Above 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 Lee Health And Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, cancer, and a G-tube for Glucerna feedings pulled out the gastrostomy tube, which staff reported to a provider who reinserted it, confirmed placement, and ordered a KUB. The care plan directed staff to observe, document, and report issues such as tube dislodgement to the MD as needed, and the facility’s notification policy required informing the patient’s legal representative or designated family member of significant changes in condition. However, there was no documentation that any emergency contact was notified of the G-tube dislodgement and reinsertion, and an RN stated they did not notify the emergency contact.
Staff failed to follow a medical provider's order for administering Oxycodone to a resident with multiple serious diagnoses, giving the medication on 17 occasions when the resident's pain intensity was below the ordered threshold for severe pain. The care plan and provider order specified administration only for severe pain, but records showed the medication was given for lower pain levels.
An expired, unlabeled carton of soy beverage was found in a resident refrigerator, contrary to facility policy requiring labeling and timely disposal of perishable items. The item, which belonged to a discharged resident, was not identified or discarded by dietary staff until brought to their attention by a surveyor.
Failure to Notify Resident Representative After G-Tube Dislodgement and Reinsertion
Penalty
Summary
Facility staff failed to notify a resident's representative of a significant change in condition requiring medical intervention. The resident had diagnoses including metabolic encephalopathy, aphasia, and dysphagia, and the most recent MDS showed a Brief Interview for Mental Status score of 3/15, indicating severe cognitive impairment. The resident’s face sheet did not list an authorized representative or responsible party but did list four emergency contacts. The resident’s comprehensive care plan included a problem for requiring tube feeding related to nutritional needs, with interventions directing staff to observe, document, and report to the MD as needed for issues such as tube dislodgement, infection at the tube site, self-extubation, tube dysfunction or malfunction, and abdominal symptoms, and to check tube placement and residual volume per facility protocol or MD orders. On a documented post-acute care visit, the progress note stated that the resident was being treated for cancer outside the facility and received Glucerna via a 20 Fr gastrostomy tube at 60 ml/hr for 16 hours per day. Staff reported that the resident had pulled out the gastrostomy tube with the balloon still intact. The clinical note documented that the abdomen was cleaned and dried, the gastrostomy tube was reinserted without difficulty with minimal bleeding, placement was confirmed by auscultation and aspiration, and a KUB was ordered to verify tube position. The resident had positive bowel sounds and even, unlabored respirations. However, there was no documentation that any of the resident’s emergency contacts were notified of the gastrostomy tube dislodgement and subsequent replacement. In an interview, an RN confirmed that the resident had pulled out the tube and that the FNP had reinserted it, and stated that, to the RN’s knowledge, no emergency contact had been notified and that the RN did not make such a notification. The facility’s Notification of Changes policy required notification of the patient’s legal representative when there is a change requiring notification, including accidents resulting in injury or accidents requiring emergent or urgent provider intervention, and also called for notifying a designated family member of significant health status changes when the patient is mentally competent.
Failure to Follow Pain Medication Orders for Resident
Penalty
Summary
Facility staff failed to administer pain medication according to the medical provider's order and the resident's person-centered care plan for one resident. The resident, who had diagnoses including a displaced intertrochanteric fracture of the left femur, end stage renal disease, and chronic obstructive pulmonary disease, was assessed as moderately cognitively impaired. The care plan specified that pain medication should be administered as ordered, and the provider's order stated that Oxycodone 10 mg should be given by mouth every four hours as needed for severe pain, defined as a pain intensity (PI) level of 7-10. Despite these orders, a review of the medication administration records showed that staff administered Oxycodone to the resident on 17 occasions when the recorded PI was below 7, with some instances as low as 1. This administration outside of the ordered parameters was confirmed through record review and staff interviews. The issue was discussed with facility leadership, but no additional information was provided to the survey team before the exit conference.
Expired, Unlabeled Resident Beverage Found in Refrigerator
Penalty
Summary
Facility staff failed to store food in accordance with professional standards for food service safety, as evidenced by the presence of an expired 8-ounce carton of Very Vanilla Soy Silk beverage in one of three resident refrigerators. The beverage, which had an expiration date of 12/19/24, was found without a resident's name or date, contrary to facility policy. The Registered Dietician (RD) confirmed that the item was expired and likely belonged to a discharged resident, but there was no way to ensure it would not be served to another resident due to the lack of labeling. Facility policy requires that all food items brought in by family or visitors be labeled with the patient's name and dated, and that perishable food be consumed within three days or discarded by staff. The RD stated that dietary staff are responsible for checking dates and maintaining the nutrition room refrigerators. The surveyor noted that the expired beverage was not identified or discarded until brought to staff attention, and that the lack of labeling created the potential for improper use.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 16 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pennington Gap
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ridgecrest Manor Nursing & Rehabilitation | 13.3 mi | ★★★★★ | 0 | 0 |
| Tri Cities Rehabilitation And Healthcare Center | 15 mi | ★★★★★ | 0 | 0 |
| Harlan Health And Rehabilitation Center | 15.1 mi | ★★★★★ | 0 | 0 |
| Hancock Manor Nursing Home | 17.7 mi | ★★★★★ | 8 | 0 |
| Heritage Hall Big Stone Gap | 18.4 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.