Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Madisonville Care Center during CMS and state inspections, most recent first.
Resident Shower Preference Not Followed: A resident with intact cognition and multiple mobility-related diagnoses was documented as receiving bed baths with no charted showers, despite stating he had been getting bed baths and would feel cleaner with a shower. The care plan did not reflect a shower preference, and staff interviews showed differing accounts about whether he wanted showers or bed baths, while the DON and RNC acknowledged shower preferences should be addressed in the care plan.
Insulin pens were not primed during insulin administration for two residents with diabetes. An LVN gave insulin to one resident with severe cognitive impairment and another resident with intact cognition after finger stick blood sugars, but both injections were administered without priming the pen. One LVN said she had not been trained on priming, and the other said she did not know it was required; the RNC stated staff were supposed to prime insulin pens to ensure the full dose was administered.
Failure to use EBP during incontinent care occurred when two CNAs entered a resident’s room for peri care without properly donning PPE. The resident had paraplegia, intact cognition, and was on EBP for a Foley catheter, PICC line, and wounds, with care plan instructions for gown and glove use during high-contact care. The CNAs used gloves but no gowns and stated PPE was available outside the room, while the RNC stated staff were expected to use PPE whenever a resident was on EBP.
A resident with stroke-related deficits, obesity, depression, and paraplegia required extensive assistance with ADLs and had a history of using a motorized wheelchair. Over an extended period, staff documented only bed baths while the resident and family reported that he preferred and repeatedly requested showers, which were not reflected in the care plan or bathing records. The resident stated he had not received a shower in over a month and felt dirty, imprisoned, and depressed, while family reported he believed he was being discriminated against as he observed other residents receiving showers. The facility also removed his electric wheelchair due to safety and vision concerns and placed him in a Geri‑chair that he could not self‑propel, making him dependent on staff for movement. Although therapy and nursing staff acknowledged responsibility for electric wheelchair safety assessments and the facility policy required admission, quarterly, and significant-change evaluations, the last documented assessment occurred months earlier, and no follow‑up reassessment was completed despite the resident’s and family’s expressed concerns and his request for reevaluation.
A resident with dementia, prior cerebral infarction, mobility limitations, and a low BIMS score was care planned for cognitive impairment and risk for wandering, but her care plan did not include any interventions to redirect her from male residents’ rooms despite staff awareness of family concerns. The resident reported that staff would not allow her and a male resident to be alone in each other’s rooms, that staff told her the male resident would get her pregnant and that her family objected, and that she felt alert, oriented, able to consent, and upset about the lack of privacy. Interviews with the MDS nurse, SW, ADON, DON, and ADM showed that the family had requested staff redirect the resident from male residents’ rooms due to concerns about her capacity, yet the IDT did not ensure the care plan was revised to reflect these preferences, contrary to the facility’s person-centered care planning policy.
A resident with Alzheimer's disease and a high elopement risk was able to exit the facility unsupervised by following a visitor out the front door. Staff were unaware of the resident's absence until she was found outside by another staff member about 20 minutes later. Although the care plan included interventions for wandering and elopement, staff assigned to the resident were not aware of her risk status or the specific interventions, and monitoring was not increased beyond routine checks. This resulted in a failure to provide adequate supervision and prevent the resident from leaving the facility without staff knowledge.
The facility failed to document necessary admission orders for three residents in the secure unit, leading to potential involuntary seclusion. The residents, with varying degrees of cognitive impairment, were admitted without the required clinical criteria in their EMRs. Staff interviews revealed confusion over responsibility for entering orders, and the Interim DON had to manually correct the oversight. The Medical Director emphasized the need for timely and reviewed orders, as per facility policy.
A resident's privacy was compromised during wound care when RNs failed to draw the privacy curtain, allowing visitors to observe the procedure. The resident, recently admitted with cellulitis, was exposed to anyone entering the room. Staff acknowledged the oversight, recognizing the breach of privacy and dignity as per facility policy.
A medical assistant in an LTC facility failed to sanitize a blood pressure monitor between uses on two residents, both with significant health conditions requiring regular monitoring. The assistant, who had not received training on infection control at the facility, admitted to the oversight. The facility lacked a specific policy for disinfecting medical equipment, contributing to the deficiency.
