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 Orchardview Post-acute And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to prevent an altercation between two residents, resulting in one resident suffering a fractured nose. The incident involved a cognitively intact resident and another with severe cognitive impairments. The altercation occurred in a hallway, and the facility's investigation confirmed that the cognitively intact resident retaliated after being hit first. The facility's policy required immediate intervention, but the incident was not prevented.
The facility did not follow its food safety policy by failing to discard dented cans found in the dry storage room. During an observation with the CDM, two cans of pork and beans and one can of cranberry sauce were identified as dented and available for resident use, contrary to the policy requiring such items to be removed from use. This oversight had the potential to affect all residents.
The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) to two residents. Both residents were discharged from therapy services, and the NOMNCs were issued on the same day services ended, contrary to the facility's policy requiring advance notice. The administrator confirmed the notices were not served timely.
A resident in a LTC facility was exploited by a CNA who exchanged vaping materials for the resident's prescribed Oxycodone. The resident, who was cognitively intact and had a history of chronic pain, admitted to pocketing her medication and trading it with the CNA over several months. The CNA confessed to the exchange and left the facility after the incident was reported. The facility's investigation confirmed the exploitation, but no discrepancies were found in the medication records.
The facility failed to report two separate abuse incidents involving residents within the required timeframe. One incident involved a resident with intellectual disabilities who fell from a Geri-chair due to improper staff assistance, and the other involved an altercation between two residents, resulting in a fractured nose. Both incidents were reported to authorities days after they occurred, contrary to state and federal regulations.
A facility failed to update the hospice plan of care for a resident with moderate cognitive impairment and multiple diagnoses, including Diabetes Mellitus and COPD. The hospice plan of care was not revised after the initial certification period ended, despite the resident continuing to receive hospice services. The Social Services Director confirmed the oversight during an interview.
Staff at the facility failed to follow proper infection control practices for residents under COVID-19 precautions. A resident with COVID-19 received a meal from a CNA without eye protection. Another resident in isolation was assisted by a CNA who did not wear a gown, gloves, or proper mask. A housekeeper cleaned rooms of COVID-19 positive residents without appropriate PPE. Staff were unaware of isolation statuses and did not adhere to PPE guidelines.
A facility failed to protect residents from abuse, resulting in physical harm when a resident with severe cognitive impairment and aggressive behavior threw a chair at two other residents, causing injuries. In a separate incident, a cognitively intact resident was observed performing a sexual act on a resident with severe cognitive impairment. The facility's abuse prevention policy was not effectively implemented, leading to these incidents.
A resident with multiple health conditions was mistakenly given another resident's Suboxone medication due to a nurse's failure to verify identity, resulting in lethargy, decreased vital signs, and hospitalization for respiratory failure. The nurse attributed the error to similar resident names and room proximity.
A resident with severe cognitive impairment and a history of falls did not have their care plan revised to include new fall interventions after two incidents resulting in injuries. Despite the facility's policy requiring updates to care plans following falls, no new interventions were implemented.
A resident with severe cognitive impairment and a need for assistance experienced two falls resulting in injuries, but the facility failed to implement new fall interventions. The incidents occurred in the reception/lobby area and the resident's room, leading to a skin tear and a hematoma. The lack of new interventions was confirmed by the ADON and MDS Nurse.
The facility failed to ensure accurate documentation of insulin administration and blood sugar checks for four residents, resulting in multiple missed entries in their medical records. Despite following physician's orders, nursing staff admitted to accidental documentation oversights. Interviews confirmed no adverse outcomes, but the records were deemed incomplete and inaccurate.
