Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Accura Healthcare Of Knoxville, Llc during CMS and state inspections, most recent first.
Unqualified Dining Services Manager: The facility failed to designate a qualified director of food and nutrition services. The Dining Services Manager reported she had been promoted into the role after working as a housekeeper, dietary aide, and cook, but she had not completed Food Manager Certification and did not have current ServSafe certification. The Administrator acknowledged hiring an unqualified person after the prior manager abruptly quit, and the personnel file lacked documentation of the required education, certification, or experience.
A resident with chronic pain, intact cognition, and an order for a 25 mcg/hr fentanyl patch every 72 hours did not receive the ordered controlled medication because the facility failed to properly receive, verify, and document it. Pharmacy records showed one fentanyl patch was delivered and signed for by an RN, but the RN, who was agency staff, only placed the tote in the med room and verbally informed another nurse without opening the package, verifying contents, or completing narcotic documentation. Subsequent staff accounts were unclear, with one LPN reporting only receiving tramadol to place in the Cubex machine, and when an LPN later attempted to apply the fentanyl patch, it was not available. The facility had no narcotic sheet or documentation of the fentanyl patch’s location after delivery, despite the DON’s expectation that nurses verify deliveries against the packing slip and log controlled substances.
Failure to Complete Significant Change MDS for Hospice Enrollment: A resident with COPD, CHF, DM, peripheral vascular disease, and a history of falls enrolled in hospice, but the facility did not complete the required significant change in status MDS when hospice began or when hospice later ended. The record showed intact cognition, dependence for several ADLs, and hospice admit paperwork completed by hospice staff, while the ADON confirmed the assessment should have been done for both the hospice election and revocation.
Inaccurate MDS coding affected two residents. One resident with malignant bladder cancer and hospice services was not coded for hospice on the MDS despite records and the resident’s report confirming hospice involvement. Another resident with depression, bipolar disorder, and schizophrenia was not coded for a serious mental illness or related condition even though PASRR identified the condition and the care plan reflected PASRR II specialized services. The MDS nurse coordinator confirmed the errors, and the Administrator stated there was no policy on MDS coding.
Care plan participation was not documented for one resident with moderately impaired cognition and stroke-related communication issues, despite the resident stating he wanted to attend care conferences and only recalling one from long ago. Staff and the DON could locate only limited, inconsistent care conference documentation. In a separate finding, a resident with intact cognition and diagnoses including COPD, CHF, DM, and PVD was admitted to hospice, but no SCSA MDS was completed and hospice was not addressed on the individualized care plan.
A nurse administered both a resident's prescribed medications and another resident's medications in error, leading to the resident becoming unresponsive and requiring emergency intervention, including Narcan and ICU admission for toxic encephalopathy and cardiogenic shock. The resident, who had severe cognitive impairment and multiple comorbidities, was found unresponsive shortly after the error and required intensive medical care.
A resident with moderate cognitive impairment and psychiatric diagnoses became agitated and refused assistance with dressing. An LPN, assisted by two CNAs, continued care despite the resident's distress, used degrading language, and attempted to physically restrain the resident's hands. Staff present reported discomfort with the LPN's actions and language, and the incident was reported to the DON.
Surveyors observed multiple instances of unclean and poorly maintained areas, including detached baseboards, exposed pipes, and persistent urine odors in several rooms and hallways. Staff interviews revealed challenges in controlling odors and maintaining cleanliness, especially for residents with incontinence or uncooperative behaviors. Several residents with complex medical needs were found in rooms with urine-soaked linens, food debris, and dirty furniture, highlighting ongoing environmental deficiencies.
The facility failed to respect residents' rights to self-determination by denying smoking breaks as a form of punishment for behaviors such as yelling or swearing. Five residents reported feeling belittled and dehumanized when their smoking privileges were revoked. Additionally, a resident with Alzheimer's was not allowed to lie down upon request, as staff adhered to a routine schedule rather than the resident's needs. Staff interviews revealed a systemic practice of using smoking breaks as a behavioral management tool, contradicting the facility's policy on residents' rights.