Resident Shower Preference Not Followed
Penalty
Summary
The facility failed to treat one resident with respect and dignity and to care for him in a manner that promoted his quality of life when his preference for showers was not followed and he received bed baths instead. The resident was admitted with diagnoses including cerebral infarction, morbid obesity, impulse disorders, depression, mood disorders, hemiplegia, hemiparesis, generalized muscle weakness, and need for assistance with personal care. His quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was his own responsible party. Record review showed the care plan identified that the resident required two staff for bathing assistance, but there were no notes reflecting a preference for showers instead of bed baths. The plan of care task from 02/20/26 through 03/18/26 showed 1-2 staff provided bed baths, and no documentation showed showers were given. During interview, the resident stated he had been getting bed baths and had not been given a shower, and said he would feel cleaner if he got a shower. Staff interviews reflected that a CNA said the resident did not mind bed baths and felt like a new man after them, while an LVN stated he never expressed a preference for showers. The DON stated CNAs were expected to shower according to the shower schedule and preferences, and the RNC stated that if the resident was not going to the shower, they should be offering the shower bed and that this should be in the care plan.
Insulin Pens Not Primed During Administration
Penalty
Summary
The facility failed to ensure insulin pens were primed during insulin administration for two residents. Resident #27, a female with diabetes mellitus and severe cognitive impairment with a BIMS score of 0, had an order for Insulin Aspart subcutaneous solution pen-injector 100 units/ml per sliding scale. During observation on 03/18/2026, LVN A performed a finger stick blood sugar, prepared the insulin pen by attaching a new needle and dialing it to 1 unit, and administered the insulin without priming the pen. In interview, LVN A stated she did not prime the insulin pens prior to administration and said she had not been trained on priming since starting work at the facility about four months earlier. Resident #46, a male with morbid obesity and diabetes mellitus type 2, had an order for Humalog subcutaneous solution pen-injector 100 units/ml before meals and was assessed with a BIMS score of 15. During observation on 03/18/2026, LVN B performed a finger stick blood sugar, prepared the insulin pen by attaching a new needle and dialing it to 10 units, and administered the insulin without priming the pen. LVN B stated she did not prime the insulin pen because she did not know she needed to. The RNC stated staff were supposed to prime insulin pens to ensure the entire dose was administered and said she was in-servicing staff to ensure nurses were aware of the facility policy. The facility policy for insulin pens stated to prime the pen by dialing 2 units and pressing the injection button until a drop appears at the needle tip.
Failure to Use Enhanced Barrier Precautions During Incontinent Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to establish and maintain enhanced barrier precautions for one resident who was on EBP for a Foley catheter, PICC line, and wounds. Resident #5 was a male admitted with paraplegia and cirrhosis of the liver, and his admission MDS reflected a BIMS score of 13, indicating intact cognition. His care plan included EBP for the Foley catheter and wounds, with instructions for staff to don gloves and a gown for high-contact care activities including hygiene and incontinent care. The physician orders also reflected EBP related to the PICC line, Foley catheter, and wounds. During observation on 03/18/2026 at 1:48 PM, CNA C and CNA D entered Resident #5's room to perform peri care without properly donning PPE. Gloves were used during peri care, but gowns were not worn. In interviews shortly afterward, both CNAs stated PPE was available outside the room and acknowledged they were supposed to wear PPE to prevent the spread of infection, but said they had been called in quickly and did not have time. The RNC later stated she expected staff to use PPE if a resident was on EBP, no matter what was going on, to prevent cross contamination.
Failure to Honor Resident’s Bathing Preferences and Timely Reassess Electric Wheelchair Use
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s rights to dignity, self-determination, and reasonable accommodation of preferences regarding bathing and mobility. The resident was an adult male with a history of cerebral infarction, morbid obesity, impulse disorder, depression, mood disorder, hemiplegia/hemiparesis, generalized muscle weakness, and need for assistance with personal care. His MDS assessments showed he initially had moderate cognitive impairment but later tested cognitively intact, and he had documented depressive symptoms on a PHQ‑9, including feeling bad about himself nearly every day. The care plan documented that he required two staff for bathing and transfers with a mechanical lift, but there were no care plan entries reflecting his stated preference for showers instead of bed baths. Point-of-care documentation over a one‑month period showed staff consistently provided bed baths, with no documentation of showers. The resident reported during interview that he had not received a shower in over a month, despite often notifying staff that he preferred showers over bed baths. He stated that staff still did not ask or shower him, and he felt like a prisoner, dirty, down, and depressed. His family corroborated that he frequently called them to report that he had not been showered for over two weeks at a time, and they stated he was supposed to receive two showers per week and needed help with showering due to paraplegia. The family reported that the resident felt like a dog, believed he was being racially discriminated against because he saw other residents receiving showers, and felt down and depressed. Multiple staff members, including the MDS nurse, SW, ADON, and DON, stated that residents were to be showered according to their choices and schedules, but each reported that the resident had not expressed to them a preference for showers over bed baths, and there was no documentation that his shower preference had been assessed or incorporated into his care plan. The deficiency also includes the facility’s failure to timely reassess the resident’s safety awareness and use of his electric wheelchair as required by policy. The resident had previously used a motorized wheelchair and had been identified in the care plan as posing a potential risk of injury to himself and others due to decreased awareness of surroundings, speed control, and later impaired vision. Electric wheelchair safety assessments documented that he initially could demonstrate safe operation but later was unable to control speed, maneuver