Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
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 Signature Healthcare Of Monteagle Rehab & Wellness during CMS and state inspections, most recent first.
The facility failed to protect residents from physical abuse by other residents, resulting in harm to two residents. One resident with a history of aggression struck another with a water pitcher, causing injury, while another resident entered a room and hit a fellow resident with a walker, leading to cuts and a skin tear. The facility's care plans and policies were not effectively implemented to prevent these incidents.
The facility failed to post accurate daily staffing information for seven days. The policy requires daily updates of staffing details, including the facility name, date, and hours worked by RNs, LPNs, and CNAs. An observation revealed outdated information, and interviews confirmed the lapse, with an LPN acknowledging the oversight.
The facility failed to maintain sanitary kitchen equipment and did not discard expired food, potentially affecting all residents. A food processor had dried food debris, and expired cottage cheese was used in cooking. The Dietary Manager confirmed these deficiencies.
A resident with severe cognitive impairment and contractures was found without access to a call light, as it was on the floor and out of reach. The resident's care plan required the call light to be accessible, but this was not followed, leading to a deficiency.
The facility failed to maintain a clean and homelike environment in three shower rooms and two residents' rooms. Observations showed broken tiles, grime, and trash in shower rooms, and peeling vinyl flooring in residents' rooms. Interviews with staff confirmed these issues had persisted, affecting the quality of the environment for residents with severe cognitive impairments.
The facility did not create person-centered care plans for two residents with PTSD, despite having active diagnoses and treatment regimens. This was confirmed by the Social Services Director, indicating a failure to meet the facility's policy requirements for comprehensive care planning.
A resident with dementia and CHF was prescribed a regular diet with double protein portions at all meals, but the facility failed to communicate this order correctly to the dietary department. As a result, the resident did not receive the prescribed double protein portions for breakfast and dinner, as confirmed by staff interviews and meal observations.
The facility failed to post signage at the entrance to alert visitors of a confirmed Covid-19 outbreak after a resident tested positive. Despite the facility's policy requiring such signage, observations revealed none was posted. The resident, with multiple diagnoses and cognitively intact, tested positive for Covid-19 and was placed on droplet precautions. The IP LPN was unaware of the requirement to post entrance signage, confirming the oversight.
Failure to Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, resulting in actual harm to two residents. Resident #283, who had a history of aggressive behavior and severe cognitive impairment, struck Resident #6 with a water pitcher, causing a laceration and bruising to the left eye. This incident occurred despite the facility's care plan for Resident #283, which included interventions to manage his aggressive behavior. The facility's policy on abuse prevention was not effectively implemented, as Resident #283's behavior was not adequately monitored or controlled, leading to the altercation. In another incident, Resident #31, who also had severe cognitive impairment and a history of agitation, entered Resident #74's room and struck him with a walker, causing a small cut to the earlobe and a skin tear to the hand. The altercation occurred after a gradual dose reduction of Resident #31's medication, which may have contributed to his increased aggression. The facility's care plan for Resident #31 included measures to anticipate and manage his behavior, but these were not sufficient to prevent the altercation. Both incidents highlight the facility's failure to adequately monitor and manage residents with known behavioral issues, resulting in harm to other residents. The facility's policies and care plans were not effectively implemented to prevent these resident-to-resident altercations, indicating a deficiency in protecting residents from abuse.
Failure to Post Accurate Daily Staffing Information
Penalty
Summary
The facility failed to post accurate daily staffing information for seven consecutive days. According to the facility's policy, revised on May 13, 2024, the daily staffing information should include the facility name, current date, total number, and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides, along with the resident census. This information is required to be posted at the beginning of each shift. However, during an observation on July 29, 2024, at 8:00 AM, the daily staff posting displayed a date of July 22, 2024, indicating it had not been updated for seven days. In an interview on July 31, 2024, the Interim Director of Nursing expressed the expectation that nurse staffing would be posted daily. Additionally, an LPN responsible for posting the daily staffing confirmed that the posting on July 29, 2024, was outdated and had not been updated for seven days, acknowledging that it "fell through the cracks."