Failure to Prevent Resident-to-Resident Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in harm to one resident. The incident involved two residents, one of whom was cognitively intact and the other with severe cognitive impairments. The cognitively intact resident, who used a wheelchair, admitted to hitting the other resident after being struck first. The other resident, who had dementia and other mental health issues, was unable to communicate effectively and had a history of refusing medication. The altercation occurred when the resident with cognitive impairments approached the other resident in the hallway. A CNA observed the aftermath, with the impaired resident bleeding and crying. The facility's investigation confirmed that the cognitively intact resident retaliated after being hit, resulting in a fractured nose for the impaired resident. The facility's policy required immediate intervention in such situations, but the incident was not prevented. The facility's investigation substantiated the abuse, and the administrator confirmed the findings. The impaired resident was sent to the hospital for evaluation and returned the same day. The incident highlights a failure to prevent resident-to-resident abuse, as the facility did not effectively separate or monitor the residents to prevent the altercation.
Failure to Discard Dented Cans in Food Storage
Penalty
Summary
The facility failed to adhere to its food safety policy by not discarding dented cans, which were found in the dry storage room. During an observation and interview with the Certified Dietary Manager (CDM), it was revealed that two 6.88-pound cans of pork and beans and one 7.312-pound can of cranberry sauce were dented on the side. The CDM confirmed that these dented cans were available for resident use, despite the facility's policy stating that such items should be removed from use and either returned to the vendor or discarded. This oversight had the potential to affect all 67 residents in the facility.
Failure to Provide Timely NOMNC to Residents
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) in a timely manner for two residents. According to the facility's policy, residents or their representatives should receive timely notices regarding Medicare eligibility and coverage. However, for Resident #5 and Resident #65, the NOMNC was issued on the same day their Medicare-covered services were discontinued, which is not in compliance with the policy that requires advance notice. Resident #5, who was admitted with diagnoses including kidney disease, difficulty walking, lack of coordination, and seizures, was discharged from physical and occupational therapy services on the same day the NOMNC was signed. Similarly, Resident #65, admitted with dementia, muscle weakness, and other conditions, was discharged from physical, occupational, and speech therapy services on the same day the NOMNC was signed. The facility administrator confirmed during an interview that the NOMNCs were not served in a timely manner, as they were provided on the day services ended.
Resident Exploited by CNA for Pain Medication Exchange
Penalty
Summary
The facility failed to protect a resident from exploitation, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The resident, who was cognitively intact and had a history of chronic pain and substance abuse, was found to have been exchanging her prescribed narcotic pain medication, Oxycodone, with a CNA in return for vaping materials. This exchange reportedly occurred over several months, beginning when the resident's medication was changed to Oxycodone in June 2024. The incident came to light when the resident reported to another CNA that she had been trading her pain medication for vape cartridges. The resident admitted to the facility's Administrator and Assistant Director of Nursing (ADON) that she had been pocketing her medication under her tongue and later giving it to the CNA. The CNA involved admitted to accepting the medication in exchange for vaping materials and subsequently quit her job and left the facility. The facility's investigation confirmed the exploitation through interviews and evidence, including a statement from the resident and the CNA's admission. The resident's care plan was reviewed, revealing interventions for behaviors such as smoking and fabricating stories, but the facility's failure to prevent the exploitation of the resident's medication for personal gain was evident. The incident was reported to the police, and the facility's narcotic sheets showed no discrepancies in medication counts.
Delayed Reporting of Abuse Incidents
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents within the required timeframe, as per state and federal regulations. Resident #52, who has diagnoses including cellulitis, diabetes, and intellectual disabilities, experienced a fall from a Geri-chair due to improper staff assistance. The incident occurred on December 8, 2024, but was not reported to the state agency until December 9, 2024, and to Adult Protective Services (APS) until December 10, 2024. This delay in reporting was confirmed by the Interim Administrator and the Director of Nursing (DON), who stated that the charge nurse responsible for the delay was terminated. Another incident involved Resident #30, who has diagnoses including anxiety, seizures, depression, and stroke, and Resident #31, who has severe cognitive impairment. An altercation occurred between the two residents on September 9, 2024, resulting in Resident #31 sustaining a fractured nose. The facility's investigation substantiated the resident-to-resident abuse, but the incident was not reported to APS until September 13, 2024, three days after it occurred. The Administrator confirmed the delay in reporting during a review of the facility's investigation. Both incidents highlight the facility's failure to adhere to the required reporting timelines for allegations of abuse, as mandated by state and federal guidelines. The delays in reporting these incidents to the appropriate authorities were acknowledged by the facility's administration, indicating a deficiency in the facility's compliance with abuse reporting protocols.
