Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Wexford House during CMS and state inspections, most recent first.
A facility failed to report an allegation of abuse involving a resident with cognitive capacity and complex medical needs, after staff reported that a CNA had taken unauthorized photos of the resident and allegedly sent them to the ombudsman. The resident stated she did not consent to the photos, and the DON documented the resident's concerns. Despite these reports, the Administrator did not notify the State Survey Agency as required by policy.
Staff responsible for testing dishwasher sanitizer levels lacked the necessary competency to follow manufacturer guidelines, as evidenced by the consistent documentation of a chlorine rinse result not available on the test strip guide and inability to explain or properly interpret test results.
Surveyors identified extensive sanitation failures in the kitchen, including dirty equipment, improper food storage, overflowing trash, and infrequent cleaning of the ice machine and deep fryer. Staff interviews confirmed the lack of a cleaning schedule and improper handwashing practices, with these deficiencies potentially affecting nearly all residents.
Facility staff did not consistently monitor or document resident refrigerator temperatures as required by policy, with several refrigerators found above the recommended temperature and some logs incomplete. Expired food items were also found in resident refrigerators, and staff failed to discard them as per facility guidelines. These deficiencies were confirmed by the DON during observations and interviews.
A resident with severe cognitive impairment and multiple medical conditions was found to be living in a room with missing wallpaper, peeling paint, and additional wallpaper damage, which the Maintenance Director was unaware of and acknowledged did not meet homelike standards.
A resident with a history of daily smokeless tobacco use, who was cognitively intact and had multiple medical diagnoses, did not have their tobacco use addressed in their care plan. Despite facility policy and staff acknowledgment that tobacco use should be included, the care plan was not updated to reflect this need, as confirmed by medical record review, observations, and staff interviews.
The facility did not follow its policy requiring on-site destruction of unused narcotics witnessed by appropriate staff. Instead, narcotics from discharged or deceased residents were collected and processed off-site, and key staff were unaware that this practice did not align with facility policy.
Staff did not provide required hand hygiene assistance to three residents with cognitive and physical impairments before meal service, despite facility policy mandating this practice. Observations and interviews confirmed that CNAs delivered meal trays and allowed residents to eat without offering hand hygiene, and the DON acknowledged the lapse in infection control procedures.
The facility did not maintain kitchen cooking equipment in a sanitary condition, potentially affecting 82 out of 86 residents. Observations revealed a large sheet pan with crusty, greenish-brown food debris, a hot food holding cabinet with dried, black, greasy food debris, and a plate warmer with dried, brownish-yellow residue. The undated policies on sanitizing pots, pans, and equipment were not followed.
The facility failed to maintain residents' dignity by serving milk products in disposable cartons without offering glasses and by having a CNA feed a resident while standing over them. Interviews revealed a lack of awareness regarding regulations for non-disposable dishware, and the practice of serving milk in cartons was routine without resident requests.
The facility failed to accurately complete MDS assessments for two residents. One resident's admission MDS did not list Quadriplegia as an active diagnosis despite being dependent on staff for various activities. Another resident's quarterly MDS did not list Hypothyroidism as an active diagnosis despite receiving daily medication for the condition.
The facility failed to include a cognitively intact resident in the care planning process, despite the resident requiring substantial assistance with daily activities. The resident did not receive invitations to quarterly care plan meetings, nor a copy of the latest care plan, which was acknowledged as an oversight by the Social Services Director and confirmed by the Director of Nursing.
The facility failed to ensure expired supplies were not available for resident use in one of the three medication carts observed. An LPN found expired cotton swabs, a specimen collection swab kit, and blood draw vials in the 300 long hall medication cart. The DON confirmed these items should not have been on the cart.
The facility failed to properly contain garbage and refuse in two dumpsters, leaving them exposed to air, elements, and potential pests. The Food Service Manager confirmed that the dumpsters should have been tightly closed, as per facility policies.
Failure to Report Alleged Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency as required by its own policy. The policy mandates that the Abuse Coordinator, who is the Administrator, is responsible for reporting all allegations or suspicions of abuse, including mental abuse facilitated through technology, to the state survey agency. In this case, several staff members reported that a CNA had taken photos of a resident's back or wounds and sent them to the ombudsman. The resident involved, who was cognitively intact and required assistance with activities of daily living, stated that she did not give permission for any photos to be taken. The Director of Nursing documented that the resident reported photos were taken without her knowledge. The Administrator interviewed the CNA, who denied taking or sending any photos and denied using her phone in the facility. No staff reported actually seeing the photos on the CNA's or any other employee's phone. Despite the allegations and statements from staff and the resident, the Administrator did not report the incident to the State Survey Agency, stating that although it is normally done, it was not done in this instance. The ombudsman confirmed not receiving any photos or having any related discussions. The failure to report the allegation of abuse, as required by facility policy and regulation, constitutes the deficiency identified in the report.
Incompetent Staff Testing of Dishwasher Sanitizer Levels
Penalty
Summary
The facility failed to employ staff with the appropriate competencies to ensure manufacturer guidelines were followed for testing chemical sanitation in the dishwasher. Review of the Dishmachine Temperature Record for the specified month showed that chlorine rinse readings of 50 were consistently documented for all meals, despite the fact that the test strips and their guide did not include a 50 ppm reading as an option. During observation, the Certified Dietary Manager (CDM) demonstrated difficulty reading the test strips and was unsure of the correct reading, asking the surveyor for guidance and instructing a Dietary Aide to test the chemical results in a manner inconsistent with standard procedure. When questioned about how the recorded results of 50 ppm were obtained, neither the CDM nor the Dietary Aide could provide an explanation.
Widespread Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain kitchen equipment and food storage, preparation, and serving areas in a clean and sanitary condition, as required by professional standards and facility policy. Observations revealed multiple sanitation issues, including a black substance on the ice machine in contact with ice, lack of paper towels at the hand washing station, and staff using a sink designated for pots and pans to wash their hands. Numerous pieces of kitchen equipment, such as can openers, mixers, microwaves, ovens, deep fryers, and warming racks, were found with dried food debris, grease, or other contaminants. Food items were improperly stored, with undated containers, wet-nested pans, and open or unlabeled items in coolers and freezers. Trash cans in food preparation areas were uncovered, overflowing, and in contact with clean storage containers. Additionally, maintenance records showed the ice machine was only cleaned twice a year, and the deep fryer was cleaned about every six months. Interviews with dietary staff and the Registered Dietician confirmed the absence of a cleaning schedule and acknowledged that the kitchen was not maintained in a sanitary condition. The Maintenance Director verified the infrequent cleaning of the ice machine. These deficiencies had the potential to affect 80 of 81 residents, as the unsanitary conditions could compromise the safety and quality of food served to residents.
Failure to Monitor Resident Refrigerator Temperatures and Remove Expired Foods
Penalty
Summary
The facility failed to adhere to its policy regarding the monitoring and maintenance of resident personal refrigerators, as well as the management of food items stored within them. Observations revealed that temperature logs for several residents' refrigerators were incomplete, with missing daily recordings on specific dates. Additionally, recorded temperatures frequently exceeded the facility's policy requirement of maintaining refrigerator temperatures below 41°F, with some logs showing temperatures as high as 44°F and 60°F. In one instance, a thermometer inside a resident's refrigerator displayed a temperature of 73°F. These lapses were confirmed during interviews and observations. Further deficiencies were noted in the handling of expired food items. Expired yogurt was found in the refrigerators of two residents, with expiration dates that had already passed. The facility's policy required that foods with use-by dates be discarded accordingly, but this was not consistently followed. The residents involved had various medical conditions, including dementia, hemiplegia, diabetes, chronic kidney disease, and other significant diagnoses. The DON confirmed that the facility did not ensure daily monitoring and documentation of refrigerator temperatures, did not maintain required temperature levels, and did not consistently discard expired foods as per policy.
Failure to Maintain Homelike Resident Room Environment
Penalty
Summary
The facility failed to provide a homelike environment for one resident who was admitted with diagnoses including hemiplegia, dysphagia, and intracranial injury, and who was noted to be severely impaired in cognitive skills for daily decision making. Observations in the resident's room revealed a large piece of wallpaper missing from the wall beside the bed, a large area of missing paint near the head of the bed, and wallpaper peeling away from the baseboard by the window. During an interview, the Maintenance Director stated he was not aware of these issues and confirmed that the room was not consistent with a homelike environment and required repairs.
