Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Madisonville during CMS and state inspections, most recent first.
Expired meds were found in three medication carts, including Artificial Tears eye drops in the A hall cart, Vitamin B-Complex tablets in the B hall cart, and Diclofenac Sodium Topical Gel in the A/D hall nurses’ cart. MA A, an LVN, the DON, and the Administrator all stated staff responsible for the carts were also responsible for checking for expired meds, and the DON said the pharmacist monitored the carts monthly for expired meds and supplies.
Expired Hypodermic Needles Stored in Medication Room: During an observation in the med storage room, multiple expired hypodermic needles were found, including several 21, 22, and 25 gauge needles with expired dates. Staff interviews identified the DON, nurses, medication aides, and pharmacist as responsible for checking for expired supplies, and the facility policy stated outdated items are to be handled through the dispensing pharmacy and discarded per manufacturer expiration dates.
A resident’s PASARR Level I screening incorrectly marked mental illness as absent despite documented depression, hallucinations, psychotic disorder, and delusional behavior in the chart. The DON, MDS Coordinator/LVN, and SW acknowledged the screening was not coded correctly and that the resident may have benefited from PASARR services. The resident was also noted to have intact cognition, sleep issues, and ongoing therapy involvement.
Care plans for two residents did not match the ADL assistance documented on the MDS. One resident had severe cognitive impairment and required extensive help with hygiene, dressing, toileting, and eating, while another resident with intact cognition required substantial/maximal assistance with several ADLs and supervision with eating. Staff stated the care plans were too general and did not specify the exact care needed, even though the ADL details were available on the Kardex.
The facility failed to ensure the IDT reviewed and revised comprehensive care plans after assessments for two residents. One resident with PTSD, schizoaffective disorder, bipolar type, and Alzheimer's disease had a care plan that did not include PTSD triggers, goals, or interventions, and the resident stated no one had asked about triggers. Another resident with cognitive impairment, CVA, and depression was on an in-room activity program, but the care plan was not updated to reflect current activity preferences. The MDS Coordinator, Activity Director, and DON acknowledged the missing care plan updates.
Failure to provide nail care for two dependent residents. Two residents who required substantial to maximal assistance with ADLs were observed with blackish/brownish substance under their fingernails. The LVN, CNA, and DON stated CNAs were responsible for nail care, usually on shower days and as needed, and that nail issues or refusals should be reported and documented. The facility policy required residents unable to perform ADLs independently to receive services needed to maintain grooming and personal hygiene.
Failure to Provide Planned In-Room Activities: Two residents with significant cognitive and physical limitations were identified for 1:1 in-room activity support based on their care plans and preferences, but activity records showed no in-room activities were provided over the review period. One resident with dementia and bed confinement stated he wanted staff to visit and talk with him several times per week, while the other resident with CVA, depression, and worsening cognition was observed in bed watching TV and was not interviewable. The Activity Director acknowledged the missed activity provision and stated she had no explanation for why the residents did not receive the planned activities.
A resident with an indwelling catheter and diagnoses including urinary retention and BPH had his catheter bag observed hanging on a garbage can with kinked tubing and overflowing trash around it. The resident said staff had placed the catheter there, and he did not want the urine bag fully covered. The DON stated the bag should not be on the garbage can and should be kept off the floor, while facility policy required tubing to be free of kinks and the drainage bag positioned lower than the bladder.
Improper Storage of CPAP Mask: A resident with OSA and intact cognition had a CPAP mask observed lying on the bed and later in a partially opened drawer instead of being stored in a plastic or zip lock bag when not in use. The resident said he had asked staff for a bag but had not received one, and the DON, ADON, LVN, and Administrator stated the mask was expected to be bagged to maintain cleanliness and prevent contamination.
A resident with PTSD, schizoaffective disorder, bipolar type, and Alzheimer's disease had a care plan that listed trauma informed care: PTSD, but it did not identify PTSD triggers or include person-centered goals related to the condition. The resident stated staff had not asked about triggers, while the MDS Coordinator, DON, and Administrator said triggers should have been identified through assessment and care planning; the facility also stated it did not have a policy specific to trauma informed care or PTSD.