Failure to Update Hospice Plan of Care
Penalty
Summary
The facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical record for a resident receiving hospice services. The facility's hospice contract, dated February 2023, required obtaining the most recent plan of care from the hospice provider. However, the medical record for a resident admitted with diagnoses including Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Adult Failure to Thrive, did not contain an updated hospice plan of care after the initial certification period ended on November 24, 2024. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 11, continued to receive hospice services without an updated plan of care. The Social Services Director, who served as the hospice coordinator, confirmed that the hospice plan of care had not been updated for the resident. This lack of documentation and coordination with the hospice provider led to the deficiency identified during the review.
Inadequate PPE Use During COVID-19 Precautions
Penalty
Summary
The facility failed to adhere to proper infection control practices during meal delivery and housekeeping services for residents under COVID-19 Transmission-Based Precautions. Resident #67, who was diagnosed with COVID-19, was observed receiving a meal from CNA D, who did not wear the required eye protection. CNA D admitted to being unaware of the need for eye protection when entering the room of a COVID-19 positive resident. Resident #17, who was in isolation due to potential COVID-19 exposure, was assisted with a meal by CNA B, who had her N-95 mask pulled down under her nose and was not wearing a gown, gloves, or eye protection. CNA B was unaware of the resident's isolation status and confirmed the lack of appropriate PPE use upon realizing the signage on the door. Housekeeper C was observed cleaning the rooms of Residents #16 and #54, both of whom were in isolation due to confirmed COVID-19, without wearing the necessary PPE, including an N-95 mask, gown, or eye protection. Housekeeper C was not aware of the residents' isolation status and did not change gloves after exiting the rooms. The Family Nurse Practitioner and Infection Control Preventionist both expressed expectations for staff to follow PPE guidelines in isolation rooms.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in incidents of both physical and sexual abuse. On May 12, 2024, a physical altercation occurred involving three residents. Resident #1, who has severe cognitive impairment and a history of aggressive behavior, became agitated and physically assaulted Residents #4 and #5 by throwing a chair at them. This resulted in Resident #4 sustaining a scrape on his shin and Resident #5 receiving a bruise and swelling on his knee. Both residents were assessed and reported no ongoing concerns or symptoms of anxiety or depression following the incident. In a separate incident on May 17, 2024, a sexual act was observed between Resident #3 and Resident #2. Resident #3, who was cognitively intact, was found on his knees in front of Resident #2, who has severe cognitive impairment, with Resident #2's shorts down and his penis exposed. The facility's investigation did not conclusively verify or refute the allegation of sexual abuse. Interviews with Resident #2 indicated that he did not recall the incident and expressed feeling safe at the facility. The facility's policy on abuse prevention, which emphasizes protecting residents from abuse by anyone, including other residents, was not effectively implemented. The incidents highlight a failure to adequately monitor and manage residents with known aggressive or inappropriate behaviors, leading to harm and potential harm to other residents. The facility substantiated the abuse for the physical altercation but did not reach a definitive conclusion regarding the sexual incident.
