Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Monroe Health And Rehabilitation Center during CMS and state inspections, most recent first.
Kitchen equipment and the walk-in freezer were found unsanitary during an observation with the CDM. Five dish scoops had dried food debris, along with a saute/fry pan and a deep pan with dried food particles, and both the CDM and ADM confirmed the items had not been cleaned and sanitized correctly. In the walk-in freezer, frozen biscuits, unused thermometers, and scattered peas were found on the floor under the storage rack, and the CDM confirmed the loose items had not been removed and the freezer had not been cleaned properly.
The facility failed to maintain a clean and sanitary environment in multiple resident rooms and bathrooms, despite policies requiring routine cleaning and disinfection. Observations over several days found a motorized wheelchair and another wheelchair with attached cushion soiled with dried, multi-colored debris. Several resident bathrooms had unclean conditions, including a trash can without a liner and with dried brown residue, toilets with dried yellow residue on the seats, and yellow/orange or brown substances around the bases of multiple toilets. During an on-site check, the Administrator confirmed that the residue around one toilet could be wiped away and that the area was not clean.
The facility failed to maintain accurate and complete medical records for three residents, including one with a history of falls and moderate cognitive impairment whose documented fall and associated evaluations were not accurately reflected in the medical record. Two other residents with diabetes and multiple comorbidities had physician orders for medications such as lacosamide, levothyroxine, sliding-scale insulin, and metoclopramide, but the MAR contained blanks where administration or required blood glucose values should have been recorded. The DON confirmed that medications must be documented when given or withheld, and that blank MAR entries indicated missing documentation, demonstrating noncompliance with the facility’s fall documentation and medication administration policies.
Failure to Report Alleged Verbal Abuse: A resident with dementia, severe cognitive impairment, prior stroke, and COPD was involved in an allegation that a CNA used profanity and yelled at the resident during care. An LPN was notified and informed the Administrator and DON, but the DON said the resident denied the incident and the facility did not treat it as abuse. The allegation was not reported to the State Agency, and there was no documentation of an investigation.
Failure to investigate alleged verbal abuse involving a resident with dementia. A CNA reportedly used profanity and yelled at the resident during care of the resident’s roommate, and another CNA reported the incident to an LPN, who notified the DON and Administrator. Although the resident denied the incident when asked, the facility did not document a full abuse investigation, did not report the allegation to the State Agency or other required entities, and had no investigation record in the file.
Medication administration rights were not followed for a resident with HTN and an intact BIMS score. MAR documentation showed lisinopril 10 mg was signed as given daily, but pharmacy and AMDS records showed only limited 10 mg supply and that 40 mg tablets were the medication available on the cart. During observation, an RN initially pulled a 40 mg card before obtaining the correct 10 mg dose from the AMDS, and MAs stated they may have given the medication from the card without properly checking the MAR and label.
Respiratory Care Deficiencies With Oxygen Orders, Storage, and Flow Rate: A resident receiving O2 had no physician order in place for a period of time, no O2 warning sign posted, and tubing that was left uncovered and not stored in a bag when not in use; staff also could not confirm when the tubing had last been changed. Another resident’s nasal cannula was likewise left open to air without proper storage, and a third resident was observed receiving O2 at 3 L/min when the physician order was for 2 L/min. The DON confirmed the ordered flow rate was not being followed.
A resident with ESRD on hemodialysis had incomplete dialysis-related physician orders that did not identify the access type/location, dialysis clinic or schedule, nephrologist contact, transportation, or medication instructions. The care plan listed the wrong dialysis days and access site, and the MAR showed several ordered meds and a nutritional supplement were not given when the resident was out for dialysis; the DON confirmed the orders, care plan, and med schedule were not aligned with the resident’s dialysis routine.
