Middlesboro Nursing and Rehabilitation Facility

In the surveyor’s words

From the most serious findings on record at Middlesboro Nursing and Rehabilitation Facility, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF684Jun 12, 2026

  Based on observation, interview, record review and facility policy review, the facility failed to administer medications in accordance with provider order and established nursing practice for 1 of 19 sampled residents, Resident 3 (R3).Review of facility investigation, and interviews with Licensed Practical Nurse (LPN) 2, revealed R3 received medications per rectum rather than the ordered oral route.The findings include:Review of facility policy, Medication Administration Policy, subtitled Medication Preparation, last reviewed 12/22/2025, revealed the facility would ensure medications were administered as prescribed in accordance with manufacturers' specifications, as well as good nursing principles and practices. […]

• No harm, potential for more than minimal, isolatedF609Jun 17, 2021

  Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure all alleged violations of abuse, which involved four (4) of five (5) sampled residents (Resident #2, #3, #4 and #5) were reported to the administrator of the facility and other officials, that included the State Survey Agency immediately but not later than two (2) hours after the allegation was made and in accordance with State Laws. Interviews with staff and review of resident records revealed Resident #2 was observed lying in bed with Resident #1 which was reported to the Administrator and State Agencies as required. […]

• No harm, potential for more than minimal, isolatedF610Jun 17, 2021

  Based on observation, interview, record review, and review of facility investigation and policy, it was determined the facility failed to ensure all alleged violations of abuse were thoroughly investigated. Review of a facility investigation revealed on [DATE] Resident #2 was observed lying in bed with his/her arms around Resident #1. Interviews with staff and review of resident records indicated Resident #2 had exhibited inappropriate sexual behaviors toward other residents, on at least three (3) different occasions, prior to the incident that occurred on [DATE]. Further interviews also indicated Resident #1 wandered into other resident rooms at times, as he/she had difficulty finding his/her room. […]

• No harm, potential for more than minimal, isolatedF744Jun 17, 2021

  Based on observation, interview, record review, and review of a facility investigation and policies, it was determined the facility failed to ensure two (2) of five (5) sampled residents (Residents #1 and #2) received appropriate dementia treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Resident #1, who was cognitively impaired and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Although, the facility had developed interventions to address Resident #1's wandering behaviors, the facility failed to implement the interventions to prevent the resident from wandering into unsafe areas. Resident #2, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . […]