Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Monette Manor, Llc during CMS and state inspections, most recent first.
The facility did not update care plans with specific fall interventions after several residents experienced falls, despite their complex medical conditions and histories of falls. Staff interviews confirmed that the process for care plan updates was not followed, and the responsibility for these updates was not fulfilled. The facility's care plan policy was requested but not provided.
The facility failed to report and investigate three incidents of resident-to-resident abuse and an unwitnessed fall with serious injury. In one case, a resident with dementia was aggressive towards another, but the administrator did not report it due to the brief duration and lack of injuries. Another resident fell from a wheelchair, resulting in a hip fracture, but the incident was not reported as it was reviewed via video. In the third case, a resident was attacked by a roommate, but the administrator did not report it, considering it a minor altercation.
The facility failed to transmit MDS assessments to CMS within the required 14-day timeframe for several residents. The assessments were either not accepted or still export-ready, contrary to the facility's policy requiring transmission within 31 days of completion. This affected residents with admission and significant change assessments.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies in addressing medical and behavioral needs. A resident with multiple diagnoses lacked a baseline care plan, while another's pain management was not reflected in their care plan. A resident with aggressive behaviors had inadequate interventions, and two residents had missing interventions for catheter care and wound management. The DON acknowledged these omissions, highlighting the need for timely updates.
The facility failed to complete timely clinical assessments for six residents, impacting their quality of care. Overdue assessments included wandering risk, side rail, fall scales, and pain interviews. Interviews revealed confusion and lack of responsibility among staff, with the DON and Social Director unclear on who should complete these assessments.
The facility did not follow the prescribed menu for pureed diets during a lunch service. A dietary aide forgot to puree white beans, resulting in residents not receiving them as part of their meal. The Assistant Dietary Manager confirmed the omission, and the DON highlighted the importance of adhering to menus for residents with specific dietary needs. The facility also lacked a policy for menus.
The facility failed to follow infection control procedures, as observed when CNAs did not perform hand hygiene between assisting two residents at the dining table. Additionally, proper infection control was not maintained during perineal and catheter care for a resident with chronic kidney disease, a PEG tube, and a suprapubic catheter. CNAs and the DON did not use personal protective equipment as required, and perineal care was performed incorrectly, leading to debris around the catheter insertion site and red open areas.
A facility failed to complete a baseline care plan within 48 hours for a resident with multiple diagnoses, including congestive heart failure and chronic kidney disease. The DON confirmed that no admission assessment or care plan was initiated, despite the facility's policy requiring these actions.
The facility's administration failed to report incidents to the SSA, including resident-to-resident altercations and an unwitnessed fall with major injury. The administrator, responsible for ensuring compliance with regulations, did not report these incidents, as confirmed during an interview.
The facility lacked an effective governing body, leading to issues in Quality Assurance and Performance Improvement Plan (QAPI) feedback systems, care plan implementation, and MDS timing and transmission. The absence of an MDS Coordinator since mid-August resulted in widespread deficiencies, with the ADON temporarily handling these duties alongside other responsibilities. The Administrator acknowledged the need to improve the feedback system and shift QAPI focus to resident concerns.
The facility failed to employ a qualified MDS Coordinator, leaving the DON, who lacked MDS training, to handle these duties with limited support from an unavailable MDS Consultant. The ADON was overwhelmed with multiple responsibilities, including admissions and infection prevention, leading to non-compliance with state regulations.
The facility's QAPI program failed to effectively address resident concerns, focusing instead on admissions and operational issues. Critical issues like falls, behaviors, and care plans were not discussed, and the Administrator acknowledged the feedback system's ineffectiveness.
Failure to Update Care Plans with Fall Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure that fall interventions were incorporated into person-centered care plans following falls for five out of seven residents reviewed. Each of these residents experienced a fall during a specified period, but their care plans were not updated to reflect new or revised interventions addressing the specific incidents. The absence of these interventions was confirmed through record reviews, care plan audits, and interviews with facility staff, including the RN Supervisor, Restorative CNA, DON, and Administrator. The residents involved had significant medical histories and varying degrees of cognitive and physical impairment. For example, one resident had severe cognitive impairment and multiple fractures, another had muscle wasting and hemiplegia following a stroke, and others had diagnoses such as congestive heart failure, encephalopathy, and gait abnormalities. Despite these complex needs and documented falls, their care plans did not include interventions specific to the falls that occurred during the review period. Interviews with facility staff revealed a lack of clarity and follow-through regarding the process for updating care plans after a fall. The RN Supervisor, who also served as the MDS Coordinator, acknowledged that fall interventions were not added to the care plans for the incidents in question. The DON and Administrator both confirmed that the responsibility for updating care plans with fall interventions rested with the MDS Coordinator, and that this had not been done for the affected residents. The facility's policy and procedure for care plans was requested but not provided during the survey.