A resident with HTN and other diagnoses had multiple lisinopril order changes, but the pharmacy sent 40 mg tablets when 10 mg was ordered. During med pass, an RN found the cart card labeled 40 mg while the MAR showed 10 mg and had to obtain the correct dose from the AMDS. The Pharmacy Director confirmed the wrong strength was delivered.
A resident with aphasia, COPD, chronic pain, diabetes, and tobacco use had documented dental pain and was found to need multiple extractions and other oral surgery, with a large upfront cost required before treatment. The facility did not accurately reflect the resident’s dentition on MDS, did not include the dental issues in the care plan, and did not assist the resident or family with alternate funding sources or other options after the family said they could not pay.
A resident with severe cognitive impairment and a history of verbal behaviors was involved in multiple altercations with other residents, resulting in physical abuse incidents. Despite having a care plan with interventions for physical behaviors, the facility failed to prevent these interactions, leading to slapping and grabbing incidents involving three other residents. The facility's policy on abuse was not effectively enforced, as staff intervened only after the incidents occurred.
Kitchen Equipment and Freezer Sanitation Lapses
Penalty
Summary
The facility failed to clean and store kitchen equipment in accordance with its sanitation policies. During an observation with the Certified Dietary Manager, 5 dish scoops were found with dried and crusted food particles under the mechanical blade and in the metal bowl, along with 1 saute/fry pan with dried beef and dried particles on the pan and 1 full deep pan with dried food particles on the inside. The Certified Dietary Manager and Assistant Dietary Manager confirmed the scoops, pan, and deep pan had not been cleaned and sanitized correctly and were ready and available for use. The facility also failed to maintain the walk-in freezer in a sanitary condition. During an observation with the Certified Dietary Manager, 4 frozen biscuits, 2 thermometers not in use, and scattered frozen peas were found on the floor under the bottom shelf of the food storage rack in the walk-in freezer. The Certified Dietary Manager confirmed the loose food items had not been removed, the thermometers were not to be placed on the floor out of view, and the freezer had not been cleaned properly.
Failure to Maintain Clean and Sanitary Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and sanitary environment in multiple resident rooms and bathrooms, contrary to its own policies on routine bathroom cleaning and routine cleaning and disinfection. The facility’s policies, dated 6/2025, required providing a clean and sanitary environment, cleaning the entire toilet including the handle and underside of the flush rim with disinfectant and appropriate contact time, and reporting damaged items in need of repair. Observations conducted on several days showed that in one room, a motorized wheelchair had dried debris on the cushion, arms, and a large amount of multi-colored debris on the undercarriage. In another room, a wheelchair with a fabric heel protector cushion used as an armrest was spattered with small to pea-sized unknown multi-colored particles. Additional observations revealed that several resident bathrooms were not maintained in a sanitary condition. One bathroom had a trash can without a bag and with a dried brown substance on the outside, rim, and inside of the can, as well as a toilet seat with two areas of dried yellow residue and a yellow/orange substance around the base of the toilet. Other bathrooms in different rooms had yellow/orange or brown residue around or at the front base of the toilets. During an observation and interview in one of the bathrooms, the Administrator initially suggested the substance around the toilets might be related to the wax ring, but after wiping a small area with a wet wipe, the yellow/orange substance was easily removed, and the Administrator confirmed the area around the toilet was not clean.
