for kidney failure), failed to provide documentation between the facility and the dialysis center, and failed to revise the care plan related to the care of a dialysis fistula for 1 of 1 (Resident #4) residents reviewed for dialysis. The findings include: 1.Review of the facility policy titled, End-Stage Renal Disease, Care of a Resident with, dated October 2010, revealed .Staff caring for resident with ESRD (End Stage Renal Disease) including residents receiving dialysis care outside facility, shall be trained in the care and special needs of these residents .The… […]
Read 20 findings in full →The most serious and the most recent: 20 of 48 on record.
Every survey on record
FindingsAt actual harm or above
- Jun 3, 2025Standard2 findings
- Jul 3, 2019Standard5 findings
- Sep 18, 2018Standard2 findings
- Jun 28, 2016Standard11 findings
- Jun 10, 2015Standard5 findings
- Mar 13, 2014Standard5 findings
- May 7, 2013—1 finding
- Dec 19, 2012—6 findings
Show the 2 earlier surveys
- Nov 15, 2012—2 findings
- Sep 21, 2011—9 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction