Cycle 1
Health 2023-03-21 · Fire 2023-03-21
4 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Madisonville, TN
Monroe Health And Rehabilitation Center
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
465 Isbill Rd, Madisonville, TN
(423) 442-3990
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
62
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Champion Care
Operator or chain grouping
Approved since
2002-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
21 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.60
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.15
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.67
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
2.96
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,174
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.23% · Performance 21.23% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.40% · Performance 7.89% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.12
Baseline 97.22% · Performance 42.10% · Measure score 7.12 · Achievement 5.28 · Improvement 7.12
Adjusted total nurse staffing
0
Baseline 2.92 hours · Performance 2.71 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.51% |
10.72%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 92 · Observed rate 17.39% · Lower 95% interval 9.35% |
| Discharge to community | 49.54% |
50.57%
1 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 46.39% · Lower 95% interval 41.16% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.83% |
95.27%
1.6 pts better
|
Numerator 61 · Denominator 63 |
| Falls with major injury | 1.59% |
0.77%
0.8 pts worse
|
Numerator 1 · Denominator 63 |
| Discharge self-care score | 38.3% |
53.69%
15.4 pts worse
|
Numerator 18 · Denominator 47 |
| Discharge mobility score | 31.91% |
50.94%
19 pts worse
|
Numerator 15 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 1.59% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 63 · Adjusted rate 2.01% |
| Healthcare-associated infections requiring hospitalization | 7.89% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 8.57% · Lower 95% interval 4.52% |
| Staff COVID-19 vaccination coverage | 2.02% |
8.2%
6.2 pts worse
|
Numerator 2 · Denominator 99 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 42.55% |
56.45%
13.9 pts worse
|
Numerator 20 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.97% |
96.28%
0.7 pts better
|
Numerator 32 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 16 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.9%
10.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
94.5%
1.7 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
3.6%
2.6 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.3% · Q3 7.5% · Q4 4.2% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
11.8%
10.5 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.5% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
6.2%
1.2 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.1% · Q3 8.8% · Q4 5.1% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.9% |
32.2%
4.7 pts worse
|
19.6%
17.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.9% · Q2 34.4% · Q3 38.2% · Q4 35.9% · 4Q avg 36.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.0% |
18.1%
14.1 pts better
|
16.7%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.8% · Q3 4.2% · Q4 3.4% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.2% |
19.9%
9.3 pts worse
|
16.3%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.8% |
15.3%
0.5 pts better
|
14.9%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 22.2% · Q3 0.0% · Q4 5.9% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.9%
0.5 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.0% · Q3 2.2% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.9%
1.9 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.5% |
20.2%
0.7 pts better
|
19.8%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 27.9% · Q3 20.4% · Q4 14.8% · 4Q avg 19.5% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
5.4%
3 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.8% · Q3 2.3% · Q4 1.8% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.5% |
79.6%
10.9 pts better
|
81.7%
8.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.1% · Q2 89.0% · Q3 88.5% · Q4 92.7% · 4Q avg 90.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.3% |
11.2%
6.1 pts worse
|
12.0%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 17.0% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.8% |
79.8%
8 pts better
|
79.7%
8.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
22.2%
1.5 pts worse
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 21.3% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-30 · Fire 2019-10-30
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-10-24 · Fire 2018-10-24
11 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-03-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-21
F · Potential for more than minimal harm
2023-03-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-21
E · Potential for more than minimal harm
2019-10-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-28
D · Potential for more than minimal harm
2019-10-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-11-28
D · Potential for more than minimal harm
2019-10-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-11-28
F · Potential for more than minimal harm
2018-10-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-10-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2018-10-24
C · Minimal harm
2018-10-24
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2018-10-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-06-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-16
D · Potential for more than minimal harm
2023-06-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-19
F · Potential for more than minimal harm
2023-03-21
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-03-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-21
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-12
B · Minimal harm
2023-03-21
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-04-12
F · Potential for more than minimal harm
2019-10-30
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2019-11-28
G · Actual harm
2018-10-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-11-16
E · Potential for more than minimal harm
2018-10-24
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2018-11-13
D · Potential for more than minimal harm
2018-10-24
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2018-11-09
D · Potential for more than minimal harm
2018-10-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-11-13
D · Potential for more than minimal harm
2018-10-24
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2018-11-16
D · Potential for more than minimal harm
2018-10-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-11-16
D · Potential for more than minimal harm
2018-10-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2018-11-09
D · Potential for more than minimal harm
2018-10-24
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2018-11-12
D · Potential for more than minimal harm
2018-10-24
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2018-11-16
D · Potential for more than minimal harm
2018-10-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-11-16
Penalties and ownership
What sits behind the stars
Ownership
Monroe Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Ruvel, Menachem
5% Or Greater Indirect Ownership Interest · Individual
Weinberg, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Landa, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
Mackie, Alicia
5% Or Greater Indirect Ownership Interest · Individual
Fink, Ephraim
5% Or Greater Indirect Ownership Interest · Individual
Champion Care LLC
Operational/Managerial Control · Organization
Ruvel, Menachem
Operational/Managerial Control · Individual
Ruvel, Menachem
Corporate Officer · Individual
Weinberg, Yisroel
Corporate Officer · Individual
Werden, Jason
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Waters Of Sweetwater A Rehabilitation & Nursing
Sweetwater, TN
2-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Wood Village
Sweetwater, TN
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Starr Regional Health & Rehabilitation
Etowah, TN
3-star overall rating with 3-star inspections with $8,697 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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