safely, or stop on command, and had diminished eyesight. The care plan was revised to indicate that his wheelchair was unplugged, he became dependent on staff for locomotion, and he was placed in a Geri‑chair for comfort and safety. The last documented electric wheelchair safety assessment occurred in late December, with no subsequent evaluations, despite the facility’s policy requiring assessments on admission, quarterly, and upon significant change of condition. During interview, the resident stated that staff had taken and stored his electric wheelchair about a month and a half earlier, telling him he was running over other residents, and that therapy had told him about a month earlier they would reevaluate him for safety awareness but never did. He reported that the Geri‑chair he was in was not his usual wheelchair, that he could not independently move himself in it, and that he had to beg staff to move him from room to room, but they often would not move him when he requested. He said he felt restrained, like he was still being treated like a prisoner, and was upset and depressed because he could not independently go anywhere. His family stated that the administrator, DON, and ADON had taken away his electric wheelchair due to his vision, that he was receiving vision treatment, and that he disliked the Geri‑chair because of his size and inability to move it himself. They described the Geri‑chair as a restraint because he could not propel it and staff did not push him when he asked, and they emphasized that he had a right to go where he wanted independently. Facility staff, including the DOR, MDS nurse, SW, ADON, DON, MD, and administrator, acknowledged that therapy was responsible for electric wheelchair safety evaluations, that the last evaluation was in December, and that they did not know why a reevaluation had not been completed, despite the resident’s expressed concerns and the facility policy requiring periodic and change‑in‑condition reassessments.
Failure to Update Care Plan to Reflect Resident and Family Preferences Regarding Room Access and Privacy
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to make choices about significant aspects of her life and to reflect those choices and family wishes in her comprehensive care plan. The resident was admitted with multiple diagnoses including cerebral infarction, dementia, generalized muscle weakness, difficulty walking, unsteadiness on feet, lack of coordination, and major depressive disorder. Her Quarterly MDS showed a BIMS score of 4/15, indicating severe cognitive impairment, and she was care planned for communication problems, impaired cognitive function/dementia, impaired thought processes, and risk for wandering. However, the care plan contained no interventions or notes addressing redirecting her from male residents’ rooms, despite staff knowledge of family concerns about her being alone with a male resident. Psychosocial and psychological evaluations documented mixed information about the resident’s cognition. A psychosocial evaluation indicated functionally intact cognition, full orientation, intact memory, adequate judgment, and circumstantial/confusing thought processes, while a psychological progress note described her as awake, alert, oriented times three, with logical and coherent thought processes and no acute concerns regarding memory or cognition during that session. In an interview, the resident stated that staff would not allow her and a male resident to be alone in each other’s rooms, reported that staff told her the male resident would get her pregnant and that her family had an issue with her being alone with him, and stated she felt alert, oriented, and able to consent or refuse. She also reported that neither she nor her family had concerns about her having privacy time alone with the male resident and that she felt rotten, down, and upset because staff did not allow them privacy and she had no privacy from staff. Multiple staff interviews revealed that the resident’s family had expressed, on unknown dates, that they did not want the male resident alone in the room with her and did not want her going into any male residents’ rooms, citing concerns about her capacity to consent and fluctuating cognition. The MDS nurse, SW, ADON, DON, and ADM all acknowledged that the IDT process and care plans are used to reflect resident and family preferences and guide staff in providing care, and that care plans should be revised when such preferences are communicated. Despite this, the MDS nurse did not revise the resident’s care plan to include interventions to redirect her from male residents’ rooms, and the DON later stated she did not know the care plan had not been updated to reflect these preferences and choices. The facility’s Comprehensive Care Planning policy states that each resident will have a person-centered care plan developed and implemented to meet preferences and goals, and that changing preferences and goals should be reflected in the care plan, but this was not done for this resident.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent an accident involving a resident with a known history of wandering and high risk for elopement. The resident, who had Alzheimer's disease, severe cognitive impairment, and a high elopement risk score on admission, was able to exit the facility unsupervised by following a visitor out the front door. Staff were unaware that the resident had left the building and only discovered her absence when she was found outside by another staff member approximately 20 minutes later. The resident was ambulatory with a walker and was found standing on the sidewalk, having exited the facility without staff knowledge or intervention. The care plan for the resident included interventions for wandering and elopement risk, such as distraction, monitoring for exit-seeking behavior, and notification of the charge nurse if such behavior was observed. However, staff interviews revealed that those assigned to the resident were not aware of her high risk for elopement or the specific interventions in her care plan. Staff monitoring was conducted every two hours, but there was no increased supervision or targeted monitoring for elopement risk, despite the resident's assessment indicating a high risk. Additionally, staff did not consistently check care plans or elopement risk scores to inform their supervision practices. Facility policies required elopement risk assessments on admission and with changes in condition, as well as care plan modifications and interventions for residents at risk. Despite these policies, the resident was able to leave the facility undetected, and staff did not recognize or respond to her exit in a timely manner. The event was only discovered after the resident was found outside, and the facility was not aware of her absence until that point. The failure to implement and communicate appropriate supervision and interventions for a high-risk resident led to the deficiency.