Failure to Maintain Accurate and Complete Medical Records for Falls and Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with its own policies and accepted professional standards for three residents. The facility’s Fall Prevention Program policy, revised 10/01/2025, required that when any resident experiences a fall, staff must document all evaluations, assessments, and actions taken. For a resident with a history of falls, moderate cognitive impairment, and care plan problems including an ADL self-care performance deficit related to stroke and risk for falls, there was a documented fall on 10/3/2025 at 5:30 PM in a Fall Scene Investigation Report and an unwitnessed fall with head injury record. However, the DON stated that the medical record documentation for this resident was not accurate and did not reflect the fall event. The facility’s Medication Administration policy required staff to review the MAR to identify medications to be administered, remove medications from the source, administer them as ordered, and sign the MAR after administration. For a resident with COPD, diabetes mellitus, end stage renal disease, and dependence on hemodialysis, whose care plan included diabetes management and who was cognitively intact per MDS, multiple physician orders were not accurately or completely documented on the MAR. Lacosamide ordered to be given in the evening after hemodialysis on specific days showed no documentation of administration on one date. Levothyroxine ordered once daily had no documentation of administration on a morning dose. A sliding-scale insulin lispro order requiring blood glucose checks every six hours had no documented blood glucose levels at several scheduled times, and metoclopramide ordered before meals for nausea had no documentation of administration at multiple scheduled times. Another resident with type 1 diabetes mellitus with chronic kidney disease, history of stroke, and congestive heart failure, whose care plan also included diabetes management and who had moderate cognitive impairment per MDS, had a physician’s order for sliding-scale insulin lispro to be given three times a day on specified days. The MAR for this resident lacked documentation of the blood glucose level needed to determine the insulin dose at a scheduled time. During an interview, the DON confirmed that medications should be documented on the MAR when administered or withheld, including the reason for holding a medication, and acknowledged that blanks on the MAR for the two residents meant those scheduled medication doses were not documented, further supporting that the medical records were incomplete and inaccurate.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the State Designated Authority for one resident with dementia, severe cognitive impairment, and a history of stroke with right hemiparesis and COPD. The resident’s care plan identified impaired thought processes related to dementia and other cerebrovascular disease. During an interview, a CNA described that while she and another CNA were assisting the resident’s roommate, the other CNA yelled at the resident, used profanity, and told the resident to shut up and not tell her what to do. The CNA reported the incident to an LPN, who then notified the Administrator and DON. The LPN stated she relayed the allegation, obtained written statements, and escorted the accused CNA off the premises as directed. However, the DON stated the resident denied the incident when questioned, and the facility therefore did not consider it abuse. The DON also stated there was no documentation of an investigation, and the Administrator confirmed the allegation had not been reported to the State Agency or other required entities. The HR file did not contain documentation of the incident, the CNA being sent home, or the decision not to schedule the CNA again.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure an allegation of verbal abuse was investigated for Resident #37, a resident with dementia, a history of stroke with right hemiparesis, and COPD. The resident’s MDS showed a BIMS score of 8, indicating severe cognitive impairment, and the care plan identified impaired thought processes related to dementia and other cerebrovascular disease. Facility policy required immediate investigation of alleged abuse, including interviewing involved persons and documenting the investigation, but the report states this did not occur. According to staff interviews, CNA D reported that while she and CNA C were caring for Resident #37’s roommate, Resident #37 yelled at them and CNA C responded with profanity, including telling the resident to “shut the f--- up,” “don’t tell me what to do,” and other vulgar statements. CNA D said she reported the incident to an LPN, who then notified the Administrator and DON. The LPN obtained written statements and escorted CNA C off the premises as directed, but the DON later stated the resident denied the incident when questioned and the facility therefore did not consider it abuse. The DON and Administrator confirmed there was no documentation of an investigation, the incident was not reported to the State Agency or other required entities, and the HR file lacked documentation of the alleged abuse incident or related actions.