A resident with anxiety, depression, mild dementia, and intact cognition attempted to obtain milk in the dining room when a housekeeper, speaking in a loud and rude tone, allegedly called the resident ugly, threatened to "beat" her, and challenged her need for a wheelchair, leading the resident to stand, almost fall, and feel humiliated and embarrassed in front of others. Another resident with intact cognition corroborated that the housekeeper initiated a loud argument and used demeaning, threatening language, causing visible embarrassment to the resident. The housekeeper admitted raising her voice and using a rude tone but denied cursing, while a dietary aide only heard loud voices. When the resident later tried to explain the incident to an LPN at the nurses’ station, she felt the LPN did not listen and focused instead on her cursing, which further upset her. The resident consistently reported feeling disrespected and humiliated by the housekeeper’s conduct, and surveyors also noted that a requested copy of Resident Rights was not provided prior to exit.
Surveyors found that a dietary aide with several inches of facial hair was working over clean dishes in the kitchen dishwashing area without a required beard guard, despite having been in-serviced on the need to wear hair restraints in the kitchen. The Dietary Manager and Administrator both confirmed that all kitchen staff are required to wear hair nets or caps and beard guards, and that the Dietary Manager is responsible for ensuring compliance. Facility policy on employee hygiene for food safety requires hair restraints, including beard restraints, to prevent hair from contacting exposed food.
Surveyors observed an unlocked medication cart positioned near a nurse’s desk with drawers easily opened and the locking mechanism protruding, leaving medications accessible. An RN assigned to the cart reported she thought it had been locked and acknowledged she had been in-serviced on the requirement to keep carts locked when not in use. The Administrator and DON both stated their expectation that medication carts remain locked whenever nurses are not actively administering medications and referenced an existing policy requiring carts to be closed, locked when out of sight, and inaccessible from outward-facing sides.
Three residents with conditions such as dementia, muscle weakness, and chronic illnesses were found to have their call lights out of reach, despite care plans and facility policy requiring accessibility. Observations and interviews confirmed that call lights were often left on the floor, behind beds, or near nightstands, making it difficult for residents to request assistance. Staff and administration acknowledged the responsibility to keep call lights accessible, but the deficiency persisted, resulting in residents having to yell or seek staff directly for help.
A deficiency was identified when an LVN left a laptop unattended in a hallway with a resident's personal and medical information visible on the screen. The incident was observed by the administrator, who closed the laptop and confirmed that staff are expected to secure resident information when leaving devices unattended, as required by facility policy. The resident involved had moderate cognitive impairment and multiple medical conditions.
A resident with Alzheimer's disease and severe cognitive impairment eloped from a facility due to inadequate supervision and lack of a security system on the front door. Despite being identified as a wander risk, the resident left unsupervised and was found by police near a school. The resident's care plan noted her as an elopement risk, but necessary preventive measures were not in place.
The facility failed to ensure that nine residents received their evening medications as ordered by their physicians on two separate occasions. This failure was due to a misunderstanding of responsibilities between the morning and evening shift nurses, leading to significant medication errors.
The facility failed to provide necessary grooming and personal care services for four residents, leading to deficiencies in their ADL care. One resident had nails 1 inch long past the fingertips, another had nails 1.5 inches long with debris, a third had contractures and long nails, and a fourth was found in a soaked adult brief with a urine ring on the bed. Staff interviews revealed a lack of adherence to facility policies and procedures for ADL care.
Expired Medications Found in Multiple Medication Carts
Penalty
Summary
The facility failed to ensure pharmaceutical services were provided to meet each resident’s needs because expired medications and/or biologicals were found in three medication carts. During observation, an Artificial Tears eye drop bottle in the A hall medication cart had an expiration date of 05/2026, a Vitamin B-Complex tablet bottle in the B hall medication cart had an expiration date of 04/2026, and a Diclofenac Sodium Topical Gel 1% tube in the A/D hall nurses’ medication cart had an expiration date of 04/2026. These items were observed while the carts were being reviewed with MA A and LVN B. During interviews, MA A stated staff with the keys were responsible for checking carts for expired medications and noted expired medications may not be processed as intended in the resident’s body. LVN B stated the person responsible for the cart was responsible for checking for expired medications and that medications may not be as effective if administered after the expiration date. The DON stated staff responsible for the medication carts were responsible for checking for expired medications and that the pharmacist monitored the carts monthly to ensure expired medications and supplies were removed. The Administrator stated nurses and medication aides were responsible for checking for expired medications on the medication carts, and that the DON and pharmacist were responsible for monitoring to ensure expired medications were removed.
