Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Tri State Health And Rehabilitation Center during CMS and state inspections, most recent first.
An LPN diverted narcotic medication by signing out extra doses of Hydrocodone-Acetaminophen for a resident without a physician order and taking the medication for personal use. The resident received all scheduled doses and did not experience harm, but the facility failed to prevent the misappropriation, resulting in a deficiency under F-602.
Medication Given Without Physician Order: An LPN administered meclizine and vitamin B-12 to a resident without a physician order, and the medications were later observed left in a cup on the bedside table. The resident had diagnoses including depression, anxiety disorder, brief psychotic disorder, and cognitive communication deficit, and was cognitively intact per BIMS. The order record showed no orders for either OTC medication, and the DON and NP confirmed the medications were given without an order.
A resident with depression, anxiety disorder, brief psychotic disorder, and cognitive communication deficit had a BIMS score of 13, indicating cognitive intactness. During an observation, a clear medication cup with 4 pills was found on the bedside table, and an LPN acknowledged she had placed the meds down without confirming the resident took them all. The DON and Administrator stated meds are expected to be administered and not left unattended at the bedside.
Opened insulin pens for three residents were found on a medication cart at room temperature without the date opened recorded, contrary to facility policy and manufacturer guidance. The residents had diagnoses including DM and other chronic conditions, and the cart contained opened Tresiba pens for two residents and an opened Lantus pen for another resident; an LPN and the DON confirmed the medications were not stored properly.
The facility failed to honor a resident's DNR order and did not ensure staff were CPR certified before performing CPR on multiple residents. A resident with a DNR order received CPR due to an EMR update failure. Uncertified staff performed CPR on other residents, revealing a systemic issue in training protocols. Interviews showed staff intended to perform CPR without certification, highlighting a critical compliance gap.
The facility failed to ensure competent nursing staff, leading to CPR being performed against a resident's DNR wishes due to an EMR update failure. Untrained CNAs participated in CPR on multiple residents, highlighting gaps in training and competency verification. Interviews revealed staff were unaware of procedures for verifying code status and performing CPR, with some expressing intent to perform CPR despite not being certified.
The facility's administration failed to honor a resident's DNR order and allowed untrained staff to perform CPR on multiple residents. The administration did not identify or address non-compliance through the QAPI committee, leading to a lack of effective training and oversight. Staff interviews revealed a lack of awareness regarding code status protocols and the location of the code book, resulting in an Immediate Jeopardy situation.
The facility's Governing Body failed to ensure that all nursing staff were educated on CPR processes, leading to untrained CNAs performing CPR on residents, including one whose DNR wishes were not honored. The administration was unaware of these incidents, and many staff were unfamiliar with the code book or its location. The facility also failed to maintain accurate medical records regarding CPR and did not have an effective QAPI program to identify and correct non-compliance.
The facility's QAPI committee failed to address deficiencies related to residents' code status and CPR training, leading to CPR being performed against a resident's wishes and by untrained staff. The committee did not implement effective processes or conduct root cause analyses, resulting in an Immediate Jeopardy situation. Documentation and meeting minutes revealed a lack of action plans and staff education on POST forms and code status protocols.
The facility failed to include code status in the care plans of four residents, despite having physician orders and POST forms indicating their preferences. This oversight was due to a template issue in the electronic medical record system, as confirmed by the MDS Coordinator. The residents had various medical conditions, and the deficiency highlights a failure to adhere to care planning policies.
The facility failed to maintain accurate CPR documentation and code status records for several residents, leading to CPR being performed against a resident's DNR wishes and incomplete documentation of staff participation in CPR events. Some staff involved were not CPR certified, and this was not communicated to the administration.
A deficiency was identified when two residents were involved in an altercation, with one resident blocking the other's doorway and a nurse intervening inappropriately. The residents, both with cognitive impairments and mobility issues, were not protected from abuse, as confirmed by staff interviews and facility investigation.
Misappropriation of Narcotic Medication by LPN
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of narcotic medications. A licensed practical nurse (LPN) signed out additional doses of Hydrocodone-Acetaminophen for a resident who was prescribed this medication for chronic pain related to osteoarthritis, but there was no physician order for extra or PRN doses. The medication administration record showed the resident only received the scheduled doses, and there was no documentation that the resident received the additional doses signed out by the LPN. The resident's pain scores on the relevant days indicated minimal pain, and the resident later reported no concerns regarding pain medication administration. The misappropriation was discovered when a registered nurse (RN) noticed discrepancies during a narcotic count and reported the issue to the Assistant Director of Nursing (ADON). An audit by the Pharmacy Nurse Consultant confirmed that extra doses had been signed out for the resident, but not administered. The LPN admitted to signing out and taking the extra medication for personal use. The facility's policy requires oversight to prevent misappropriation of resident property, but the LPN was able to divert narcotic medication by signing out extra doses without detection until the audit and count revealed the discrepancy. Interviews with staff and review of documentation confirmed that the resident did not miss any scheduled doses and did not experience harm as a result of the incident. The misappropriation was limited to the LPN signing out and diverting narcotic medication intended for the resident, in violation of facility policy and resident rights. The incident was reported to appropriate authorities, and the facility's failure to prevent this misappropriation constituted a deficiency under F-602.
Medication Given Without Physician Order
Penalty
Summary
The facility failed to follow a physician's order for one resident when medications were administered without an order. Resident #9 was admitted with diagnoses including Depression, Anxiety Disorder, Brief Psychotic Disorder, and Cognitive Communication Deficit, and the annual MDS indicated a BIMS score of 13, showing the resident was cognitively intact. During observation, a clear medication cup containing 4 unknown pills was seen on the resident's bedside table. Later, an LPN identified the medications left there as meclizine and vitamin B-12, both over-the-counter medications, and confirmed she administered them without a physician's order. Review of the Order Summary Report for the resident showed no order for meclizine or vitamin B-12. The facility's policy stated medications are to be administered in a safe and timely manner, in accordance with prescriber orders, and according to the right patient and right medication. The Administrator and DON confirmed the expectation that medications be administered as ordered by the physician. The NP stated she was notified of the additional medications given and confirmed the resident did not have orders for them.
Medications Left Unattended at Bedside
Penalty
Summary
The facility failed to ensure the safety of Resident #9 by leaving medications unattended at the bedside. Resident #9 was admitted with diagnoses including Depression, Anxiety Disorder, Brief Psychotic Disorder, and Cognitive Communication Deficit, and the annual MDS assessment showed a BIMS score of 13, indicating the resident was cognitively intact. During an observation, a clear medication cup containing 4 pills was seen on the resident’s bedside table. An LPN stated that the resident takes medications one at a time and acknowledged that she had put the medications down without seeing the resident take them all, calling it her mistake. The Administrator and DON stated that medications are expected to be administered and not left unattended at the bedside.
Opened insulin pens were left undated on a medication cart
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when insulin pens for three residents were found undated after opening on one medication cart observed for medication storage. The facility policy titled, Administering Medications, stated that when opening medications, the date opened is recorded on the container. Manufacturer guidance reviewed by surveyors stated that Tresiba should be thrown away after 56 days and Lantus should be used for up to 28 days after first use and then discarded. Resident #15 had diagnoses including Type 2 Diabetes, Generalized Anxiety Disorder, and Dementia and had an order for Tresiba 100 UNIT/ML to inject 50 units subcutaneously daily. Resident #25 had diagnoses including Type 2 Diabetes, Obesity, and Anxiety Disorder and had an order for Lantus 100 UNIT/ML pen-injector to inject 40 units subcutaneously daily. Resident #78 had diagnoses including Type 2 Diabetes, Hypertension, and Congestive Heart Failure and had an order for Tresiba 200 UNIT/ML pen-injector to inject 28 units subcutaneously two times a day. During observation of the 200/400 hallway medication cart, surveyors found two opened Tresiba FlexPens for Residents #15 and #78 and one opened Lantus FlexPen for Resident #25 at room temperature, and all three were undated when opened. An LPN confirmed the medications were not stored properly, and the DON later confirmed the same.
Failure to Honor DNR and Ensure CPR Certification
Penalty
Summary
The facility failed to honor a resident's end-of-life wishes and did not ensure that staff were appropriately trained and certified in CPR before performing CPR on multiple residents. Resident #3, who had a Do Not Resuscitate (DNR) order, was subjected to CPR against their wishes due to a failure in updating the electronic medical record (EMR) with the correct code status. The oversight occurred because the new physician's order from the POST form was not entered into the EMR, leading to the staff performing CPR under the assumption that the resident was a full code. Additionally, the facility did not ensure that staff performing CPR on Residents #8, #9, and #10 were CPR certified. Untrained staff, including CNAs and housekeeping personnel, participated in CPR efforts without the necessary certification, which was a significant oversight in staff training and preparedness. This lack of certification and training was evident in the cases of Resident #8, who was found unresponsive and subjected to CPR by uncertified staff, and Resident #9, where uncertified CNAs performed chest compressions. Similarly, Resident #10 received CPR from a CNA who was not certified, highlighting a systemic issue in the facility's training protocols. Furthermore, interviews with staff revealed that several CNAs and housekeeping staff expressed an intent to perform CPR without adequate training or certification. This intent, coupled with the actual performance of CPR by untrained staff, underscores a critical gap in the facility's compliance with CPR certification requirements. The facility's failure to ensure that only trained and certified staff performed CPR placed residents at risk and demonstrated a lack of adherence to established policies and procedures regarding emergency response and resident rights.
