Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Avir At Madisonville during CMS and state inspections, most recent first.
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.
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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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 | ★★★★★ | 2 | 0 |
| Huntsville Health Care Center | 27.5 mi | ★★★★★ | 5 | 0 |
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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 July 2026) and official state health department websites.