Medication Administration Rights Not Followed for Lisinopril
Penalty
Summary
The facility failed to ensure the basic rights of medication administration were followed for one resident with hypertension, polyneuropathy, and alcohol use with withdrawal. The resident was cognitively intact with a BIMS score of 14 and had physician orders for lisinopril that changed over time, including an order for lisinopril 10 mg daily with blood pressure parameters and a later order for lisinopril 10 mg daily without parameters. Review of pharmacy delivery records showed the pharmacy sent lisinopril 40 mg tablets on multiple occasions and only 4 tablets of lisinopril 10 mg. Review of the AMDS transaction report showed no lisinopril doses were retrieved from the AMDS for the resident until 2/24/2026 by RN D. However, the MAR for 2/1/2026 through 2/28/2026 showed lisinopril 10 mg daily was signed as administered each day, primarily by MA A and MA B. During observation, RN D initially retrieved a card labeled lisinopril 40 mg from the medication cart while preparing the resident’s morning medication and then obtained the correct 10 mg dose from the AMDS. In interviews, MA B and MA A stated they gave the resident medication from the card on the cart and acknowledged they may not have checked the MAR and medication card label against the order before administration. The DON confirmed the expectation was to verify the MAR against the medication card to ensure the correct medication and dosage, and confirmed the standard of practice for the rights of medication administration was not followed.
Respiratory Care Deficiencies With Oxygen Orders, Storage, and Flow Rate
Penalty
Summary
Safe and appropriate respiratory care was not provided for multiple residents receiving oxygen therapy. For Resident #61, the medical record showed diagnoses including acute respiratory failure with hypoxia, COPD, and heart failure, and therapy documentation reflected oxygen use at 2 liters via nasal cannula. However, the record contained no physician order for oxygen administration until 2/24/2026, even though staff and the resident reported he had been using oxygen for weeks and mostly at night. During observations, his oxygen concentrator was at the bedside with tubing lying uncovered and open to air, there was no storage bag available, and no oxygen warning sign was posted outside the room. The resident stated he had not been educated on storing the tubing when not in use, and RN A confirmed the tubing was not stored appropriately and that she was unaware of the oxygen order until reviewing the chart. Resident #61 also had tubing that was not documented as changed timely. RN A stated oxygen tubing was to be changed every 2 weeks and documented on the TAR, while the DON later stated tubing was to be changed every 7 days and as needed. The DON confirmed there was no documentation showing when the tubing had last been changed because it was not dated and there had been no order for oxygen initiation to appear on the TAR. Observations on multiple occasions showed the tubing lying on the bed or bedside table uncovered and open to air, and the resident was observed smoking without oxygen on during facility smoking time. For Resident #41, the physician ordered oxygen at 2 liters per minute via nasal cannula continuously, and the care plan noted the resident preferred to use oxygen at night only. Observations showed the oxygen concentrator at the bedside with the nasal cannula lying uncovered and open to air, and there was no bag in the room to store the tubing when not in use. The resident stated staff had not provided education or a plastic bag for storage. For Resident #5, the physician ordered oxygen at 2 liters per minute via nasal cannula every shift, but an observation showed the resident receiving oxygen at 3 liters per minute. The DON confirmed the resident’s oxygen was not set at the prescribed rate.
Dialysis Orders, Care Plan, and Medication Timing Were Inconsistent
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not ensured for Resident #5, who was admitted with COPD, DM, ESRD, and dependence on hemodialysis. The facility policy required dialysis-related physician orders to include the type and location of access, dialysis schedule, nephrologist contact information, transportation arrangements, and medication instructions. However, the resident’s current orders did not include the access type and location, the dialysis clinic or schedule, the nephrologist’s name and phone number, transportation arrangements, or an order to adjust medications on dialysis days. The care plan also listed dialysis on Tuesday, Thursday, and Saturday, which did not match the physician orders showing Monday, Wednesday, and Friday. Observation and interview showed the resident was transported out for dialysis on Monday, Wednesday, and Friday, and later was observed with a dialysis catheter in the left chest with a dressing in place. Review of the MAR for February 2026 showed multiple ordered medications and a nutritional supplement were held or not given when the resident was out of the facility for dialysis, including house shake, metoclopramide, guaifenesin, and insulin lispro. The DON confirmed the resident did not have the physician orders required by facility policy, the dialysis care plan was incorrect for dialysis days and access site, and the medication schedule had not been adjusted for the resident’s time out at the dialysis clinic.