Failure to Address Tobacco Use in Resident Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan addressing tobacco use for a resident who was cognitively intact and used smokeless (chewing) tobacco daily. Despite the facility's policy requiring comprehensive assessments and care plans that include all resident needs, preferences, and treatments, the resident's ongoing use of smokeless tobacco was not incorporated into their care plan. Medical record reviews confirmed the resident's tobacco use, and observations over several days showed the resident keeping and using smokeless tobacco in their room. Interviews with staff, including an LPN and the DON, confirmed that the resident's tobacco use was known and that such information should be included in the care plan. However, the care plan had not been updated to reflect this aspect of the resident's care, despite clear evidence from assessments, observations, and staff interviews that the resident regularly used smokeless tobacco.
Failure to Follow Policy for On-Site Destruction of Narcotics
Penalty
Summary
The facility failed to follow its own policy regarding the destruction of unused narcotics. According to the facility's undated policy, the destruction of drugs must be conducted on the premises and witnessed by the consultant pharmacist along with either an agent of the State Board of Pharmacy, the facility administrator, or the director of nursing services. However, review of the Narcotic Destruction Logs revealed that while the logs listed residents' names, medications, amounts of narcotics remaining, nurses' initials, and reasons for destruction, they did not document the actual destruction of the narcotics as required by policy. Interviews with the Assistant Director of Nurses (ADON), the Administrator, and the Consultant Pharmacist confirmed that narcotics belonging to residents who had expired or been discharged were not destroyed on the facility premises. Instead, a collection process was used, and the drugs were processed off-site. Both the ADON and the Administrator were unaware that the facility's practice did not align with its written policy, and the Consultant Pharmacist was also not aware of the discrepancy between the policy and the actual process for narcotic destruction.
Failure to Provide Hand Hygiene Assistance During Meal Service
Penalty
Summary
During meal service, staff failed to follow proper infection control practices related to hand hygiene for three residents who required assistance with activities of daily living (ADLs), including personal hygiene. Facility policy required staff to perform hand hygiene before and after eating, but observations revealed that staff did not offer or provide hand hygiene assistance to these residents prior to their lunch meals. Specifically, staff brought meal trays, opened silverware, and allowed residents to begin eating without ensuring hand hygiene was performed. The residents involved had significant medical conditions and cognitive impairments, including pelvis fracture, chronic kidney disease, anemia, diabetes, anxiety, weakness, hemiplegia, chronic respiratory failure, and heart failure. Their care plans and Minimum Data Set (MDS) assessments indicated they were dependent on staff for personal hygiene. Interviews with staff and the Director of Nursing confirmed that hand hygiene assistance was not provided as required by facility policy during the observed meal service.
Sanitation Issues with Kitchen Cooking Equipment
Penalty
Summary
The facility failed to ensure kitchen cooking equipment was maintained in a sanitary condition, potentially affecting 82 out of 86 residents. The undated policies on sanitizing pots and pans and equipment were not followed, as evidenced by observations on 3/18/2024. A large sheet pan had crusty, greenish-brown food debris, the hot food holding cabinet had dried, black, greasy food debris, and the plate warmer had dried, brownish-yellow residue.
