Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tri Cities Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Meals were not served according to the posted menu or required portion sizes. Dietary staff used smaller scoops than the menu called for when serving beef noodle casserole and preparing chicken salad sandwiches, and one DA did not reference the menu when making alternative meals. A resident reported still being hungry after meals at times, while the DON, RD, and DM acknowledged that incorrect portions affected accurate intake documentation and reflected that dietary staff were not consistently following menu requirements.
A facility failed to maintain its infection prevention and control program when surveyors found multiple unsanitary conditions in a shared bathroom used by two residents. Observations showed an unbagged trash can, bed pan and graduate on the floor, opened wipes on a geri-chair, an unbagged urinal, an unbagged bedside commode with an opened brief on top, opened briefs on the floor, and oxygen tubing hanging on the toilet handle. A CNA said briefs and wipes should be kept in resident closets and bathroom items should be bagged for sanitary reasons, while the DON, IP, and Administrator acknowledged expectations for proper infection control and storage.
Cold, unpalatable coffee was served during meal service, affecting multiple residents. Dietary staff prepared coffee and left it on a non-insulated cart while trays were delayed, and the beverage was later sampled by the DM and SSA surveyors as slightly above room temperature, acidic, and bitter. Residents reported the coffee was frequently served cold, and both the DM and Administrator stated they were not actively monitoring tray line temperatures or auditing the process.
The facility failed to ensure the dietary department was managed by a qualified director, affecting 67 of 69 residents. The Dietary Manager (DM) was not a Certified Dietary Manager (CDM) and had no prior management experience. The Registered Dietitian (RD) confirmed the DM's lack of certification and encouraged her to complete the necessary courses.
The facility failed to follow menus and portion control guidelines, affecting 67 out of 69 residents. Observations revealed unapproved food substitutions and incorrect scoop sizes used for serving meals. The Dietary Manager admitted to not having the correct menus, and the Registered Dietitian confirmed the use of incorrect scoop sizes. The Administrator was unaware of these issues, which could impact the nutritional adequacy and palatability of meals.
The facility failed to maintain proper food safety practices, affecting 67 residents. Food items were not dated or labeled, and temperature logs were incomplete. Unlabeled food and improper storage of utensils posed risks of food-borne illnesses and cross-contamination. The issues were confirmed by the Dietary Manager and reported to the Administrator and DON.
The facility failed to properly dispose of and contain garbage, affecting 69 residents and staff. Observations revealed dumpsters with lids off, exposing contents, and debris around the area, attracting bears. The Maintenance Director noted daily cleaning efforts and ineffective animal control measures. The Administrator confirmed the lack of a formal policy on this issue.
The facility failed to ensure staff used proper PPE while cleaning dumpsters disturbed by bears, posing an infection control risk. The Maintenance Director cleaned without PPE, and the Infection Preventionist and Director of Housekeeping acknowledged the issue. The Administrator and DON were unaware of the situation.
The facility failed to ensure residents and/or their representatives were invited to participate in care plan meetings, as required. Six residents' records lacked evidence of invitations or participation in quarterly care conferences. The Social Services Director admitted to only sending invitations annually or upon significant changes, unaware of the quarterly requirement. The Administrator and DON acknowledged the failure to conduct quarterly care plan meetings and the lack of documentation of invitations.
Two residents, one severely and one moderately cognitively impaired, engaged in a physical altercation in the smoking area, resulting in minor injuries. The facility's failure to implement its abuse prevention policy led to this incident, as confirmed by records and staff interviews.
A resident with severe cognitive impairment and multiple diagnoses did not receive prescribed Mighty Shakes with meals, leading to significant weight loss. Facility staff failed to document the administration of the supplements, and the resident was not re-weighed as per policy. The Dietary Manager was unaware of the weight loss, and the Registered Dietitian's recommendations were not followed.
A facility failed to provide trauma-informed care to a resident with PTSD, schizoaffective disorder, and other conditions. The resident's care plan did not address PTSD, and staff were unaware of the diagnosis. The Social Services Director did not document the resident's mental health history, and the DON expected staff to assess PTSD triggers, which was not done.
