Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Claiborne Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and reduced mobility was found to have her legs wrapped with a sheet and covered with a blanket while seated in a geri-chair, restricting her movement. Staff interviews and video surveillance confirmed that a CNA performed this action to manage the resident's restlessness and prevent her from moving or throwing her blanket, without a physician order or proper documentation. The facility's policy prohibits the use of restraints for staff convenience, and the action was not medically justified.
Staff failed to report an allegation of sexual abuse involving a resident with severe cognitive impairment within the required two-hour timeframe. Multiple staff members became aware of the resident's and her family's concerns but did not notify administration or authorities as required by policy, resulting in a delay until the police informed the facility and an investigation was initiated.
A resident with severe cognitive impairment was the subject of an alleged sexual abuse concern that was communicated to multiple staff members, including a CNA, RN, social worker, and MDS coordinator. Despite the facility's policy requiring immediate investigation of abuse allegations, staff did not report or investigate the concern until it was brought to the facility's attention by local authorities several days later.
Failure to Obtain Consent for Psychotropic Medication: A resident with anxiety, dementia, and depression received PRN lorazepam/Ativan for anxiety and agitation, with 3 doses documented on the MAR. The resident had severe cognitive impairment per BIMS, and the RN MDS Coordinator confirmed there was no consent on file for the psychotropic medication despite the facility policy requiring advance resident or representative informed consent.
Call Lights Out of Reach for Two Residents: Two residents with cognitive impairment and significant assistance needs were observed lying in bed with their call lights hanging behind the bed and out of reach. One resident had a care plan intervention to keep the call light in reach, and the DON confirmed both call lights were out of reach during observation.
Two residents had inaccurate MDS assessments because their PASRR Level II serious mental illness status was not coded. One resident with bipolar disorder, depression, anxiety, and dementia had a significant change MDS that did not reflect the Level II PASRR outcome, and another resident with anxiety, depression, and schizoaffective disorder had an annual MDS that also omitted the Level II PASRR status. The RN MDS Coordinator confirmed both assessments were inaccurate.
Care plans for two residents did not address documented PASRR Level II outcomes related to serious mental illness. Both residents had psychiatric diagnoses and BIMS scores of 15 indicating cognitive intactness, but their comprehensive care plans failed to reflect the PASRR findings. The RN MDS Coordinator confirmed the omissions during record review and interview.
Failure to offer hand hygiene before meal tray service. A CNA delivered and set up a resident’s lunch tray without offering hand hygiene, despite facility policy requiring proper hand hygiene before and after eating. The resident had severe cognitive impairment, required assistance with eating and personal hygiene, and the DON confirmed hand hygiene was expected before meal trays were served.
Failure to Prevent Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as required by its policy and federal regulations. The policy defined a physical restraint as any device or material that restricts a resident's freedom of movement and cannot be easily removed by the resident. The incident involved a resident with reduced mobility, dementia, and anxiety, who was dependent on staff for personal hygiene and required substantial assistance with bed mobility and transfers. There was no documentation or physician order for the use of restraints for this resident. On the day of the incident, video surveillance showed a CNA wrapping a sheet around the resident's lower legs while she was seated in a geri-chair, then covering her legs with a blanket and tucking it under her legs. The CNA and other staff members later described this action as a way to prevent the resident from moving her legs, kicking off her blanket, or potentially falling. Multiple witness statements and interviews confirmed that the CNA had wrapped or tied the resident's legs to the chair, and that this was done to manage the resident's restlessness and prevent her from throwing her blanket on the floor. The CNA stated that this practice was common among staff, especially when they were short-staffed, and did not consider it a restraint because the resident could still move her legs to some extent. Despite the CNA's and some staff's belief that the resident was not fully restrained, the video and witness accounts indicated that the resident's ability to move her legs independently was restricted. The facility's own Human Resources Manager and Administrator acknowledged that the sheet was wrapped and tucked in a manner that limited the resident's movement, and the Quality and Regulation Manager stated that such wrapping would be considered a restraint if it prevented independent movement of the legs. There was no evidence that the use of the sheet as a restraint was medically necessary or properly documented, and the action was taken for staff convenience rather than to address a medical symptom.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse involving a resident with severe cognitive impairment within the required two-hour timeframe. The facility's policy mandates immediate reporting of all alleged violations, including abuse, to the Administrator, state agency, and other authorities within two hours if the allegation involves abuse or results in serious bodily injury. Despite this, multiple staff members, including a Family Nurse Practitioner, Certified Nurse Assistant, Registered Nurse, Social Worker, and RN MDS Coordinator, became aware of the resident's and her family's concerns about possible sexual abuse but did not report the allegation to administration or authorities as required. The resident in question was admitted with diagnoses including dementia, heart failure, and a mixed receptive-expressive language disorder, and was assessed as having severe cognitive impairment. The concern was initially raised by the resident's daughter, who reported that her mother believed someone had touched her inappropriately. Staff interviews revealed that the daughter's concerns were communicated to several staff members, who either did not act on the information or assumed others would report it. The Social Worker and other staff did not notify administration, citing the family's belief that the incident may have been imagined and their stated desire not to file a complaint. The failure to report persisted until the local police department notified the facility that an allegation had been filed with Adult Protective Services by the resident's daughter, at which point the facility initiated an investigation. The Administrator confirmed that staff had prior knowledge of the allegation before being notified by the police, indicating a clear delay in reporting as required by facility policy and federal regulations.