Failure to Maintain Resident Dignity in Meal Service and Feeding Assistance
Penalty
Summary
The facility failed to ensure staff maintained residents' dignity by serving milk products in disposable cartons without offering glasses to nine residents across three of five hallways observed for meal tray distribution. The facility's policy on patient/resident rights and dining experience emphasized the importance of dignified and courteous treatment, yet this was not upheld. Observations and interviews revealed that residents were routinely served milk and nutritional shakes in disposable cartons without being offered glasses, and there was no evidence in the medical records that residents had requested this practice. Several residents, including those with cognitive impairments and those who were cognitively intact, confirmed they had not requested to receive their milk in disposable cartons and were not offered glasses, although they expressed varying levels of concern about the practice. Additionally, the facility failed to maintain a resident's dignity during feeding. One resident, who was totally dependent on staff for eating due to severe cognitive impairment and physical limitations, was observed being fed by a CNA who stood over the resident rather than sitting at eye level. This practice was contrary to the facility's expectations for feeding assistance, which required staff to be seated and at eye level with the resident. The CNA admitted to standing over the resident because it was more convenient for her, indicating a disregard for the resident's dignity and the facility's policies. Interviews with the facility's administration and dietary staff revealed a lack of awareness regarding regulations related to providing non-disposable cutlery and dishware, including cups and glasses. The Administrator, Director of Nursing, and dietary staff all confirmed that milk and nutritional shakes were routinely served in disposable cartons and that glasses were only provided upon resident request. This practice was a long-standing one, and there was no evidence that the facility had considered the impact on residents' dignity or made efforts to align with regulatory requirements for a dignified dining experience.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for two residents. Resident #78, who was admitted with diagnoses including Amyotrophic Lateral Sclerosis (ALS) and Quadriplegia, had an admission MDS that did not list Quadriplegia as an active diagnosis. This was despite the resident being dependent on staff for personal hygiene, dressing, transfers, and bed mobility, and the comprehensive care plan noting the risk for limitations in range of motion related to Quadriplegia. The Director of Nursing confirmed that the admission MDS assessment for Resident #78 was not accurate and did not reflect the resident's active diagnosis of Quadriplegia upon admission. Similarly, Resident #56, who was admitted with diagnoses including Adult Failure to Thrive, Hypothyroidism, Alzheimer's Dementia, and Major Depressive Disorder, had a quarterly MDS assessment that did not list Hypothyroidism as an active diagnosis. This was despite the resident having a physician's order for Levothyroxine and receiving the medication daily, as noted in the Medication Administration Record (MAR). The MDS Coordinator confirmed that Resident #56's quarterly MDS assessment was coded incorrectly and did not include the active diagnosis of Hypothyroidism.
Failure to Include Cognitively Intact Resident in Care Planning Process
Penalty
Summary
The facility failed to include Resident #31 in the care planning process, despite the resident being cognitively intact and requiring substantial assistance with daily activities. The facility's policy mandates that residents and their families be informed and invited to care plan meetings, with documentation of these attempts. However, Resident #31 did not receive invitations to the quarterly care plan meetings, nor did she receive a copy of the latest care plan. The Social Services Director (SSD) admitted that the resident was not invited to the meetings and had no documentation to show that the resident did not want to participate. Resident #31 was admitted with diagnoses including Pneumonia, Arthritis, and Diabetes Mellitus. Despite being cognitively intact, the resident was not included in the care planning process. The SSD acknowledged the oversight and confirmed that the resident had never received an invitation to or attended the quarterly care plan meetings. The Director of Nursing (DON) also confirmed that it was her expectation for cognitively intact residents to be involved in their care plan meetings, indicating a lapse in following the facility's policy.
Expired Supplies Found on Medication Cart
Penalty
Summary
The facility failed to ensure expired supplies were not available for resident use in one of the three medication carts observed. During an observation and interview with an LPN, it was found that the 300 long hall medication cart contained expired supplies, including a package of two cotton swabs, a specimen collection swab kit, three vacuum blood draw vials, and one blood draw vial. The LPN acknowledged the presence of the expired supplies and stated that the protocol was to remove such items and notify the supervisor. The Director of Nursing confirmed that the expired supplies should not have been on the medication cart.
Improper Containment of Garbage and Refuse
Penalty
Summary
The facility failed to ensure garbage and refuse were properly contained in two dumpsters. During an observation, it was noted that the hard, plastic roof covering dumpster #1 was open, and dumpster #2's sliding door on the right side was also open. This left the contents of both dumpsters exposed to air, elements, and potential pests. The Food Service Manager confirmed that the dumpsters should have been tightly closed to prevent exposure to elements and potential rodents, as per the facility's policies on garbage and trash cans and maintaining a home-like environment.
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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 | 0.4 mi | ★★★★★ | 2 | 0 |
| Holston Rehabilitation And Care Center | 1.5 mi | ★★★★★ | 13 | 0 |
| Orchardview Post-acute And Rehabilitation Center | 2 mi | ★★★★★ | 0 | 0 |
| Nova Health And Rehab | 5.3 mi | ★★★★★ | 0 | 0 |
| Asbury Place Kingsport | 6.1 mi | ★★★★★ | 6 | 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.