Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Buchanan Place during CMS and state inspections, most recent first.
A cognitively intact resident with chronic kidney disease, hypertension, and type 2 DM was struck on two occasions by another resident with severe cognitive impairment and aphasia who entered the resident’s room and hit her after being asked to leave. After the first incident, the care plan was revised to include a stop sign on the door, but staff failed to consistently maintain this intervention, including not reattaching it after an appointment and forgetting to put it back up after exiting the room. Surveyors later observed the stop sign missing and no staff in sight while the resident sat on the bed, and the resident reported that the other resident had entered her room and struck her twice and that staff did not keep the stop sign up much. Skin assessments documented transient redness but no lasting injury, and the DON confirmed that physical contact occurred on both occasions.
A resident with chronic kidney disease, essential hypertension, and type 2 DM, who was cognitively intact per MDS/BIMS, had a comprehensive care plan that required a stop sign to be maintained on the room door, with staff assistance as needed to keep it in place. During observation, the stop sign was not on the door, no staff were in sight while the resident sat on the side of the bed, and the resident reported that staff did not keep the stop sign up much anymore. An LPN admitted forgetting to replace the stop sign after leaving the room, and the DON confirmed that the care plan intervention requiring the door stop sign was not followed.
A resident with severe cognitive impairment eloped from a secure unit by following visitors out of the facility, remaining unsupervised for over an hour. The incident occurred due to inadequate supervision and access control, as family members were allowed to have keypad codes. The resident was found at a gas station 1.1 miles away and returned by a CNA.
The facility failed to maintain control over narcotic inventories, leading to diversion incidents involving three residents. Discrepancies in narcotic counts were not reported immediately, and missing narcotics were unaccounted for. A former employee found controlled substances linked to a current employee, and an LPN was found impaired on duty, with missing morphine from a deceased resident's cart. The facility's failure to promptly remove discontinued medications and ensure accurate counts contributed to these issues.
A resident with severe cognitive impairment and wandering behaviors was struck by another resident with aggressive behaviors in a LTC facility. The incident was witnessed by a CNA who intervened and reported it. Despite the facility's policy to protect residents from harm, the altercation occurred, highlighting a deficiency in safeguarding residents from abuse.
Failure to Consistently Implement Safety Measures After Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from physical abuse by another resident on two separate occasions. One resident, admitted with chronic kidney disease, essential hypertension, and type 2 diabetes mellitus, had a quarterly MDS BIMS score of 15, indicating intact cognition. Another resident, admitted with aphasia, cognitive communication deficit, chronic kidney disease, and non-Hodgkin lymphoma, had a quarterly MDS BIMS score of 3, indicating severe cognitive impairment. On one date, nursing documentation showed staff were called to the room and observed a CNA removing the cognitively impaired resident from the cognitively intact resident’s room after the latter reported being hit three times on the left arm. A same-day skin assessment documented slight redness above the antecubital area. Following this first incident, the cognitively intact resident’s care plan was revised to include a stop sign on the door as an intervention. Despite this, a second incident occurred when a nurse at the nurse’s station heard yelling in the hall and then observed the cognitively impaired resident exiting the same resident’s room. When questioned, the cognitively intact resident reported that she had asked the other resident to leave and was then hit. The facility’s investigation documented that the residents were separated and that a skin assessment revealed redness to the left upper breast and left index finger knuckle, with no open areas or swelling and the resident denying pain. A later skin assessment the same evening documented no areas of concern. Surveyor observations and interviews showed that the stop sign intervention was not consistently implemented, contributing to the recurrence of resident-to-resident physical contact. An employee warning form documented that a staff member failed to reattach the stop sign across the doorway after returning the resident from an appointment. During surveyor observation, the stop sign was again not in place outside the resident’s room, and no staff were in sight while the resident sat on the side of the bed. The resident reported that the other resident had come into her room on two occasions and struck her and stated that staff did not keep the stop sign up much. An LPN acknowledged that the stop sign was supposed to be in place and admitted forgetting to put it back up after exiting the room. The DON confirmed that physical contact occurred on both dates when the cognitively impaired resident struck the cognitively intact resident, although neither resident sustained injuries.