Failure to Timely Investigate Alleged Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse in a timely manner for a resident with severe cognitive impairment, as required by its own policy. The policy mandates that an immediate investigation is warranted when there is suspicion or report of abuse, neglect, or exploitation, and outlines specific procedures for such investigations. Despite this, the facility did not initiate an investigation until nine days after staff first became aware of the allegation. The resident involved had diagnoses including dementia, heart failure, and a mixed receptive-expressive language disorder, and was assessed as having severe cognitive impairment. Multiple staff members, including a CNA, RN, social worker, and MDS coordinator, became aware of the resident's or her family's concerns that someone may have sexually abused her. These concerns were communicated to various staff members, but none of them reported the allegation to the facility's Abuse Coordinator or administration as required. The social worker and other staff did not act on the information, partly because the family expressed doubt about the allegation and did not wish to file a complaint. The delay in reporting was only identified after the local police department notified the facility that an allegation had been made and reported to Adult Protective Services. At that point, the facility initiated an investigation, but it was confirmed by the administrator that staff had prior knowledge of the allegation and failed to report or investigate it promptly, resulting in a failure to follow the facility's abuse investigation policy.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain consent for the administration of a psychotropic medication for one resident. The facility policy on psychotropic medications stated that the resident or resident representative would be informed in advance of the risks and benefits of the proposed care, treatment alternatives or other options, and the preferred option to accept or decline, using a written consent form or narrative note. However, review of the medical record for Resident #3 showed diagnoses including anxiety, dementia, and depression, and a physician order dated 7/27/2025 for lorazepam oral concentrate 2 mg/ml, 1 ml by mouth every 4 hours as needed. Resident #3’s quarterly MDS assessment showed a BIMS score of 0, indicating severe cognitive impairment, and the resident received an antianxiety medication during the 7-day look-back period. A psychiatric periodic evaluation note dated 9/19/2025 documented ongoing management of anxiety and that hospice had more recently initiated lorazepam for anxiety and agitation. The MAR for 11/01/2025 through 11/20/2025 showed three doses of Ativan 2 mg were administered. During observation on 11/17/2025, the resident was lying in bed watching TV and showed no signs of anxiety, distress, or adverse effects. On 11/20/2025, the RN MDS Coordinator confirmed there was no consent for the use of Ativan for Resident #3.
Call Lights Out of Reach for Two Residents
Penalty
Summary
The facility failed to ensure call lights were in reach for two residents. Resident #15 had diagnoses including Reduced Mobility, Adult Failure to Thrive, Dementia, and Anxiety, and the care plan for ADL deficit related to Dementia included keeping the call light in reach while in the room. A quarterly MDS assessment showed severe cognitive impairment, and the resident was dependent on staff for ADLs, bed mobility, and transfers. Resident #58 had diagnoses including Muscle Weakness, Need for Assistance with Personal Care, and Dementia. A quarterly MDS assessment showed a BIMS score of 12, indicating moderate cognitive impairment, and the resident required substantial/maximal assistance with showering/bathing and transfer from bed to chair. During observations of both residents in their rooms, each was lying in bed with the call light hanging on the wall behind the bed and out of reach. Resident #15's call light was clipped to the cord and hanging behind the bed during observations at 12:00 PM and again at 2:54 PM. Resident #58's call light was looped and hanging behind the bed during observations at 12:10 PM and again at 3:00 PM. During later observations with the DON, the DON confirmed that both residents' call lights were out of reach.