Expired Hypodermic Needles Found in Medication Storage Room
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in the medication storage room. During an observation in the medication storage room with LVN B, multiple expired hypodermic needles were found stored there, including ten 21 gauge x 1 inch needles, thirty-nine 22 gauge x 1 inch needles, three 25 gauge x 1 inch needles, eight 22 gauge x 1 inch needles, and one 22 gauge x 1.5 inch needle, all with expired dates. During interviews, MA A, LVN B, the DON, and the Administrator each identified the DON, nurses, medication aides, and the pharmacist as responsible for checking the medication room for expired supplies. MA A and LVN B stated that using expired supplies on residents could expose them to possible infections and increase the risk of infection. The DON stated he was responsible for checking for expired supplies and that the pharmacist monitored the medication room monthly to ensure expired supplies were removed. The facility policy titled Medication Labeling and Storage stated that discontinued, outdated, or deteriorated medications or biologicals are to be handled through the dispensing pharmacy and that unopened multi-dose vials are discarded according to the manufacturer's expiration date.
PASARR Screening Did Not Reflect Mental Illness
Penalty
Summary
The facility failed to ensure the PASARR Level I screening accurately reflected Resident #53’s status. The resident’s record showed diagnoses including major depressive disorder, hallucinations due to physiological condition, and insomnia, and the quarterly MDS reflected a BIMS score of 13 with intact cognition. The care plan also documented altered mood risk related to inadequate sleep patterns, and interventions included administering medications as ordered and monitoring sleep patterns. The PASARR Level I screening dated 03/29/2022 and another dated 12/25/2023 both marked mental illness as “No” and indicated no dementia. However, the resident’s record and assessments documented depression, hallucinations, psychotic disorder other than schizophrenia, and delusional ideas. The report also noted inappropriate behavior such as rummaging in drawers and things that did not belong to him, and the resident stated he had been talking to a therapist and thought he could benefit from more psychiatry visits when he did not feel like his normal self. During interviews, the DON, MDS Coordinator/LVN, and Social Worker each acknowledged the PASARR was not coded correctly and that the resident had mental illness that should have been reflected on the screening. They stated the hospital had completed the PASARR prior to admission, that the screening was missed, and that the resident did not have a primary diagnosis of dementia. The facility policy stated the PASRR process was intended to identify residents with MI, ID, or DD and ensure they receive needed services.
Care plans lacked specific ADL needs for two residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for two residents whose needs were identified in their comprehensive assessments. For Resident #14, the admission MDS dated 04/09/2026 showed a BIMS score of 2, indicating severely impaired cognition, and documented substantial/maximal assistance with personal hygiene, lower and upper body dressing, and oral hygiene, dependence for showers and toileting hygiene, and partial/moderate assistance with eating. The comprehensive care plan completed on 04/20/2026 and revised several times thereafter did not reflect these ADL needs in a specific way and instead used general interventions such as assisting with movements/tasks, ensuring proper positioning, and monitoring/documenting abilities. For Resident #34, the quarterly MDS dated 04/17/2026 showed a BIMS score of 13, indicating intact cognition, and documented substantial/maximal assistance with personal hygiene, oral hygiene, and upper body dressing, dependence for lower body dressing, toileting hygiene, taking off shoes, and showers, and supervision or touching assistance with eating. The comprehensive care plan dated 04/22/2026 also did not reflect these ADL needs specifically and instead included general interventions such as assisting with movements/tasks, ensuring proper positioning, evaluating ability to perform ADLs, and providing assistance as needed. The care plan entries identified impaired physical mobility, impaired social interaction, and risk for self-care deficit, but did not match the level and type of assistance documented on the MDS. During interviews on 06/04/2026, the MDS Coordinator stated the care plans were not specific to the type of care each resident needed and should reflect the MDS. The DON stated the care plan was a communication tool for staff to know exactly what type of care each resident needed, and the Administrator stated the IDT was expected to ensure resident information for appropriate care was documented on the care plan. Record review also showed the residents’ ADL information was documented on the Kardex used by CNAs, but it was not identified on the comprehensive care plan. The facility’s Care Plan Policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables is to be developed and implemented for each resident.