A resident with moderate cognitive impairment and complete dependence on staff was found to have side rails in use without proper assessment, care plan, or informed consent. Observations and staff interviews confirmed the lack of necessary documentation, and facility leadership acknowledged the oversight.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.14% error rate. One resident with COPD was not prompted to rinse his mouth after receiving an inhaled steroid, and another resident with diabetes did not have the insulin pen needle left in place for the required time. Both errors were acknowledged by the staff involved, and the DON and Administrator confirmed the expectation for adherence to medication administration guidelines.
Meals Served in Incorrect Portion Sizes
Penalty
Summary
The facility failed to serve meals in accordance with the established menu and required portion sizes. Facility policies required menus to be developed, prepared, followed, reviewed by the RD, and implemented using standardized portions, but during observation dietary staff used a 4-ounce scoop for beef noodle casserole when the posted menu/serving guide called for a 6-ounce portion. During another observation, a DA prepared chicken salad sandwiches using a 1 7/8-ounce scoop and did not add any additional portion, even though the menu was not referenced to confirm the planned sandwich portion size. Interviews showed that dietary staff were aware the portions being served did not match the menu. One dietary staff member stated that when the menu required a scoop size not available at the facility, the closest smaller scoop was used instead of a larger scoop, which meant residents were not receiving the portion sizes indicated on the menu. That staff member also stated the facility did not have scoops for several listed portion sizes and that the smaller scoop sizes were used because larger portions were avoided. The same staff member stated she always used the same smaller scoop for chicken salad and did not reference the menu when preparing alternative meals such as sandwiches. Resident and leadership interviews confirmed the impact of the inaccurate portioning on meal service and intake documentation. A resident stated meals were sometimes not enough to make him feel full and that he would still be hungry. The DON stated residents depended on dietary staff to follow menus and serve correct portions so meal intake could be accurately recorded. The RD stated inaccurate portioning interfered with her ability to assess residents' nutritional status because documented intake could not be accurately determined when staff did not serve the planned portions. The DM stated she had not been performing tray audits or actively monitoring tray line service and acknowledged that dietary staff did not always follow the correct portion sizes.
Infection Control Lapses in Shared Resident Bathroom
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 12 of 22 sampled residents. Review of the facility policy stated environmental cleaning and disinfection were to be performed according to facility policy, and all staff had responsibilities related to cleanliness and were to report problems outside their scope to the appropriate department. During observations of the shared bathroom in the rooms of two residents, surveyors found multiple infection control issues. These included an empty trash can with no bag, a bed pan and graduate on the bathroom floor, an opened pack of wipes on a geri-chair, an unbagged urinal between the wall and handrail next to the toilet, a bedside commode stored in the bathroom unbagged with an opened brief on top of it, two opened packages of briefs on the bathroom floor, an opened package of briefs on the floor, an opened unpackaged brief between the wall and handrail behind the toilet, and oxygen tubing hanging on the toilet handle. A CNA stated personal items such as briefs and wipes were to be kept in the resident's closet and items in the bathroom were to be placed in a bag for sanitary reasons. The DON stated the conditions were unacceptable and that staff were educated monthly on infection control, while the IP stated staff were expected to bag items not being used and that she had not found issues on the floors. The Administrator stated dirty items were to be put in dirty storage until cleaned and returned to service.