Medication Error Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in actual harm. A resident with multiple diagnoses, including cerebral palsy, diabetes, and chronic obstructive pulmonary disorder, was mistakenly administered another resident's medication, Suboxone, which is used for opioid dependence. This error occurred because the administering nurse did not verify the resident's identity before giving the medication, as required by the facility's policy. The nurse involved attributed the mistake to the similarity in the residents' names and the proximity of their rooms. The resident who received the wrong medication experienced lethargy and decreased vital signs, leading to an emergency room visit. The resident was found to have altered mental status and required Narcan administration, although there was no immediate change in condition. The resident was hypoxic and required a non-rebreather mask, and it was noted that the CPAP device, which the resident was supposed to use at night, was not on. The resident was subsequently admitted to the hospital with hypercarbic respiratory failure and required intubation, resulting in an ICU stay. The incident was reported by the nurse who administered the wrong medication, and the Director of Nursing confirmed that the nurse did not follow the five rights of medication administration. The nurse involved cooperated with the facility's investigation but was not reassigned to the facility. The error was documented, and the resident's family and medical director were notified of the incident.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise a comprehensive person-centered care plan related to falls for a resident who was reviewed for comprehensive care plans. The facility's policy on Fall Prevention & Management Program requires that when a resident experiences a fall, their care plan should be reviewed and updated as indicated. However, after the resident experienced falls on two separate occasions, no new fall interventions were implemented. The resident, who was admitted with diagnoses including the need for assistance with personal care, muscle weakness, and dysarthria, had severe cognitive impairment as per the 5-Day Minimum Data Set (MDS) assessment. The first incident occurred in the reception/lobby area where the resident was found on the floor after attempting to get out of a chair without assistance, resulting in a skin tear on the left elbow. The second incident took place in the resident's room, where the resident was found on the floor by a nurse, leading to a hematoma on the left eye/eyebrow, and the resident was sent to the hospital for evaluation. Despite these incidents, the MDS Nurse confirmed that the comprehensive care plan for the resident was not revised to include new fall interventions after these falls.
Failure to Implement New Fall Interventions for a Resident
Penalty
Summary
The facility failed to implement new fall interventions for a resident who was reviewed for falls. The resident, who was admitted with diagnoses including the need for assistance with personal care, muscle weakness, and dysarthria, had severe cognitive impairment as per a 5-Day Minimum Data Set (MDS) assessment. On two separate occasions, the resident experienced falls, one in the reception/lobby area and another in their room, resulting in injuries including a skin tear on the left elbow and a hematoma on the left eye/eyebrow. Despite these incidents, the facility did not implement new fall interventions following the falls on both occasions. The lack of action was confirmed during an interview with the Assistant Director of Nursing and the MDS Nurse, who acknowledged the failure to introduce new measures to prevent further falls for the resident.
Incomplete Documentation of Insulin Administration and Blood Sugar Checks
Penalty
Summary
The facility failed to ensure accurate and complete medical records for four residents regarding blood glucose monitoring and insulin administration. The facility's policy requires that charting and documentation be complete, concise, accurate, and without blank lines. However, the medical records for Residents #7, #17, #3, and #12 showed missed entries for insulin administration and blood sugar checks on various dates. These omissions were acknowledged by the nursing staff, who admitted to failing to document the procedures despite following the physician's orders. Resident #7, who was cognitively intact and diagnosed with Diabetes, had a missed entry for insulin administration and blood sugar check on a specific date. Similarly, Resident #17, with severe cognitive impairment, also had a missed entry for insulin administration and blood sugar check. Resident #3, who was cognitively intact, had multiple missed entries for insulin administration and blood sugar checks on different dates. Resident #12, with severe cognitive impairment, had several missed entries for insulin administration and blood sugar checks over a period of time. Interviews with the nursing staff, including RN Supervisor A, LPN B, LPN E, and LPN C, revealed that the omissions were accidental and related to documentation oversights. The Family Nurse Practitioners and the Pharmacy Consultant confirmed that there were no adverse outcomes from these omissions, and the facility was notified of any abnormal blood sugar values. The Director of Nursing confirmed that the medical records were incomplete and inaccurate due to the omitted documentation.
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What surveyors actually found near you
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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 Kingsport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, Kingsport | 1.7 mi | ★★★★★ | 2 | 0 |
| Wexford House | 2 mi | ★★★★★ | 1 | 0 |
| Holston Rehabilitation And Care Center | 2.7 mi | ★★★★★ | 13 | 0 |
| Asbury Place Kingsport | 4.1 mi | ★★★★★ | 6 | 0 |
| Nova Health And Rehab | 4.2 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.