Deficiency in Staff Competency and Code Status Verification
Penalty
Summary
The facility failed to provide competent and proficient nursing staff to ensure resident safety and well-being, particularly in honoring end-of-life wishes and ensuring staff were knowledgeable about code status and CPR. This deficiency was evident when CPR was performed against a resident's wishes due to a failure to update the electronic medical record (EMR) with the resident's DNR status. The resident, who had chronic congestive heart failure and other significant health issues, was subjected to CPR despite having a POST form indicating a DNR preference. The staff involved did not verify the resident's code status before initiating CPR, leading to a breach of the resident's end-of-life wishes. Additionally, the facility failed to ensure that staff performing CPR were appropriately trained and certified. Several CNAs, who were not CPR certified, participated in CPR on multiple residents. These residents had various medical conditions, including chronic respiratory failure, dysphagia, and dementia, and had requested full treatment, including CPR, as per their POST forms. However, the involvement of untrained staff in these critical situations highlighted a significant gap in the facility's training and competency verification processes. Interviews with staff revealed a lack of awareness and training regarding the facility's procedures for verifying code status and performing CPR. Some staff members were unsure of their CPR certification status, and others expressed an intent to perform CPR despite not being certified. The facility's administration was unaware of these deficiencies, indicating a lack of communication and oversight in ensuring that only trained and certified staff performed CPR. This oversight placed residents at risk and demonstrated a failure to adhere to established policies and procedures.
Deficiency in CPR Protocols and End-of-Life Wishes
Penalty
Summary
The facility's administration failed to provide effective leadership and oversight, resulting in a significant deficiency related to the handling of residents' end-of-life wishes and CPR protocols. Specifically, the administration did not honor the end-of-life wishes of one resident, who had a Do Not Resuscitate (DNR) order, and allowed CPR to be performed against the resident's Physician's Order for Scope of Treatment (POST). Additionally, four staff members who were not trained or certified in CPR performed life-sustaining measures on three residents, which was not identified or addressed by the administration. The administration's failure extended to not identifying non-compliance and not developing or implementing effective processes through the facility's Quality Assurance and Performance Improvement (QAPI) committee. The administration did not ensure that staff were adequately trained, even after identifying that CPR was performed on a resident against their DNR status. Furthermore, the administration failed to recognize that non-CPR certified and untrained staff performed CPR on residents and did not take action to educate or implement steps to prevent untrained staff from performing CPR in the future. Interviews with staff revealed a lack of awareness and training regarding the facility's code book, its contents, and the location, as well as the protocols for verifying a resident's code status before performing CPR. The administration did not maintain effective oversight and leadership to identify quality deficiencies, put action steps in place, or have an effective QAPI program to prevent or address patterns of non-compliance. This lack of oversight resulted in an Immediate Jeopardy situation, posing a risk of serious harm to residents.
Failure in CPR Protocols and Oversight
Penalty
Summary
The facility's Governing Body failed to identify non-compliance and implement effective corrective action plans through the facility's Quality Assurance and Performance Improvement (QAPI) program. This failure was evident when the facility did not ensure that all nursing staff, including Certified Nursing Assistants (CNAs), were educated on the Cardiopulmonary Resuscitation (CPR) process. As a result, Resident #3's end-of-life wishes for Do Not Resuscitate (DNR) were not honored, and CPR was performed on three residents by CNAs who were not trained or certified in CPR life-sustaining measures. Additionally, the facility did not identify, educate, and implement action steps when CNAs and Housekeeping Staff, who were not CPR certified, expressed an intent to perform CPR without adequate training. The facility's administration, including the Administrator and the Director of Nursing (DON), were not aware that untrained staff had performed CPR and did not have an effective QAPI program in place to prevent such occurrences. Interviews with staff revealed that many were not familiar with the code book, its contents, or its location, and relied solely on the Electronic Medical Record (EMR) for verification of a code status. The Administrator confirmed that further education and communication were needed to prevent recurrence and acknowledged that the CPR documentation completed after the code events did not contain all the required information on all staff who participated or performed CPR. The Governing Body also failed to maintain effective leadership and oversight related to CPR/DNR or code status protocols. They did not establish and implement policies and procedures to ensure all staff were educated on the code book, its contents, or location, and the likelihood of staff performing CPR when not CPR certified. Furthermore, the facility failed to ensure medical records regarding CPR were complete and accurate for the residents involved, and the Administration did not maintain oversight to ensure an effective QAPI program that identified and corrected non-compliance.