Care plans not revised after assessments for PTSD and activity preferences
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for two residents. The facility's policy stated the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment and when a resident experienced a status change. Assessments were ongoing, and care plans were to be revised as resident conditions changed. For one resident, the record showed diagnoses including PTSD, schizoaffective disorder, bipolar type, and Alzheimer's disease. The quarterly MDS reflected a BIMS score of 10 and that the resident felt down, depressed, or hopeless, with active psychiatric diagnoses of PTSD and schizophrenia. The care plan dated 04/21/2026 did not include a focus area for PTSD, related person-centered goals and interventions, or possible PTSD triggers. During observation and interview, the resident stated no one in the facility had asked about PTSD triggers and said he preferred to speak with the social worker about them. The MDS Coordinator stated the PTSD diagnosis was not documented on the comprehensive care plan and that she missed documenting it. For the second resident, the record showed diagnoses including cognitive communication deficit, cerebral infarction, and depression. The admission MDS reflected a BIMS score of 11 and activity preferences that included listening to music, being around animals, keeping up with the news, doing things with a group, favorite activities, going outside for fresh air, and participating in religious services and practices. The quarterly MDS later reflected a BIMS score of 5. The comprehensive care plan revised on 04/23/2026 was not updated to reflect the resident's current activity preference of receiving in-room activities, even though the resident was listed on the in-room activity program. The Activity Director stated she did not revise the care plan to meet the resident's current activity preferences, and the MDS Coordinator and DON stated activity preferences and mental health issues were expected to be care planned.
Failure to Provide Nail Care for Two Dependent Residents
Penalty
Summary
The facility failed to ensure that two residents who were unable to perform activities of daily living received necessary assistance with nail care. Resident #14 was admitted with diagnoses including muscle weakness, cerebral infarction, and cognitive communication deficit, and his admission MDS showed a BIMS score of 2 with substantial to maximal assistance needed for personal hygiene, dressing, oral hygiene, and toileting hygiene. His care plan identified impaired physical mobility, dependence on staff for ADLs, and contractures to all extremities, with interventions to monitor and document ADL abilities and assist as needed. On observation, Resident #14 was lying in bed and had blackish/brownish substance under the fingernails of the right hand, including the forefinger, middle, and ring fingernails. When asked about nail cleaning, he stated he did not know and did not respond further. Resident #34 was admitted with diagnoses including muscle weakness and nontraumatic subarachnoid hemorrhage, and his quarterly MDS showed a BIMS score of 13 with substantial to maximal assistance needed for personal hygiene, oral hygiene, and upper body dressing, and dependence for lower body dressing, toileting hygiene, shoes, and showers. His care plan identified impaired physical mobility, impaired social interaction, and risk for self-care deficit with interventions to provide assistance with ADLs as needed. On observation, Resident #34 was lying in bed watching television and had blackish/brownish substance under the fingernails of both hands, including the middle and ring fingernails. He did not want to answer questions. In interviews, the LVN, CNA, and DON stated CNAs were responsible for cleaning and trimming residents' nails, usually on shower days and as needed, and that any nail issues or refusals were to be reported and documented. The facility's ADL policy stated residents unable to carry out ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene, including bathing, dressing, grooming, and oral care.