Inaccurate MDS Coding for PASRR Level II Status
Penalty
Summary
The facility failed to ensure MDS assessments were accurate for two residents reviewed for MDS coding. Review of the MDS 3.0 RAI Manual showed that residents covered by a Level II PASRR process may require certain care and services and that the MDS should be coded “yes” if PASRR Level II screening determined the resident has a serious mental illness. For one resident, the medical record showed diagnoses of Bipolar Disorder, Depression, and Anxiety, and the PASRR assessment identified a Level II outcome related to serious mental illness. However, the significant change MDS showed a BIMS score of 15, indicating cognitive intactness, listed active psychiatric diagnoses, and was not coded for the Level II PASRR condition. The psychiatric periodic evaluation also documented bipolar disorder, generalized anxiety disorder, and dementia. The RN MDS Coordinator confirmed the resident had a Level II PASRR and that the MDS and care plan did not reflect it. For the second resident, the medical record showed diagnoses of Anxiety, Depression, and Schizoaffective Disorder, and the PASRR dated 11/5/2021 identified a Level II outcome related to serious mental illness. The annual MDS showed a BIMS score of 15, listed active diagnoses of Anxiety, Depression, and Schizophrenia, and was not coded for a PASRR Level II condition. During review, the RN MDS Coordinator confirmed the annual MDS was inaccurate and did not reflect the resident’s PASRR Level II outcome status.
Care Plans Did Not Address PASRR Level II Outcomes for Two Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed the PASRR Level II outcome for 2 residents. Resident #9 was admitted with diagnoses including Bipolar Disorder, Depression, and Anxiety. A PASRR Level II outcome related to a serious mental illness was documented on 6/5/2025, and a significant change MDS assessment showed a BIMS score of 15, indicating the resident was cognitively intact. However, the comprehensive care plan revised on 10/15/2025 did not address the resident’s PASRR Level II condition and outcome. Resident #10 was admitted with diagnoses including Depression, Anxiety, and Schizoaffective Disorder. A PASRR dated 11/5/2021 documented a PASRR Level II outcome related to a serious mental illness, and an annual MDS assessment showed a BIMS score of 15, indicating the resident was cognitively intact. The comprehensive care plan dated 2/6/2024 did not reflect the resident’s PASRR Level II condition and outcome. During record review and interview on 11/19/2025, the RN MDS Coordinator reviewed the records for both residents and confirmed that the comprehensive care plans did not reflect their PASRR Level II outcome status.
Failure to Offer Hand Hygiene Before Meal Service
Penalty
Summary
The facility failed to provide hand hygiene before serving a resident’s lunch tray as part of its infection prevention and control program. Facility policy titled Hand Hygiene stated that all staff will perform proper hand hygiene procedures to prevent the spread of infection before and after eating using proper technique consistent with accepted standards of practice. Resident #74 was admitted with diagnoses including hypertensive heart disease, type 2 diabetes, and chronic kidney disease. The resident’s MDS assessment showed a BIMS score of 5, indicating severe cognitive impairment, and the resident required set up or clean up assistance with eating and supervision or touching assistance with personal hygiene. The care plan also identified an activities of daily living self-care deficit requiring assistance with eating and personal hygiene. During an observation, a CNA delivered the lunch meal tray, set up the tray, and failed to offer hand hygiene to the resident. The CNA later confirmed that hand hygiene had not been provided before the lunch tray was served, and the DON confirmed it was her expectation that hand hygiene be offered to residents prior to meal trays being served.
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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 Tazewell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Buchanan Place | 1 mi | ★★★★★ | 2 | 0 |
| Tri State Health And Rehabilitation Center | 9.5 mi | ★★★★★ | 8 | 0 |
| Ridgeview Terrace Of Life Care | 12.6 mi | ★★★★★ | 0 | 0 |
| Middlesboro Nursing And Rehabilitation Facility | 14.9 mi | ★★★★★ | 1 | 0 |
| Willow Ridge Center | 17.8 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.