QAPI Committee's Failure to Address CPR and Code Status Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to ensure an effective program that identified and addressed quality deficiencies, particularly concerning residents' code status and end-of-life wishes. The committee did not implement performance improvement activities or conduct a root cause analysis related to staff performing Cardio-Pulmonary Resuscitation (CPR) efforts without proper training or certification. This failure resulted in CPR being performed on a resident against their Physician's Order for Scope of Treatment (POST) and end-of-life wishes, and non-CPR certified staff performing CPR on multiple residents. The QAPI committee did not develop and implement effective processes to train staff after identifying that CPR was performed incorrectly. There was a lack of action plans to correct deficiencies when non-CPR certified and untrained staff performed CPR. Additionally, the committee failed to address the issue of Certified Nursing Assistants (CNAs) and Housekeeping Staff expressing intent to perform CPR without adequate training or certification. This oversight led to an Immediate Jeopardy situation, indicating a high risk of serious injury, harm, impairment, or death to residents. The facility's documentation and meeting minutes revealed that the QAPI committee did not adequately address the issues related to POST forms, advanced directives, or CPR in their meetings. There was no documentation of non-CPR certified staff's intent to perform CPR or the facility's code book, which contained residents' POST forms. Furthermore, there was no evidence that all nursing staff had been educated or in-serviced on the new process for POST forms and the code book, highlighting a significant gap in the facility's quality assurance processes.
Failure to Document Code Status in Care Plans
Penalty
Summary
The facility failed to develop and implement care plans that included the code status for four residents. The interdisciplinary team (IDT) is responsible for creating comprehensive, person-centered care plans based on resident assessments. However, the care plans for Residents #3, #8, #9, and #10 did not include their code status, despite having physician orders and POST forms indicating their preferences. For instance, Resident #3 had a change in code status from CPR/Full Code to Do Not Resuscitate (DNR), but this was not reflected in the care plan. Similarly, Residents #8, #9, and #10 had CPR/Full Code orders that were not documented in their care plans. The deficiency was identified during an audit conducted by the MDS Coordinator, who confirmed that the code status was not entered due to a template issue in the electronic medical record system. The residents involved had various medical conditions, including chronic heart failure, respiratory failure, and Parkinson's disease, with some residents being cognitively intact while others had severe cognitive impairments. The lack of proper documentation of code status in the care plans represents a failure to adhere to the facility's policy and the requirements for comprehensive care planning.
Incomplete CPR Documentation and Code Status Errors
Penalty
Summary
The facility failed to ensure that medical records regarding Cardio-Pulmonary Resuscitation (CPR) were complete and accurate for several residents. For Resident #3, there was a discrepancy between the physician's order and the Tennessee Physician Orders for Scope of Treatment (POST) form regarding the resident's code status. The EMR was not updated to reflect the resident's DNR status, leading to CPR being performed against the resident's wishes. The facility's investigation revealed that the failure to update the EMR was due to staff not entering the new physician's orders from the POST form. For Resident #8, the facility's documentation was incomplete as it did not include all staff members who participated in the CPR event. The nurse's note and the CPR/Code Blue Documentation form failed to document all individuals involved, including some who were not CPR certified. This lack of documentation contributed to the administration's unawareness of untrained staff performing CPR. Similarly, for Residents #9 and #10, the facility's documentation was incomplete, failing to list all staff members who participated in the CPR events. Some staff members involved in the CPR were not CPR certified, and this was not documented or communicated to the administration. The facility's failure to maintain accurate and complete records of CPR events and code statuses led to deficiencies in the care provided to these residents.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a deficiency. Resident #1, who has moderate cognitive impairment and several medical conditions including cerebral infarction and hemiplegia, was involved in an altercation with Resident #2, who has Alzheimer's disease and anxiety disorder. The incident occurred when Resident #2, who uses a wheelchair and has memory problems, blocked the doorway of Resident #1's room. Resident #1 attempted to push Resident #2 back into the hallway, resulting in his hand grazing Resident #2's face. During the incident, RN A intervened by pulling Resident #1 out of the doorway and smacking Resident #2 on the leg. The facility's investigation confirmed the altercation and the actions of RN A. Interviews with staff revealed that Resident #1 is generally not aggressive but can be loud and curse, while Resident #2 is often confused, combative with care, and refuses medications at times. Observations showed Resident #2 moving independently in a wheelchair and interacting with others without noted behaviors. The administrator confirmed the occurrence of the resident-to-resident altercation, highlighting the facility's failure to ensure a safe environment free from abuse for both residents.
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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 Harrogate
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Middlesboro Nursing And Rehabilitation Facility | 6.7 mi | ★★★★★ | 1 | 0 |
| Buchanan Place | 9.5 mi | ★★★★★ | 2 | 0 |
| Claiborne Health And Rehabilitation Center | 9.5 mi | ★★★★★ | 10 | 0 |
| Mountain View Rehabilitation And Healthcare Center | 12.3 mi | ★★★★★ | 2 | 0 |
| Ridgeview Terrace Of Life Care | 22 mi | ★★★★★ | 0 | 0 |
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