Failure to Provide Planned In-Room Activities
Penalty
Summary
The facility failed to provide an ongoing activity program that supported residents’ interests and preferences for two residents who were identified for in-room activities. Resident #5 had diagnoses including unspecified dementia, bed confinement status, and unspecified mood disorder, with severely impaired cognition on MDS assessments and highly impaired vision. His care plan identified a need for encouragement to attend group activities, 1:1 bedside or in-room activities when unable to attend out-of-room events, and activities such as reminiscing and watching hunting and fishing shows. His preferences also included keeping up with the news and watching fishing, westerns, and hunting television channels. Record review showed that in-room activities were not provided for Resident #5 from 05/18/2026 through 06/01/2026, despite being listed on the in-room activity program. During an observation, he was in bed watching a western on television and stated he wished someone would come into his room and talk to him, that he would enjoy it very much, and that he would prefer visits about 3 or 4 times per week. He stated he enjoyed television but that it got old sometimes and he wanted someone to talk to. The Activity Director stated Resident #5 was on the in-room activity program, needed in-room activities for mental stimulation and emotional support, and that she had not been providing them during the majority of May 2026. Resident #52 had diagnoses including cognitive communication deficit, cerebral infarction, and depression, with a BIMS score that declined from moderately impaired to severely impaired on later MDS assessment. His activity preferences included listening to music, being around animals, keeping up with the news, doing things with a group, favorite activities, going outside for fresh air when weather was good, and participating in religious services and practices. His care plan directed staff to provide activities of interest that encouraged choice, self-expression, and responsibility. Record review showed in-room activities were not being provided for Resident #52 from 05/18/2026 through 06/01/2026, although he was listed on the in-room activity program. During observation, he was lying in bed watching a western movie on television and was not interviewable. The Activity Director stated she did not have an answer for why he did not receive in-room activities and acknowledged that residents who did not receive activities could become bored or lonely.
Catheter tubing left kinked and drainage bag placed on garbage can
Penalty
Summary
The facility failed to ensure a resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections. Resident #4 was a male admitted and readmitted to the facility with diagnoses including urinary retention, benign prostatic hyperplasia with lower urinary tract symptoms, and obstructive and reflux uropathy. His quarterly MDS reflected a BIMS score of 10, indicating moderately impaired cognition, and he required partial/moderate assistance with personal hygiene, showers, and lower body dressing. He also had an indwelling catheter. The resident’s care plan, completed on 04/21/2026, noted that he was resistive to proper care of his Foley catheter bag related to not keeping it in a covered/protective manner. The interventions included encouraging as much participation as possible during care activities and giving clear explanations of care activities prior to and as they occurred. During observation on 06/02/2026 at 11:02 a.m., the resident’s catheter bag was hanging on the garbage can and the tubing had a kink in it, with overflowing garbage around the tubing and catheter bag. During interview, the resident stated a staff member had picked up his clothes and placed the catheter on the garbage can, and he said he did not like for the cover to be completely on the urine bag. The DON stated the catheter was not to be placed on the garbage can and should be hanging on the bed off the floor, and that there was a possibility the resident could develop a UTI if bacteria were in the tubing from the garbage. The Administrator stated the facility followed the catheter policy of keeping the catheter off the floor, and an LVN and the MDS Coordinator both stated there was a possibility of infection if the catheter bag or tubing was near garbage. Facility policy required the catheter and tubing to be free of kinks and the drainage bag to be positioned lower than the bladder at all times.
Improper Storage of CPAP Mask
Penalty
Summary
The facility failed to ensure that Resident #55’s CPAP mask was properly stored when not in use. Resident #55 was a male resident with diagnoses including obstructive sleep apnea and seizures, and his annual MDS reflected a BIMS score of 14, indicating intact cognition. His comprehensive care plan addressed CPAP use and included interventions to monitor symptoms and proper mask fitting, and the physician order directed weekly cleaning of the CPAP machine and filter. During observation, Resident #55’s CPAP mask was seen lying on his bed with the CPAP machine on the bedside table, and no plastic bag was observed for storage. Later, when the resident was not in the room, the mask was still observed lying on the bed, and on another observation it was found in a partially opened drawer to the nightstand. The resident stated there had not been a plastic bag in his room for several days and that he had asked staff for one. The DON, LVN, ADON, and Administrator each stated the mask was expected to be stored in a plastic bag or zip lock bag when not in use, and the facility policy stated that PAP devices were to be cleaned according to manufacturer instructions and were for single-resident use.
