Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Failure to Submit Timely PASRR After New Mental Health Diagnoses: The facility failed to submit new Level I PASRRs for two residents after new mental health diagnoses were identified. One resident had a new psychotic disorder diagnosis, and another had PTSD documented in the record; both had prior PASRRs, but no updated PASRR was submitted after the new diagnoses were identified. The DON confirmed that a new Level I PASRR should be submitted with any new major mental health diagnosis.
A resident with obstructive sleep apnea and shortness of breath had a C-PAP machine present in the room and reported using it for over 15 years, but the medical record did not include a physician order for C-PAP use. An LPN and the ADON both confirmed the missing order.
Failure to Perform Hand Hygiene During Meal Service and Keep C-PAP Equipment Clean: An AD delivered and set up meal trays for four residents but did not offer hand hygiene to the residents or sanitize her hands between trays, despite facility policy requiring hand hygiene before serving food and between residents. In a separate finding, a resident’s C-PAP mask and tubing were observed resting on the bed with a brown substance caked inside the mask; the resident did not know when it was last cleaned, and an LPN and ADON confirmed the mask was dirty and needed cleaning.
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 Submit Timely PASRR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a timely Pre-admission Screening and Resident Review (PASRR) after new mental health diagnoses were identified for 2 residents reviewed for PASRR. Facility policy stated that residents requiring Resident Review due to a significant change in status should be identified timely and that an initial Level I screening is performed prior to admission or when a significant change in status occurs. Resident #4 had a prior Level I PASRR showing Anxiety Disorder and Mild or Situational Depression before admission, and the medical record showed admission diagnoses including Anxiety Disorder and Major Depressive Disorder. The record also showed a new diagnosis of Psychotic Disorder with Delusions on 7/4/2025, and later care plan and MDS documentation listed Major Depressive Disorder, Anxiety Disorder, and Psychotic/Delusional Disorder, but no new PASRR was submitted for the new diagnoses. Resident #79 had a prior Level I PASRR listing multiple mental health diagnoses, was admitted with PTSD, and had care plan and MDS documentation reflecting PTSD, but no new PASRR was submitted for that diagnosis. During interview, the DON stated a new Level I PASRR should be submitted with any new major mental health diagnosis and confirmed that neither resident had a new Level I PASRR submitted after the new diagnosis was identified.
Missing Physician Order for C-PAP Use
Penalty
Summary
The facility failed to obtain a physician's order for the use of a C-PAP machine for one resident with diagnoses including obstructive sleep apnea and shortness of breath. Review of the medical record showed the resident was admitted with the C-PAP machine and had a quarterly MDS assessment indicating a BIMS score of 15, showing the resident was cognitively intact. However, the physician orders dated 6/23/2026 did not include an order for C-PAP use. During observations in the resident's room, the C-PAP machine was seen on the bedside nightstand on multiple occasions. In an interview, the resident stated the C-PAP had been used for over 15 years and had been brought to the facility at admission. An LPN later confirmed the resident did not have an order for the C-PAP machine, and the ADON also confirmed there was no physician's order for its use.
Failure to Perform Hand Hygiene During Meal Service and Keep C-PAP Equipment Clean
Penalty
Summary
The facility failed to perform appropriate hand hygiene during meal tray service for four residents. The facility policy stated employees must wash their hands before serving food to residents and before serving the next resident, and the hand washing policy identified hand hygiene as the primary means to prevent the spread of infections. During observations on 6/22/2026, the Activities Director delivered lunch trays to Residents #75, #74, #78, and #6, set up each tray, did not offer hand hygiene to any of the residents, and did not sanitize her hands after serving each tray. The AD later confirmed she had not offered hand hygiene while passing the meal trays and had failed to sanitize her hands after serving the residents. Resident #75 had diagnoses including COPD, DM, and depression, scored 15 on the BIMS, and required setup or clean-up assistance with eating and partial/moderate assistance with ADLs. Resident #74 had diagnoses including adult failure to thrive, DM, dementia, and need for assistance with personal care, scored 3 on the BIMS, and required supervision or touching assistance with eating and partial/moderate assistance with ADLs. Resident #78 had diagnoses including heart failure, DM, and COPD, scored 14 on the BIMS, and required supervision or touching assistance with eating and partial/moderate assistance with personal hygiene. Resident #6 had diagnoses including anxiety, depression, and need for assistance with personal care, scored 10 on the BIMS, and required supervision or touching assistance with eating and dependent assistance with personal hygiene. The facility also failed to ensure C-PAP equipment was kept in a clean and sanitary condition for Resident #26. The resident had obstructive sleep apnea and shortness of breath, scored 15 on the BIMS, and used a C-PAP for over 15 years. During multiple observations in the resident's room, the C-PAP tubing and mask were found resting on the mattress, with the tubing under a pillow at one point, and the inside of the mask had a brown substance caked on it. The resident stated he did not know when the mask had last been cleaned. An LPN confirmed the mask was dirty with a brown substance and could not say when it was last cleaned, and the ADON confirmed the mask was dirty and stated it definitely needed to be cleaned.
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 | ★★★★★ | 9 | 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 October 2026) and official state health department websites.