Cycle 1
Health 2024-10-10 · Fire 2024-10-10
11 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cumberland, KY
Tri Cities Rehabilitation and Healthcare Center
3-star overall rating with 2-star inspections with $5,346 in total fines with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
19101 US Highway 119 North, Cumberland, KY
(606) 589-5421
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Principle Long Term Care
Operator or chain grouping
Approved since
1997-03-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
44 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.83
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.91
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
4.47
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.03
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
4.31
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,112
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.24
Composite VBP score used to determine payment impact.
Payment multiplier
0.9941
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.26
Baseline 22.51% · Performance 21.54% · Measure score 1.26 · Achievement 0 · Improvement 1.26
Healthcare-associated infections
4.89
Baseline 11.92% · Performance 8.19% · Measure score 4.89 · Achievement 0 · Improvement 4.89
Total nurse turnover
7.25
Baseline 30.77% · Performance 34.04% · Measure score 7.25 · Achievement 7.25 · Improvement 0
Adjusted total nurse staffing
3.09
Baseline 3.94 hours · Performance 3.96 hours · Measure score 3.09 · Achievement 3.09 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.24% |
10.72%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 27.08% · Lower 95% interval 9.71% |
| Discharge to community | 40.21% |
50.57%
10.4 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 28.95% · Lower 95% interval 28.18% |
| Medicare spending per beneficiary | 1.5 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 46 · Denominator 46 |
| Falls with major injury | 2.17% |
0.77%
1.4 pts worse
|
Numerator 1 · Denominator 46 |
| Discharge self-care score | 42.86% |
53.69%
10.8 pts worse
|
Numerator 12 · Denominator 28 |
| Discharge mobility score | 42.86% |
50.94%
8.1 pts worse
|
Numerator 12 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 46 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.19% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 13.79% · Lower 95% interval 4.34% |
| Staff COVID-19 vaccination coverage | 3.23% |
8.2%
5 pts worse
|
Numerator 3 · Denominator 93 |
| Staff flu vaccination coverage | 19.23% |
42%
22.8 pts worse
|
Numerator 25 · Denominator 130 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 14 · Denominator 28 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4% |
25.2%
21.2 pts worse
|
Numerator 1 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.9
0.4 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.2
1.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
94.3%
2.7 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 95.4% · Q3 98.3% · Q4 98.0% · 4Q avg 97.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.8% |
96.2%
0.4 pts worse
|
95.5%
0.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.8%
About the same
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.1% · Q3 1.7% · Q4 8.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.2%
15.2 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 8.8% |
6.7%
2.1 pts worse
|
5.4%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 13.3% · Q3 7.5% · Q4 4.5% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.7% |
29.6%
9.1 pts worse
|
19.6%
19.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 37.5% · Q3 40.0% · Q4 40.4% · 4Q avg 38.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.5% |
17.6%
6.9 pts worse
|
16.7%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 23.3% · Q3 28.9% · Q4 19.4% · 4Q avg 24.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.5% |
17.3%
0.2 pts worse
|
16.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
15.6%
2.7 pts better
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 10.5% · Q3 14.3% · Q4 21.4% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.6% |
1.7%
4.9 pts worse
|
1.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 1.6% · Q3 6.9% · Q4 14.9% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.5% |
19.8%
13.3 pts better
|
19.8%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 9.2% · Q3 3.7% · Q4 12.1% · 4Q avg 6.5% |
| Percentage of long-stay residents with pressure ulcers | 2.7% |
5.5%
2.8 pts better
|
5.1%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 6.1% · Q3 1.3% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.3% |
83.8%
19.5 pts worse
|
81.7%
17.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 77.3% · Q2 61.9% · Q3 63.2% · Q4 54.5% · 4Q avg 64.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.1% |
13.9%
0.2 pts worse
|
12.0%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.1% · Observed 13.3% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.8%
0.7 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 53.5% |
83.6%
30.1 pts worse
|
79.7%
26.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 53.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 39.9% |
24.5%
15.4 pts worse
|
23.9%
16 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 39.9% · Observed 33.3% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-07-11 · Fire 2019-07-11
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-04-26 · Fire 2018-04-26
2 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-10
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-10-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-24
E · Potential for more than minimal harm
2024-10-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-22
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-10
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-10
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-10
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-10
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-10
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-15
D · Potential for more than minimal harm
2019-07-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-07-30
D · Potential for more than minimal harm
2018-04-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-05-17
D · Potential for more than minimal harm
2018-04-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-05-17
Penalties and ownership
What sits behind the stars
$5,346
2024-10-10
Fine
Fine · fine $5,346
Fine
Ownership
Nearby options
Other facilities in reach
#1
Lee Health And Rehab Center
Pennington Gap, VA
5-star overall rating with 5-star inspections with 2 recent health deficiencies
#2
Letcher Manor
Whitesburg, KY
2-star overall rating with 3-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Heritage Hall Big Stone Gap
Big Stone Gap, VA
3-star overall rating with 3-star inspections with $71,620 in total fines with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Jump out