Failure to Identify PTSD Triggers in Care Planning
Penalty
Summary
The facility failed to ensure a resident with a history of PTSD received culturally competent, trauma-informed care that identified possible triggers. Resident #4 was admitted and readmitted with diagnoses that included PTSD, schizoaffective disorder, bipolar type, and Alzheimer's disease. The quarterly MDS dated 04/15/2026 showed a BIMS score of 10, indicating moderately impaired cognition, and the resident was assessed as feeling down, depressed, or hopeless. The comprehensive care plan completed on 04/21/2026 included trauma informed care: PTSD, but it did not include a focus area for PTSD with related person-centered goals or possible triggers. During interview on 06/02/2026, Resident #4 stated no one in the facility had asked about his PTSD or what might trigger an episode, and he preferred to speak with the social worker about his triggers. The MDS Coordinator stated the resident should have PTSD triggers identified and documented and that a trauma screening should have been completed upon admission. The DON stated the social worker was responsible for ensuring an assessment was completed for any resident with PTSD and that triggers were expected to be identified during the assessment. The Administrator stated the social worker and IDT were responsible for identifying PTSD triggers during care planning, and also stated the facility did not have a policy specific to Quality of Care related to Trauma Informed Care or PTSD.
Failure to Treat Resident with Respect and Dignity During Staff–Resident Interaction
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be treated with respect and dignity during an interaction with a housekeeper. The resident was an older female with generalized anxiety disorder, recurrent major depressive disorder, and mild unspecified dementia, but with intact cognition as evidenced by a BIMS score of 14. Her care plan noted potential for verbal aggression and disrespect toward staff related to dementia, with interventions focused on assessing needs, allowing her to express feelings, and monitoring for risks of harm to self or others. On the day of the incident, the resident went to the dining room and attempted to obtain milk from the kitchen area while a housekeeper and a dietary aide were talking. According to the resident’s interview, she tried to get the attention of the housekeeper and dietary aide, then propelled herself to another kitchen door and knocked. She reported that the housekeeper spoke to her in a loud, rude tone, and after the dietary aide provided milk, the housekeeper escalated by saying, “You are ugly and I am going to beat your ass,” and challenged her by saying she could walk and did not need her wheelchair, telling her to stand up if she thought she could do something. The resident stated she stood up, almost fell, and felt humiliated and embarrassed, particularly because other residents could hear the exchange. She reported that she became angry and upset, then later went to the nurses’ desk to talk about smoking and to explain what had happened, but felt that the LVN at the desk did not listen to her and focused instead on telling her not to curse people, which further upset her and led to her yelling and cursing. A second resident with intact cognition corroborated key aspects of the event, stating he was in the dining room and observed the first resident trying to get milk, initially unable to get staff attention, then obtaining milk at a second door. He reported that the housekeeper began arguing with the resident in a loud tone, almost yelling, and stated to the resident, “I am going to beat your ugly ass. You need to go on with your funky ass.” He stated the resident then yelled back in an attempt to defend herself and that he felt sorry for her because she was embarrassed and disrespected. The housekeeper, when interviewed, acknowledged raising her voice and possibly using a rude tone but denied cursing the resident, instead stating that the resident had called her a “stinking looking man.” Other staff interviews, including the dietary aide, indicated they heard loud talking between the housekeeper and the resident but did not witness the full exchange. The social worker later documented that the resident reported feeling embarrassed and disrespected by the housekeeper during the incident. The Administrator and DON both acknowledged the possibility that the resident felt embarrassed, humiliated, or not respected by staff as a result of how the housekeeper spoke to her. The report also notes that the resident’s behavior and mood assessments, activity participation records, and multiple staff and psychiatric provider interviews indicated that the resident’s physical, emotional, and social status remained at baseline after the incident, with no documented decline in activity participation, socialization, appetite, or mood. However, the core deficiency centers on the interaction itself: the housekeeper’s loud, rude, and allegedly threatening and demeaning statements toward the resident in a public setting, and the resident’s perception and report of humiliation, embarrassment, and lack of respect. Additionally, when the resident attempted to report and discuss the incident with the LVN at the nurses’ station, she felt that her concerns were not heard, which contributed to her distress. The facility also did not provide a copy of Resident Rights requested by surveyors via email prior to exit.