Pharmacy Sent Incorrect Lisinopril Dose
Penalty
Summary
The facility failed to ensure pharmacy services provided an accurate physician-prescribed medication for one resident, who had diagnoses including hypertension, polyneuropathy, and alcohol use with withdrawal. The resident’s care plan identified altered cardiovascular status related to hypertension, and the admission MDS showed a BIMS score of 14, indicating the resident was cognitively intact. The pharmacy services agreement required the pharmacy to maintain accurate drug profiles consistent with information provided by the facility. Review of the resident’s orders showed multiple changes to lisinopril, including a transition from 40 mg to 10 mg with blood pressure parameters and later a 10 mg daily order without parameters. However, the pharmacy delivery manifests showed lisinopril 40 mg was sent to the facility on 1/26/2026 instead of the ordered lisinopril 10 mg. During medication administration observation, the RN initially retrieved a lisinopril card from the medication cart labeled 40 mg while the MAR read 10 mg, and then obtained the correct 10 mg dose from the AMDS. The Pharmacy Director confirmed that the 40 mg medication had been sent instead of the ordered 10 mg dose.
Failure to Assess and Arrange Dental Care
Penalty
Summary
The facility failed to accurately assess the dental status of a resident and failed to assist in obtaining alternate funding sources or delivery systems to meet the resident’s dental needs. The resident had a history of stroke with aphasia, COPD, chronic pain syndrome, and diabetes, and was documented as cognitively intact on MDS assessments. The record showed a dental referral for mouth pain, followed by a dental evaluation that identified the need for multiple fillings, extractions, and debridement, with later documentation showing the resident required 13 simple extractions, 3 surgical extractions, and alveoplasty with an estimated cost of $5,780.00, including $1,855.00 due at the time of surgery. The resident’s record showed no further dental visits after the oral surgery appointment, and the facility did not document assistance with alternate funding or other delivery options after the resident’s mother stated she could not pay the upfront fee. The resident was observed by the surveyor with darkened or decayed teeth and broken or chipped areas throughout the mouth, and the resident stated he had difficulty chewing but wanted the recommended extractions. The annual MDS was inaccurate for dentition, and the care plan did not include the resident’s dental issues or need for extractions, despite documentation that the resident used tobacco and required oral care assistance.
Failure to Prevent Resident Abuse by Another Resident
Penalty
Summary
The facility failed to prevent abuse for three residents, resulting in incidents involving Resident #2, who was involved in altercations with Residents #3, #4, and #5. Resident #2, who had severe cognitive impairment and a history of verbal behaviors, slapped Resident #4 and Resident #3 on separate occasions and grabbed Resident #5's arm. These incidents occurred over a span of five days, during which Resident #2 was not adequately supervised to prevent these interactions. Resident #2 was admitted with multiple diagnoses, including unspecified dementia with behaviors, and had a care plan that included interventions for physical behaviors. Despite this, the facility did not effectively implement measures to prevent Resident #2 from physically interacting with other residents. The facility's policy on abuse, neglect, and exploitation was not adequately enforced, as evidenced by the repeated incidents involving Resident #2. The facility's investigation documentation and interviews revealed that staff were aware of Resident #2's behaviors but failed to prevent the altercations. The Director of Nursing confirmed that Resident #2's aggression was unprovoked and that the facility did not prevent the abuse of the other residents. The incidents were witnessed by staff, who intervened after the fact, but the lack of proactive measures to prevent these interactions highlights the deficiency in protecting residents from abuse.
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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 Madisonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Sweetwater A Rehabilitation & Nursing | 8.1 mi | ★★★★★ | 0 | 0 |
| Wood Village | 8.3 mi | ★★★★★ | 0 | 0 |
| Starr Regional Health & Rehabilitation | 12.6 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Athens | 13.1 mi | ★★★★★ | 12 | 1 |
| Nhc Healthcare, Athens | 13.8 mi | ★★★★★ | 0 | 0 |
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