Failure to Document Admission Orders for Secure Unit
Penalty
Summary
The facility failed to ensure that medical records were accurately documented for three residents admitted to the secure unit. The electronic medical records (EMRs) for these residents did not contain the necessary clinical criteria or problems referenced for their admission to the secure unit. This deficiency was identified during a review of the residents' records, which showed that the orders for admission to the secure unit were missing or not entered in a timely manner. Resident #1, a male with Alzheimer's Disease and severe cognitive impairment, was admitted without the required clinical criteria in his EMR. Similarly, Resident #2, a male with Vascular Dementia and severe cognitive impairment, and Resident #3, a female with Alzheimer's Disease and moderate cognitive impairment, also had missing clinical criteria in their EMRs for admission to the secure unit. Interviews with staff revealed confusion and lack of clarity regarding who was responsible for entering these orders, with some staff members assuming it was the responsibility of corporate nurses or the Assistant Director of Nursing (ADON). The Interim Director of Nursing (IDON) acknowledged the oversight and stated that she had to manually enter the missing orders after auditing the system. The Medical Director expressed expectations that orders should be completed timely and reviewed by a physician or midlevel provider. The facility's policy requires a physician's order for admission to the SecureCare Environment, which was not adhered to in these cases.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during personal care, specifically wound care, which was observed by surveyors. Resident #172, who had been admitted to the facility two days prior, was receiving wound care for cellulitis of the left foot. During the procedure, RN B and RN C did not draw the privacy curtain, leaving the resident exposed to anyone entering the room or passing by if the door was open. This oversight was noted during an observation and interview, where it was confirmed that visitors, including a friend and a family member of the resident, entered the room and observed the wound care without the resident's privacy being adequately protected. Interviews with the staff involved revealed that RN B, who was the Assistant Director of Nursing and in charge of wound care, acknowledged the mistake and stated that she thought it was acceptable to leave the curtain open since the resident was not sharing the room. RN C, a recently hired but experienced RN, also admitted to the oversight, recognizing that the resident's privacy and dignity were compromised. The facility's Clinical Care Nurse (CCN) emphasized the importance of maintaining privacy and dignity during care, as outlined in the facility's policy on resident rights, which mandates closing doors and drawing privacy curtains during medical treatment and personal care.
Inadequate Infection Control: Failure to Sanitize Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medical assistant (MA A) who did not clean and disinfect a blood pressure monitor between uses on two residents. This oversight was observed during a survey, where MA A used the same blood pressure monitor on two residents consecutively without sanitizing it before or after use. The residents involved were a male with a history of cerebral infarction, chronic kidney disease, type 2 diabetes, and hypertension, and another male with type 2 diabetes, hypertension, acute kidney failure, and other conditions. Both residents required regular blood pressure monitoring as part of their care plans. During interviews, MA A admitted to not sanitizing the equipment and stated she had not received any training on infection control since starting at the facility. The facility's Clinical Care Nurse (CCN) confirmed that MA A should have sanitized the equipment to prevent the spread of infections. The CCN also noted that the facility lacked a specific policy for disinfecting durable medical equipment between residents, which contributed to the noncompliance with infection control practices. The facility's general infection control policy emphasized the importance of hygienic practices to prevent the spread of infections, but it did not specifically address the disinfection of equipment like blood pressure monitors.
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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) |
|---|---|---|---|---|
| Avir At Madisonville | 0.6 mi | ★★★★★ | 3 | 0 |
| Cass Valley Healthcare Center | 20.9 mi | ★★★★★ | 7 | 0 |
| Mrc Creekside | 26.4 mi | ★★★★★ | 5 | 0 |
| Focused Care At Huntsville | 27.5 mi | ★★★★★ | 2 | 0 |
| Huntsville Health Care Center | 28.1 mi | ★★★★★ | 5 | 0 |
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