Failure to Enforce Beard Guard Use in Kitchen Dishwashing Area
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service sanitation practices when a dietary aide was observed working in the kitchen dishwashing area without a beard guard. During the observation, the aide, who had facial hair approximately 3–4 inches long around his chin, was standing over clean plates in the dishwashing section of the kitchen. In an interview immediately afterward, the aide acknowledged he was expected to wear a beard guard anytime he was in the kitchen area and stated he had been in-serviced on this requirement, though he could not recall the date. He also stated that hair carries germs and that if hair fell onto plates and transferred to residents’ food, there was a possibility residents could develop stomach issues. The Dietary Manager confirmed in an interview that hair nets or caps and beard guards on facial hair are required for all staff while in the kitchen and stated it was her responsibility to ensure male staff wore beard restraints. She acknowledged that failure to wear hair restraints could result in hair falling on clean plates that might then be used for meals, and that residents ingesting such hair could become physically ill with symptoms such as nausea, vomiting, or diarrhea, depending on the bacteria present on the hair. The Administrator similarly stated that all staff in the kitchen are expected to wear hair restraints, that all kitchen staff are responsible for doing so, and that the Dietary Manager is ultimately responsible for ensuring compliance. Review of the facility’s 2023 Employee Hygiene for Food Safety policy showed it requires all food and nutrition services employees to wear hair restraints, including beard restraints, to prevent hair from contacting exposed food.
Unlocked Medication Cart Left Accessible in Nurse Station Area
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were stored in locked compartments when not in use. During observation, surveyors found Medication Cart A unlocked in front of a nurse’s desk, with its back against the nurse’s station. The cart’s locking mechanism was protruding outward, and the drawers could be easily opened, allowing access to the medications inside. Photographs of the unlocked cart were taken by the state surveyor. In interviews, the RN assigned to the cart stated she believed she had locked it before entering the nurse’s station and acknowledged she had the only set of keys for that cart. She confirmed she had been in-serviced previously on the requirement to lock medication carts and was aware the cart should have been locked. The Administrator and the DON both stated their expectation that all medication carts be locked when nurses were not administering medications and confirmed that staff had been in-serviced on securing the carts, though neither could recall the specific in-service dates. The facility’s Administering Medications Policy, dated April 2019, states that during medication administration the cart must be kept closed and locked when out of sight of the medication nurse or aide, with no medications kept on top of the cart and all outward sides inaccessible to others.
Failure to Ensure Call Lights Were Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that three residents had their call lights within reach, as required by their care plans and facility policy. Observations on the specified date revealed that the call lights for these residents were either hanging towards the floor, placed behind the bed against the wall, or located near a nightstand out of reach. At the time of these observations, the residents were either asleep or, in one case, calling out for assistance because the call light was not accessible. Interviews with the residents confirmed that their call lights were frequently not within reach, requiring them to yell or seek staff assistance directly. One resident specifically stated that the call lights were never within reach and that residents often had to yell or find staff when they needed help. Staff interviews corroborated these findings, with both CNAs and the DON acknowledging that it was the responsibility of all staff to ensure call lights were accessible, and that failure to do so would prevent residents from calling for assistance. Record reviews indicated that each resident had care plans specifying the need for call lights to be within reach due to their medical conditions, such as rheumatoid arthritis, muscle weakness, dementia, parkinsonism, morbid obesity, and chronic obstructive pulmonary disease. The facility's policy also required staff to ensure call lights were accessible to residents at all times. Despite these documented requirements, the deficiency was observed for three residents, placing them at risk of unmet needs.
Unattended Laptop Exposes Resident Health Information
Penalty
Summary
A deficiency occurred when an LVN left a laptop unattended in the hallway with a resident's personal and medical information displayed on the screen. This incident was observed by the administrator, who subsequently closed the laptop and addressed the situation with the LVN. The LVN denied leaving the laptop unattended with the resident's information visible. The Director of Nursing (DON) and the administrator both confirmed that staff are expected to ensure resident information is not displayed when devices are unattended, in accordance with facility policy. The resident involved was a female with a history of cerebral infarction, muscle weakness, muscle wasting and atrophy, and unspecified convulsions. She had moderate cognitive impairment as indicated by a BIMS score of 08. The facility's policy requires all employees to keep portable electronic devices and the data on them secure at all times, which was not followed in this instance.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision, leading to an incident where a resident with Alzheimer's disease and severe cognitive impairment eloped from the facility. The resident, who was identified as a wander risk, left the facility unsupervised through the front door, which lacked a security system. The resident was later found by the police near a school approximately one mile from the facility. The resident's medical history included Alzheimer's disease, cognitive communication deficit, difficulty in walking, essential hypertension, and unsteadiness on feet. Despite these conditions, the resident was independent with walking and had a severely impaired cognition with a BIMS score of 4. The resident's care plan identified her as an elopement risk, but the necessary supervision and preventive measures were not adequately implemented, resulting in her unsupervised departure from the facility. Interviews with staff revealed that the resident did not have a history of exit-seeking behavior prior to the incident. However, on the day of the elopement, the resident was last seen by another resident expressing a desire to go for a walk. The facility's failure to have a functioning alarm system on the front door and to provide continuous supervision contributed to the resident's ability to leave the premises without detection.
