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 Monroe Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain a clean and sanitary environment in multiple resident rooms and bathrooms, despite policies requiring routine cleaning and disinfection. Observations over several days found a motorized wheelchair and another wheelchair with attached cushion soiled with dried, multi-colored debris. Several resident bathrooms had unclean conditions, including a trash can without a liner and with dried brown residue, toilets with dried yellow residue on the seats, and yellow/orange or brown substances around the bases of multiple toilets. During an on-site check, the Administrator confirmed that the residue around one toilet could be wiped away and that the area was not clean.
The facility failed to maintain accurate and complete medical records for three residents, including one with a history of falls and moderate cognitive impairment whose documented fall and associated evaluations were not accurately reflected in the medical record. Two other residents with diabetes and multiple comorbidities had physician orders for medications such as lacosamide, levothyroxine, sliding-scale insulin, and metoclopramide, but the MAR contained blanks where administration or required blood glucose values should have been recorded. The DON confirmed that medications must be documented when given or withheld, and that blank MAR entries indicated missing documentation, demonstrating noncompliance with the facility’s fall documentation and medication administration policies.
A resident with severe cognitive impairment and a history of verbal behaviors was involved in multiple altercations with other residents, resulting in physical abuse incidents. Despite having a care plan with interventions for physical behaviors, the facility failed to prevent these interactions, leading to slapping and grabbing incidents involving three other residents. The facility's policy on abuse was not effectively enforced, as staff intervened only after the incidents occurred.
Failure to Maintain Clean and Sanitary Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean and sanitary environment in multiple resident rooms and bathrooms, contrary to its own policies on routine bathroom cleaning and routine cleaning and disinfection. The facility’s policies, dated 6/2025, required providing a clean and sanitary environment, cleaning the entire toilet including the handle and underside of the flush rim with disinfectant and appropriate contact time, and reporting damaged items in need of repair. Observations conducted on several days showed that in one room, a motorized wheelchair had dried debris on the cushion, arms, and a large amount of multi-colored debris on the undercarriage. In another room, a wheelchair with a fabric heel protector cushion used as an armrest was spattered with small to pea-sized unknown multi-colored particles. Additional observations revealed that several resident bathrooms were not maintained in a sanitary condition. One bathroom had a trash can without a bag and with a dried brown substance on the outside, rim, and inside of the can, as well as a toilet seat with two areas of dried yellow residue and a yellow/orange substance around the base of the toilet. Other bathrooms in different rooms had yellow/orange or brown residue around or at the front base of the toilets. During an observation and interview in one of the bathrooms, the Administrator initially suggested the substance around the toilets might be related to the wax ring, but after wiping a small area with a wet wipe, the yellow/orange substance was easily removed, and the Administrator confirmed the area around the toilet was not clean.
Failure to Maintain Accurate and Complete Medical Records for Falls and Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with its own policies and accepted professional standards for three residents. The facility’s Fall Prevention Program policy, revised 10/01/2025, required that when any resident experiences a fall, staff must document all evaluations, assessments, and actions taken. For a resident with a history of falls, moderate cognitive impairment, and care plan problems including an ADL self-care performance deficit related to stroke and risk for falls, there was a documented fall on 10/3/2025 at 5:30 PM in a Fall Scene Investigation Report and an unwitnessed fall with head injury record. However, the DON stated that the medical record documentation for this resident was not accurate and did not reflect the fall event. The facility’s Medication Administration policy required staff to review the MAR to identify medications to be administered, remove medications from the source, administer them as ordered, and sign the MAR after administration. For a resident with COPD, diabetes mellitus, end stage renal disease, and dependence on hemodialysis, whose care plan included diabetes management and who was cognitively intact per MDS, multiple physician orders were not accurately or completely documented on the MAR. Lacosamide ordered to be given in the evening after hemodialysis on specific days showed no documentation of administration on one date. Levothyroxine ordered once daily had no documentation of administration on a morning dose. A sliding-scale insulin lispro order requiring blood glucose checks every six hours had no documented blood glucose levels at several scheduled times, and metoclopramide ordered before meals for nausea had no documentation of administration at multiple scheduled times. Another resident with type 1 diabetes mellitus with chronic kidney disease, history of stroke, and congestive heart failure, whose care plan also included diabetes management and who had moderate cognitive impairment per MDS, had a physician’s order for sliding-scale insulin lispro to be given three times a day on specified days. The MAR for this resident lacked documentation of the blood glucose level needed to determine the insulin dose at a scheduled time. During an interview, the DON confirmed that medications should be documented on the MAR when administered or withheld, including the reason for holding a medication, and acknowledged that blanks on the MAR for the two residents meant those scheduled medication doses were not documented, further supporting that the medical records were incomplete and inaccurate.
Failure to Prevent Resident Abuse by Another Resident
Penalty
Summary
The facility failed to prevent abuse for three residents, resulting in incidents involving Resident #2, who was involved in altercations with Residents #3, #4, and #5. Resident #2, who had severe cognitive impairment and a history of verbal behaviors, slapped Resident #4 and Resident #3 on separate occasions and grabbed Resident #5's arm. These incidents occurred over a span of five days, during which Resident #2 was not adequately supervised to prevent these interactions. Resident #2 was admitted with multiple diagnoses, including unspecified dementia with behaviors, and had a care plan that included interventions for physical behaviors. Despite this, the facility did not effectively implement measures to prevent Resident #2 from physically interacting with other residents. The facility's policy on abuse, neglect, and exploitation was not adequately enforced, as evidenced by the repeated incidents involving Resident #2. The facility's investigation documentation and interviews revealed that staff were aware of Resident #2's behaviors but failed to prevent the altercations. The Director of Nursing confirmed that Resident #2's aggression was unprovoked and that the facility did not prevent the abuse of the other residents. The incidents were witnessed by staff, who intervened after the fact, but the lack of proactive measures to prevent these interactions highlights the deficiency in protecting residents from abuse.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Madisonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Sweetwater A Rehabilitation & Nursing | 8.1 mi | — | 0 | 0 |
| Wood Village | 8.3 mi | — | 0 | 0 |
| Starr Regional Health & Rehabilitation | 12.6 mi | — | 3 | 0 |
| Life Care Center Of Athens | 13.1 mi | — | 12 | 1 |
| Nhc Healthcare, Athens | 13.8 mi | — | 0 | 0 |
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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.