Failure to Report and Investigate Incidents
Penalty
Summary
The facility failed to report three incidents of resident-to-resident abuse and an unwitnessed fall with serious injury, as well as failed to conduct thorough investigations of these incidents. In the first case, a resident with severe dementia and behavioral disturbances was aggressive towards another resident in the dining room. Despite the incident being captured on video and witnessed by staff, the administrator did not report it to the State Office of Long-Term Care, citing the brief duration and lack of injuries. In the second incident, a resident with severe cognitive impairment fell from a wheelchair, resulting in a hip fracture that required surgical repair. The fall was unwitnessed, and although the staff responded quickly, the administrator did not report it, considering the video review as sufficient. No witness statements or investigation documentation were available, and the video was not accessible due to the time elapsed since the incident. The third incident involved a resident with intact cognition who was physically attacked by a roommate. The resident recorded the altercation and showed it to staff, who intervened and moved the resident to a different room. Despite the evidence and reported injuries, the administrator did not report the incident, believing it to be a minor altercation. No incident reports or investigation documentation were provided, and the facility failed to document the injuries reported by the resident and staff.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required time frame of 14 days. This deficiency affected six residents whose MDS assessments were reviewed. Specifically, the assessments for these residents were either not accepted or were still export-ready, indicating a failure in the transmission process. The facility's policy, revised in December 2002, requires comprehensive assessments to be transmitted electronically within 31 days of the MDS completion date, but this was not adhered to for the residents in question. The residents involved had various types of assessments, including admission and significant change assessments, with Assessment Reference Dates (ARDs) ranging from November 2023 to March 2024.
Deficiencies in Care Plan Implementation and Updates
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their medical and behavioral needs. Resident #120 was admitted with multiple diagnoses, including congestive heart failure and chronic kidney disease, but lacked a baseline care plan and admission assessment. This oversight resulted in the absence of documented interventions for cognitive function, fall risk, and medication management, including oxygen and anxiety medication. The Director of Nursing acknowledged the missing care plan and the need for correction. Resident #220, diagnosed with osteoarthritis and kidney disease, had orders for pain medication that were not reflected in the care plan. Similarly, Resident #37, with a diagnosis of altered mental status, exhibited aggressive behaviors and wandering tendencies that were not adequately addressed in the care plan. Despite multiple incidents of physical altercations with staff and complaints from other residents, the care plan lacked interventions for monitoring and managing these behaviors. The facility's failure to update the care plan as the resident's needs changed potentially put other residents at risk. Residents #13 and #14 also experienced deficiencies in their care plans. Resident #13, with a suprapubic catheter, did not have interventions for catheter care or enhanced barrier precautions documented. Resident #14, with diagnoses including congestive heart failure and blood clots, lacked interventions for anticoagulant use and wound care in the care plan. The Director of Nursing confirmed these omissions, highlighting the facility's failure to implement necessary interventions and update care plans in a timely manner.
Failure to Complete Timely Clinical Assessments
Penalty
Summary
The facility failed to complete necessary clinical assessments for six residents, which affected their quality of care. The overdue assessments included wandering risk assessments, side rail assessments, fall scales, pain interviews, neurological checklists, skin observation tools, and skilled charting. These assessments were crucial for accurately portraying the residents' care in the Minimum Data Set (MDS) and implementing care plan interventions. The lack of timely assessments indicates a significant oversight in maintaining up-to-date and comprehensive care plans for the residents. Interviews with the Director of Nursing (DON) and the Social Director revealed a lack of clarity and responsibility regarding the completion of these assessments. The DON, who was also handling Infection Preventionist duties and assisting with MDS tasks, admitted to not being fully familiar with the MDS process. The MDS nurse had left, and the DON was temporarily responsible for certain sections of the MDS, while the Social Director was responsible for others. However, there was confusion about who was responsible for the overdue assessments, leading to a gap in the residents' care documentation.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed menu for pureed diets during a lunch service, as observed on 09/26/2024. Dietary Aide #2 was overheard stating that they did not puree white beans, which were part of the menu for residents requiring pureed diets. During the lunch service, residents received pureed pork chop, turnip greens, cornbread, and banana creme pie, but the pureed white beans were not served. The Assistant Dietary Manager confirmed that the menu should have included pureed white beans and acknowledged that the omission was due to Dietary Aide #2 forgetting to puree them. The Director of Nursing emphasized the importance of following menus, especially for residents with specific dietary needs such as those with swallowing issues or diabetes. It was also noted that the facility lacked a policy for menus.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to adhere to infection control procedures, as observed during a survey. Two CNAs did not perform hand hygiene between assisting two residents at the assisted dining table, potentially spreading infection. Additionally, the facility did not follow proper infection control procedures during perineal and catheter care for a resident with chronic kidney disease, a PEG tube, and a suprapubic catheter. The CNAs and the DON did not use personal protective equipment as required for Enhanced Barrier Precautions, and perineal care was performed incorrectly, leading to debris around the catheter insertion site and red open areas in the perineal region. The resident involved was cognitively intact and had informed staff about the condition of the open areas, which had been present for a couple of days. The facility's training materials and policies clearly outlined the correct procedures for catheter and perineal care, as well as the use of gowns and gloves during high-contact care activities. However, these procedures were not followed, as confirmed by interviews with the CNAs and the DON, who acknowledged the lapses in protocol.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan with the minimum necessary information within 48 hours after the admission of a resident, which is required to promote continuity of care. The resident, who was admitted within the last 30 days, had diagnoses including congestive heart failure, atrial fibrillation, chronic kidney disease, and repeated falls. A review of the resident's electronic records revealed that there was no admission assessment or care plan initiated on the date of admission. During an interview, the Director of Nursing (DON) confirmed that the nurses are responsible for completing assessments upon admission or readmission, and she is responsible for the baseline care plan within 4 hours of admission. However, she acknowledged that no admission assessment or care plan had been completed for the resident.