Failure to Administer Evening Medications
Penalty
Summary
The facility failed to ensure that nine residents were free from significant medication errors. Specifically, these residents did not receive their evening medications as ordered by their physicians on two separate occasions. The medications were scheduled to be administered between 4:00 pm and 6:00 pm, but the residents did not receive them on the specified dates. This failure placed the residents at risk of not receiving the intended therapeutic benefits of their medications. Resident #1, for example, did not receive her prescribed Propranolol, Gabapentin, and Hydralazine on the specified dates. Similarly, Resident #2 missed doses of Depakote and Metformin. Other residents, including Resident #3, Resident #4, and Resident #5, also missed critical medications such as Gabapentin, Isosorbide Dinitrate, and Lisinopril. These omissions were confirmed through record reviews, observations, and interviews with the residents and staff. The issue was attributed to a misunderstanding of responsibilities between the morning and evening shift nurses. LVN A, who worked the evening shift, assumed that the morning shift nurse had administered the evening medications. However, the facility's policy indicated that the evening shift nurse was responsible for administering these medications. This misunderstanding led to the medication errors, and the facility's auditing process failed to catch these omissions in a timely manner.
Deficiencies in Grooming and Personal Care Services
Penalty
Summary
The facility failed to provide necessary grooming and personal care services for four residents, leading to deficiencies in their activities of daily living (ADL) care. Resident #1, a male with cerebral palsy and muscle weakness, had nails that were 1 inch long past the fingertips on both hands and expressed a desire to have them trimmed. Resident #2, a male with severe cognitive impairment and dementia, had fingernails extending 1.5 inches past his fingertips with brown stains and debris underneath. He was unable to recall his last shower, and staff acknowledged the potential for self-inflicted scratches and bacterial presence under his nails. Resident #3, a male with severe cognitive impairment and a history of cerebral infarction, had contractures in his left hand and fingernails on his right hand that were 1 inch long past the fingertips. Despite his refusal to allow staff to cut his nails, the facility had not developed a plan to address this issue. Resident #4, a male with moderate cognitive impairment and hemiplegia, was found in a soaked adult brief with a urine ring on his bed, indicating a lack of timely incontinent care. The resident was asleep and did not wake up for an interview, but staff acknowledged the potential risks of skin breakdown and infection from prolonged exposure to urine. Interviews with staff, including CNAs, the ADON, the interim DON, and the V.P. of Clinical Operations, revealed a lack of adherence to facility policies and procedures for ADL care. Staff admitted to not regularly checking residents' fingernails and relying on aides to report issues. The facility's Skin Monitoring sheets did not include fingernail care, and there was a general lack of oversight and accountability in ensuring residents received necessary grooming and personal hygiene services. The V.P. of Clinical Operations emphasized the need for administrative personnel to make life rounds and review resident care, highlighting the deficiencies in the current processes and the need for staff education.
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What surveyors actually found near you
We read the 14 citations issued within 25 miles in the last 12 months — including the 1 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.
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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) |
|---|---|---|---|---|
| Madisonville Care Center | 0.6 mi | ★★★★★ | 7 | 1 |
| Cass Valley Healthcare Center | 21.4 mi | ★★★★★ | 7 | 0 |
| Mrc Creekside | 25.8 mi | ★★★★★ | 5 | 0 |
| Focused Care At Huntsville | 26.9 mi | ★★★★★ | 9 | 0 |
| Huntsville Health Care Center | 27.5 mi | ★★★★★ | 5 | 0 |
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 October 2026) and official state health department websites.