Failure to Implement Care Plan Intervention for Door Stop Sign
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan intervention for one resident as required by facility policy. The facility’s care plan policy, revised March 2022, states that comprehensive care plans must include measurable objectives and interventions derived from a thorough analysis of information to meet residents’ physical, psychosocial, and functional needs. Resident #15 was admitted with chronic kidney disease, essential hypertension, and type 2 diabetes mellitus, and a quarterly MDS showed the resident was cognitively intact with a BIMS score of 15. The resident’s comprehensive care plan, revised 4/21/2025, included an intervention for a stop sign to be placed on the resident’s door, with staff to assist as needed to keep the stop sign in place. On 4/14/2026 at 8:24 AM, surveyors observed that the stop sign outside Resident #15’s room was not in place, and no staff were in sight of the room while the resident was sitting on the side of the bed. During an interview at 8:25 AM, the resident stated that staff did not keep the stop sign up much anymore. At 8:27 AM, an LPN acknowledged that the stop sign was supposed to be in place and admitted it was their fault, explaining they had forgotten to put the stop sign back up after exiting the resident’s room. At 8:40 AM, the DON, upon interview and medical record review, confirmed that the care plan intervention for the stop sign on the resident’s door had not been followed and stated she expected the stop sign to be in place for this resident.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a resident, identified as Resident #6, who was at risk due to severe cognitive impairment. Resident #6, admitted to the secure unit with diagnoses including dementia and delusional disorders, was assessed to be at risk for elopement. On the day of the incident, the resident followed a visitor out of the secure unit and subsequently exited the facility through the main entrance doors, remaining unsupervised for over an hour. The incident occurred when Resident #6 followed a visitor out of the secure unit and then a group of visitors out of the main entrance doors. The facility's staff were unaware of the resident's absence until the resident's son arrived and could not locate him. A Code Pink was initiated, and staff searched the facility. The resident was eventually found at a gas station 1.1 miles away by a CNA who drove him back to the facility. Interviews with staff revealed that prior to the elopement, family members were allowed to have access codes for the keypads, which may have contributed to the incident. The facility's failure to provide adequate supervision and control access to secure areas placed Resident #6 and other residents at risk for elopement, leading to the citation of Immediate Jeopardy at F-689.
Narcotic Diversion and Control Failures
Penalty
Summary
The facility failed to maintain proper controls over narcotic inventories, leading to the diversion of narcotic stocks for three residents. The facility's policies required nursing staff to document the full chain of custody for discontinued medications and ensure accurate narcotic counts at each shift change. However, discrepancies in narcotic counts were not immediately reported, and missing narcotics were not accounted for, as seen in the case of a resident whose morphine supply was found to be 7.5 ml short. The involved LPNs did not follow protocol, with one failing to report irregularities immediately and the other not updating the narcotic logs as promised. In another incident, a former employee discovered controlled substances in the possession of a current employee, who denied any wrongdoing. The facility's investigation could not determine how the medications, which were supposed to be destroyed, were diverted. The facility failed to identify the perpetrator or how the misappropriation went undetected, indicating a lapse in the facility's control over discontinued medications. Additionally, an LPN was found impaired on duty, later testing positive for narcotics after being transported to a hospital. An audit revealed missing morphine from a deceased resident's medication cart, which had not been disposed of properly. The facility's failure to promptly remove discontinued medications and ensure accurate narcotic counts at shift changes contributed to multiple incidents of narcotic diversion over the past year.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving two residents. Resident #12, who has a history of Major Depressive Disorder and Dementia with Psychotic Disturbance, was admitted to the facility and had documented wandering behaviors. On the day of the incident, Resident #12, who was severely cognitively impaired and exhibited physical and verbal behaviors, wandered into the room of Resident #21. Resident #21, who was moderately cognitively impaired with aggressive behaviors, struck Resident #12 multiple times on the arms and jaw. A Certified Nursing Assistant (CNA) witnessed the altercation and intervened to separate the residents, reporting the incident to the charge nurse. The facility's policy on abuse and neglect emphasizes the protection of all residents from harm, including physical assault. Despite this policy, the incident occurred, and the facility's documentation confirmed that Resident #12 had no visible injuries following the altercation. The Assistant Director of Nursing confirmed the occurrence of the altercation during an interview. The facility's failure to prevent this incident indicates a deficiency in protecting residents from abuse, as outlined in their policy.
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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 New Tazewell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Claiborne Health And Rehabilitation Center | 1 mi | ★★★★★ | 10 | 0 |
| Tri State Health And Rehabilitation Center | 9.5 mi | ★★★★★ | 8 | 0 |
| Ridgeview Terrace Of Life Care | 12.5 mi | ★★★★★ | 0 | 0 |
| Middlesboro Nursing And Rehabilitation Facility | 14.5 mi | ★★★★★ | 1 | 0 |
| Willow Ridge Center | 17 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 July 2026) and official state health department websites.