Failure to Report Incidents to SSA
Penalty
Summary
The facility's administration failed to ensure the administrator was knowledgeable regarding reporting requirements, leading to the failure to immediately report certain incidents to the State Survey Agency (SSA). Specifically, a resident-to-resident altercation involving Resident #71 on January 14, 2024, an unwitnessed fall with major injury involving Resident #48 on July 10, 2024, and another resident-to-resident altercation involving Resident #46 on August 16, 2024, were not reported to the SSA. The administrator acknowledged during an interview that they were responsible for reporting such incidents, as outlined in the job description provided by the Business Office Manager, which includes ensuring compliance with all local, state, and federal regulations.
Deficiency in Governing Body and MDS Coordination
Penalty
Summary
The facility failed to maintain an effective governing body to ensure proper management and operation, particularly in the areas of Quality Assurance and Performance Improvement Plan (QAPI) feedback systems, care plan implementation, and the timing and transmission of Minimum Data Sets (MDS). The survey team found that there was no MDS Coordinator in place since the previous coordinator left on 08/14/2024, leading to widespread issues with MDS timing and care plan implementation. The Assistant Director of Nursing (ADON) was temporarily assigned these duties, along with other responsibilities such as admissions, infection prevention, and assessments, which may have contributed to the deficiencies. Interviews with the Administrator revealed that the current feedback system was ineffective, as evidenced by the concerns brought to his attention. The Administrator acknowledged the need to shift the focus of the QAPI from admissions to more resident concerns. The governing body, as described by the Director of Nursing (DON), involves an interdisciplinary team including the administrator, business office manager, medical director, and therapy. However, the facility's policy states that the governing body is responsible for the QAPI program, and the Administrator is accountable to the governing body. The lack of a dedicated MDS Coordinator and the ineffective feedback system indicate a failure in the governing body's responsibilities.
Facility Lacks Qualified MDS Coordinator
Penalty
Summary
The facility failed to ensure that qualified staff were employed to accurately encode, transmit, and implement assessments and care plans. The Minimum Data Set (MDS) Coordinator position, responsible for completing all MDS and Care Area Assessments (CAAs), scheduling and leading Care Plan Conferences, and transmitting completed MDS assessments to the state, was vacant after the previous coordinator left on 08/14/2024. The Director of Nursing (DON), who lacked training in MDS, was temporarily assigned these duties with assistance from an MDS Consultant. However, the consultant was not available for interviews, and the DON admitted to not being familiar with the MDS process. The Administrator acknowledged that the workload assigned to the Assistant Director of Nursing (ADON), who was also handling admissions, infection prevention, assessments, and other duties, was unrealistic for long-term success. The facility was in the process of hiring new staff to fill the DON and MDS positions, but at the time of the survey, the ADON was overwhelmed with responsibilities, and the facility was not in compliance with state regulations requiring qualified staff for MDS tasks.
Ineffective Feedback System in QAPI
Penalty
Summary
The facility failed to ensure an effective feedback system was in place for its Quality Assurance and Performance Improvement Plan (QAPI). A review of the Quarterly QAPI Minutes indicated that discussions were held on admissions, staffing issues, facility issues, ongoing staff education, shower scheduling, improving transport, and staff scheduling. However, there was no mention of critical resident concerns such as falls, behaviors, Minimum Data Sets (MDS), or care plans, which were identified during the survey. This omission suggests a lack of comprehensive review and discussion of all pertinent issues affecting resident care and safety. During an interview, the Administrator acknowledged that issues are typically brought to their attention through observation, staff, family, or resident concerns. The Administrator admitted that the current feedback system is ineffective, as evidenced by the concerns raised that week. The Administrator also noted that the facility had been focused on admissions in their QAPI efforts over the past year, neglecting to address resident concerns adequately. This lack of focus on resident issues, such as behaviors or abuse/neglect, during QAPI meetings contributed to the deficiency identified by the surveyors.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 31 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Monette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeside Health And Rehab | 8.6 mi | — | 0 | 0 |
| Manila Healthcare Center | 10.9 mi | — | 9 | 0 |
| The Green House Cottages Of Belle Meade | 13.5 mi | — | 0 | 0 |
| Greene Acres Nursing Home | 14.8 mi | — | 6 | 0 |
| Ridgecrest Health And Rehabilitation | 16.5 mi | — | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Monette Manor, Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.