Cold, Unpalatable Coffee Served During Meal Service
Penalty
Summary
The facility failed to ensure beverages were served in a palatable manner, including proper temperature and taste, for 6 of 22 sampled residents: R27, R33, R23, R35, R51, and R40. The deficiency was identified during observation, interview, and review of the facility’s policy titled Standardized Menus, which required nourishing and palatable meals and consistent implementation of menus to support meal acceptability and palatability for residents. During breakfast meal service, dietary staff prepared coffee and placed it in mugs with plastic lids on an open metal cart behind the tray line, where it remained before being served. The facility’s posted mealtimes showed staggered meal delivery times across units and dining rooms, and the test tray did not leave the kitchen until 8:08 AM. It was observed in the Railroad dining area at 8:09 AM while waiting for nursing staff to deliver trays, and the last resident tray was not delivered until 8:21 AM, when temperatures were checked on the test tray by staff and verified by the DM. At that time, the thermometer read 98.6, and the coffee sampled by the DM and two SSA surveyors was described as slightly above room temperature, acidic, and bitter, and not served at an acceptable temperature. Resident and staff interviews supported that the issue had been ongoing. R35 stated the coffee he drank was cold and bitter and that he had told staff something needed to be done about the temperature. During Resident Council, members including R27, R33, R23, and R51 stated hot food and beverages, especially drinks, were frequently served cold and that they had previously reported the concern. R40 stated his coffee was always served ice cold in his room and that he should not have to go to the kitchen to get hot coffee himself. Dietary staff stated coffee was prepared and placed on a non-insulated cart, that its temperature would likely decrease if it remained there for an extended period, and that they had not been given guidance on monitoring beverage temperature once on the cart or on replacing coffee if meal service was delayed. The DM and Administrator stated they had not been actively monitoring tray line temperatures or auditing the process to ensure beverages were served palatably.
Unqualified Dietary Management in Facility
Penalty
Summary
The facility failed to ensure that the dietary department was managed by a qualified director of food and nutrition services, which had the potential to affect 67 of the 69 residents living at the facility. The deficiency was identified through document review, interviews, and policy review. The 2022 Food Code US FDA requires that the person in charge be a certified food protection manager, which was not the case at this facility. The facility's own document titled 'Food Service Manager' also indicated the need for a certified food protection manager. The Dietary Manager (DM) was hired as a cook and later transitioned to a weekend manager role, with plans to become a full-time manager and begin testing for her dietary credentials as a Certified Dietary Manager (CDM). However, the DM confirmed she had no prior management experience in a nursing facility and was not far along in her studies for the CDM exam. The Registered Dietitian (RD) confirmed that the DM was not a CDM and had encouraged her to complete the necessary courses. The RD did not supervise the current DM, and the Administrator and Director of Nursing stated that the RD would provide additional training to the DM.
Menu and Portion Control Deficiencies
Penalty
Summary
The facility failed to ensure that menus and menu extensions were followed, which included providing appropriate approved food substitutions, ensuring recipes were followed, and proper scoop sizes were utilized for 67 out of 69 residents. During an initial tour of the kitchen, it was observed that Cook1 replaced lima beans with pinto beans without evidence of an approved substitution. The Dietary Manager (DM) admitted that the menu for the week was incorrect and that the kitchen staff did not have the correct menus to follow. Additionally, the DM acknowledged that beef bouillon was available but not used, which could affect the nutritional adequacy of pureed meat dishes. Further observations revealed that incorrect scoop sizes were used for serving various food items, such as pureed beef, pinto beans, mashed potatoes, and ground fried steak. The DM and the Registered Dietitian (RD) confirmed that the wrong scoop sizes were used, which deviated from the standard practice outlined in the menu extension. The Administrator was unaware of these discrepancies and acknowledged that using water instead of bouillon could affect the palatability and caloric content of the food served.
Food Safety Deficiencies in Kitchen and Storage Areas
Penalty
Summary
The facility failed to ensure proper food safety practices in the kitchen and storage areas, affecting 67 out of 69 residents. Observations revealed that food items were not consistently dated and labeled, and food temperature logs were incomplete. Specifically, temperature logs for breakfast, lunch, and dinner were missing entries for several days in September 2024. The Registered Dietitian had previously discussed the importance of maintaining these logs with the Dietary Manager to prevent food from entering unsafe temperature zones. During a kitchen tour, it was found that several food items in the reach-in refrigerator were not labeled or dated, including cooked cabbage, mandarin oranges, and other perishable items. Additionally, scoops were left in containers of cereal, posing a risk of cross-contamination. The Dietary Manager confirmed these issues, acknowledging the potential for food-borne illnesses, especially for residents with compromised immune systems. The Administrator and Director of Nursing were informed of these concerns, which highlighted lapses in food safety protocols.
Improper Garbage Disposal and Containment
Penalty
Summary
The facility failed to ensure proper disposal and containment of garbage, which had the potential to affect 69 residents and staff. During an initial tour of the kitchen, two outside dumpsters were observed with lids off the hinges, exposing the contents. Debris, including old food, soup containers, disposable cups, and used adult briefs, was found both inside and outside the fenced area, emitting a strong odor. A Dietary Aide noted that bears would climb over the fence, pulling or tossing trash bags, which they then tore apart. The Maintenance Director stated that he cleaned the area daily and mentioned that animal control did not assist with managing the bears. He also noted that the dumpster lids could be fixed and that the electric deterrent on the fence was ineffective against the bears. During an interview, the Administrator confirmed the expectation for the area around the dumpster to be cleaned but acknowledged the absence of a formal policy addressing this issue.
Inadequate PPE Use During Dumpster Cleanup
Penalty
Summary
The facility failed to ensure that staff donned appropriate personal protective equipment (PPE) while cleaning the outside of two facility dumpsters, which posed a potential infection control issue. During an observation, it was noted that the Maintenance Director (MD) cleaned up trash scattered by bears without wearing any PPE except for latex gloves. The trash included used adult incontinence briefs and food waste, which could carry bacteria such as salmonella and E. coli. The MD acknowledged the risk of carrying bacteria back into the facility. Dietary Aides confirmed that the MD did not wear PPE during the cleanup process. The Infection Preventionist (IP) was aware of the bear activity but was unaware that staff were not using PPE, recognizing this as a potential infection control issue. The Director of Housekeeping also noted that her staff, who took out trash to the dumpsters, sometimes assisted in cleaning without wearing rubber boots, which could lead to contamination. The Administrator and the Director of Nursing (DON) were unaware of the situation, indicating a lack of communication and oversight regarding infection control practices related to the cleanup of bear-disturbed trash.
Failure to Conduct and Document Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were invited to participate in the development or revision of their care plans, as required. This deficiency was identified for six residents out of a sample of 23. The facility's policy mandates documentation of invitations to care conferences in the progress notes, and if a resident or their representative chooses not to participate, this should also be noted. However, the records for these residents lacked evidence of such invitations or participation in care planning meetings. For Resident 3, the electronic medical record did not show any evidence of invitations or participation in quarterly care conferences, despite the resident being moderately cognitively impaired. Similarly, Resident 19's records also lacked documentation of invitations or participation in care conferences. The Social Services Director admitted to only sending invitations annually or upon significant changes, unaware of the quarterly requirement. Resident 46, who was cognitively intact, also did not have any care plan meetings documented, with the Director of Nursing confirming no meetings had been held. Resident 56 had not had a care plan meeting since January 2023, and the facility had not followed up on an invitation sent in August 2024. Resident 1's records showed no care planning meetings since March 2024, and the resident's father, who was the medical decision-maker, stated he had not received any invitations. Resident 8, who was moderately cognitively impaired, had not had a care plan meeting since March 2022, and the Social Services Director confirmed that meetings were not held if residents declined. The Administrator and Director of Nursing acknowledged the failure to conduct quarterly care plan meetings and the lack of documentation of invitations.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents, R15 and R48, from physical abuse, resulting in a physical altercation between them in the smoking area. R48, who was severely cognitively impaired, and R15, who was moderately cognitively impaired, engaged in a confrontation that led to both residents sustaining minor injuries. The incident occurred when R15 attempted to direct R48 to a specific spot, leading to a physical exchange. Both residents were separated by staff, and minor first aid was administered for scratches. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the altercation between R15 and R48. The facility's records, including incident logs and investigation summaries, confirmed the occurrence of the altercation and the subsequent injuries. Interviews with staff and residents indicated that this was the first incident of its kind between these two residents, and the facility's administration acknowledged the expectation that residents should not be subjected to abuse.