Unsanitary Kitchen Equipment and Expired Food Use
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary condition and did not discard expired food, which had the potential to affect all 71 residents. During an observation and interview with the Dietary Manager (DM), it was found that the food processor in the food preparation area had dried white food debris, likely bread, and the DM was unsure of its last use. Additionally, in the walk-in refrigerator, a 5-pound container of cottage cheese was found to be expired, yet it was used in cooking lasagna. The DM confirmed that the expired cottage cheese was available for resident use and acknowledged that the food processor was not maintained in a sanitary condition.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach and to provide an adaptive call device suitable for the resident's needs. The resident, who was admitted with diagnoses including encephalopathy, cognitive communication deficit, anxiety, intellectual disabilities, and contractures of the bilateral upper and lower extremities, was observed multiple times with the call bell lying on the floor under the bed, making it unavailable for use. The resident had severe cognitive impairment and was dependent on staff for all activities of daily living, with contractures that prevented the use of a standard push button call bell. Observations on the same day revealed the resident lying in bed, unable to utilize the call bell due to their physical and cognitive limitations. The Interim Director of Nursing and a Certified Nursing Assistant confirmed the call bell was out of reach and acknowledged the resident's inability to use the push button call bell due to severe contractures and cognitive impairment. The care plan indicated the need for the call light to be within reach, but this was not adhered to, resulting in the deficiency.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment in three of four shower rooms and two residents' rooms. Observations revealed missing or broken tiles in the [NAME] and East Shower Rooms, with additional grime and trash present. The East Central Shower Room was noted to have a missing shower control cover. Interviews with CNAs and the Maintenance Director confirmed these issues had persisted for an undefined period, indicating a lack of timely maintenance and attention to the environment. Resident #3, who has severe cognitive impairment, was found to have a room with peeling vinyl flooring at the base of the toilet and walls painted in two different colors, detracting from a homelike environment. Similarly, Resident #74, also with severe cognitive impairment, had peeling vinyl flooring around the toilet with missing pieces. The Maintenance Director confirmed these conditions, acknowledging that both residents' rooms did not reflect a homelike environment as required by the facility's policy on resident rights.
Failure to Develop PTSD Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents diagnosed with Post Traumatic Stress Disorder (PTSD). The facility's policy mandates the creation of such care plans to address the mental and psychosocial needs identified in comprehensive assessments. However, upon review, it was found that Resident #61 and Resident #78, both with active PTSD diagnoses, did not have specific care plans addressing their PTSD. This oversight was confirmed during an interview with the Social Services Director. Resident #61 was admitted with multiple diagnoses, including PTSD, and had severe cognitive impairment as indicated by a quarterly Minimum Data Set (MDS) assessment. Despite having an active treatment regimen for PTSD, there was no person-centered care plan developed for this condition. Similarly, Resident #78, who also had an active PTSD diagnosis and moderate cognitive impairment, lacked a care plan tailored to their PTSD needs, despite having an active treatment regimen in place. These deficiencies highlight a failure to adhere to the facility's policy on comprehensive care planning for residents with PTSD.
Failure to Follow Physician's Dietary Orders
Penalty
Summary
The facility failed to follow a physician's order for a resident who was at risk for nutritional alteration due to diagnoses including dementia and congestive heart failure. The resident was prescribed a regular diet with double protein portions at all meals to address weight stability concerns. However, the dietary department did not receive the complete order, resulting in the resident not receiving the prescribed double protein portions for breakfast and dinner, as confirmed by multiple staff interviews and observations. The resident's meal tickets did not reflect the order for double protein portions, and the dietary manager admitted that the information was not communicated correctly. Despite the resident's weights being stable, the failure to provide the ordered diet was identified during interviews with staff, including a CNA, LPNs, the lead dietician, and the director of regulatory. The deficiency was noted when the resident's meal was observed without the prescribed double protein portions, and the error in communication was confirmed by the dietary manager.
Failure to Post Covid-19 Outbreak Signage
Penalty
Summary
The facility failed to post signage at the entrance to alert visitors of a confirmed SARS-CoV-2 (Covid-19) outbreak after a resident tested positive for Covid-19. The facility's policy, updated in March 2024, required the posting of signs at the entrance to provide guidance during a Covid-19 outbreak. However, observations on July 29 and July 30, 2024, revealed that no such signage was posted at the facility entrance, despite the resident being placed on droplet precautions and having an active Covid-19 infection care plan. The resident involved was admitted with multiple diagnoses, including respiratory failure and schizophrenia, and was cognitively intact according to a recent assessment. The resident complained of a sore throat, leading to a Covid-19 test that returned positive on July 29, 2024. During interviews, the Infection Preventionist LPN stated that she was unaware of the requirement to post signage at the facility entrance, confirming the oversight in the facility's infection prevention and control measures.
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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 Monteagle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Waters Of Winchester, Llc | 15 mi | — | 0 | 0 |
| Southern Tenn Medical Center Snf | 15.4 mi | — | 0 | 0 |
| Elk River Health & Nursing Center Of Winchester | 15.7 mi | — | 0 | 0 |
| Signature Healthcare Of South Pittsburg Rehab & We | 18 mi | — | 0 | 0 |
| Legacy Health And Rehab | 21.3 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.