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to provide a resident, identified as R38, with the recommended and physician-prescribed nutritional interventions to prevent weight loss. R38, who was severely cognitively impaired and had diagnoses including heart disease, chronic kidney disease, and acute respiratory failure, was ordered to receive a regular diet with Mighty Shakes, a nutritional supplement, with each meal. However, documentation from the Medication Administration Record, Treatment Administration Record, and Certified Nursing Assistant daily documentation revealed that R38 did not receive the Mighty Shakes as ordered, and there was no record of refusal by the resident. Observations and interviews confirmed that R38 was not receiving the Mighty Shakes with meals. Certified Nursing Assistants familiar with R38 indicated that the resident was not on the list of those receiving supplements and that the resident did not receive the shakes consistently. The Dietary Manager was unaware of R38's weight loss and did not follow up on the Registered Dietitian's recommendations until receiving an order from the nursing staff. The Registered Dietitian confirmed that her recommendations for Mighty Shakes were communicated weekly to the Director of Nursing and the Dietary Manager, but the facility staff did not document the administration of the supplements. The facility's policy required re-weighing residents after significant weight changes, but R38 was not re-weighed after a 5.65% weight loss in two weeks. The Registered Dietitian was not informed of the deviation from the recommended plan of care, which included the administration of Mighty Shakes. The Director of Nursing and the Administrator stated that their expectation was for residents to be re-weighed with any significant weight loss and for the Registered Dietitian's recommendations to be followed.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to a resident diagnosed with PTSD, among other conditions. The resident, who had right side paralysis and was aphasic, was admitted with a history of stroke, schizoaffective disorder, bipolar disorder, depression, anxiety, and chronic PTSD. Despite these diagnoses, the facility did not develop a care plan addressing the resident's PTSD or identify specific traumatic events. The resident's medical record lacked a trauma-informed care approach, and sections related to mental health history were left blank in assessments. Interviews with facility staff revealed a lack of awareness and understanding of the resident's psychiatric diagnoses. A CNA and an RN were unaware of the resident's PTSD diagnosis, and the Social Services Director admitted to not documenting the resident's mental health history. The Director of Nursing expressed that staff should assess residents with PTSD for causes and triggers, but this was not done for the resident in question. This oversight had the potential to affect the resident's quality of life by not addressing their trauma-related needs.
Failure to Assess and Document Use of Side Rails
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the use of side rails, had a care plan in place, and obtained informed consent for their use. The resident, who was moderately cognitively impaired and completely dependent on staff for movement and transfers, was observed with side rails in use on her bed. However, there was no documentation in the resident's medical records, including the Admission Record, Minimum Data Set, Order Summary Report, or comprehensive care plan, indicating an assessment or informed consent for the use of side rails. Observations confirmed the presence of side rails, and staff interviews revealed that the resident was unable to use the rails for movement or transfers. The Registered Nurse responsible for ensuring the necessity of bedrails acknowledged the lack of assessment, care plan, and informed consent documentation. The Director of Nursing and the Administrator also confirmed that the resident's use of side rails had not been properly documented, indicating a lapse in the facility's procedures.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.14% error rate during the survey. Two specific incidents contributed to this deficiency. In the first incident, a resident with chronic obstructive pulmonary disease (COPD) was administered an inhaled steroid medication, Tiotropium Bromide Monohydrate (Spiriva), without being prompted to rinse his mouth afterward. This oversight was observed during a medication administration by a Certified Nursing Assistant/Kentucky Medication Assistant (CNA/KMA), who later admitted to being unaware of the need for the resident to rinse his mouth after using the inhaler. In the second incident, a resident with type two diabetes was administered insulin using a Kwikpen Insulin Pen. The Registered Nurse (RN) administering the insulin failed to leave the needle inserted in the resident's subcutaneous tissue for the required amount of time to ensure full absorption of the medication. The RN acknowledged the mistake, stating she believed the needle should have been left in place for 10 seconds but did not do so. The Director of Nursing (DON) and the facility Administrator confirmed that the expectation was for medications to be administered according to established guidelines and procedures.
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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 Cumberland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lee Health And Rehab Center | 15 mi | ★★★★★ | 1 | 0 |
| Letcher Manor | 15.8 mi | ★★★★★ | 1 | 0 |
| Heritage Hall Big Stone Gap | 16.4 mi | ★★★★★ | 0 | 0 |
| Harlan Health And Rehabilitation Center | 19.1 mi | ★★★★★ | 0 | 0 |
| Ridgecrest Manor Nursing & Rehabilitation | 21.1 mi | ★★★★★ | 0 | 0 |
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