The facility failed to protect residents from mental abuse by denying smoke breaks based on behaviors. Five residents with intact cognition reported feeling belittled and dehumanized when their smoking breaks were revoked for actions like yelling or disagreements with staff. Staff confirmed that smoking was treated as a privilege and could be withheld for inappropriate behaviors, contributing to the deficiency.
A facility failed to ensure a housekeeper completed the required Dependent Adult Abuse Mandatory Reporter Training within the specified timeframe. The housekeeper, who started employment in May, had not completed the training by the due date in November. The Administrator acknowledged the lapse and stated that the Business Office Manager was responsible for tracking training completion. The facility's policy requires initial training within six months of hire and recertification every three years.
A resident with severe cognitive impairment and multiple diagnoses did not receive a required bath or shower on the morning of a scheduled colonoscopy, as per physician orders. The facility lacked specific policies for bathing or following physician's orders, leading to the oversight.
The facility failed to maintain sanitary practices by improperly storing food, with multiple instances of unlabeled and undated food items found in freezers and refrigerators. The facility's policy requires all containers to be labeled and dated, but this was not followed.
The facility failed to employ a certified dietary manager, with the Dining Manager lacking formal training in food safety and nutrition. The Administrator planned to enroll the Dining Manager in a course, and the facility had a contract dietitian present only on Tuesdays. The facility did not have a policy addressing Dietary Manager certification.
Unqualified Dining Services Manager
Penalty
Summary
The facility failed to designate a person to serve as the director of food and nutrition services who met the minimum qualifications to carry out the food and nutrition services. During interviews, the Dining Services Manager stated she had been promoted from cook to Dining Services Manager after previously working as a housekeeper, dietary aide, and then in another kitchen role. She reported that she and another dietary aide managed the dietary department after the prior Dining Services Manager abruptly quit, and that she was fully in the role as Dining Services Manager on January 1, 2026, even though she had only started an online Food Manager Certification course on January 13, 2026 and had not completed it. She also confirmed she did not have a current ServSafe certification. The Administrator stated he believed there was a six-month period to get someone qualified for the Dining Services Manager position and acknowledged that he had hired someone who was not qualified because the previous Dining Services Manager had quit abruptly. Review of the Dining Services Manager’s personnel file did not contain documentation showing one of the required qualifications, such as certification as a dietary manager or food service manager, a national food service management and safety certification, an associate’s or higher degree in food service management or hospitality, or the required experience and course of study. The job description for Director of Dining Services stated that ServSafe certification or willingness to obtain it prior to employment was required, along with meeting state requirements for food service managers or dietary managers.
Failure to Account for and Document Receipt of Controlled Fentanyl Patch
Penalty
Summary
The facility failed to maintain a system to properly receive and account for a controlled substance (fentanyl patch) prescribed for a resident with chronic pain syndrome, seizure disorder, and depression. The resident’s MDS showed intact cognition with a BIMS score of 15/15, and the MAR contained an order for a 25 mcg/hr fentanyl transdermal patch to be applied every 72 hours for chronic pain. A pharmacy packing slip documented that one fentanyl patch was delivered and signed for by an RN on the evening of 10/25/25. The facility’s policy on controlled substances required proper handling, storage, disposal, and record keeping, including verifying medications against the packing slip, logging them, and keeping controlled substances double locked. However, there was no narcotic sheet documenting receipt of the fentanyl patch, and the facility lacked documentation of the patch’s location after it was signed in. Staff interviews and record review showed multiple breakdowns in the receipt and logging process. The RN who signed for the delivery stated she was agency staff, did not know she needed to open the package, and only placed the tote in the medication room and verbally informed another nurse that medications had arrived, without verifying contents or documenting the controlled substance. Other staff gave inconsistent or limited accounts of handling the delivery bag and medications, and one LPN reported only receiving tramadol from another nurse to place in the Cubex machine. When an LPN later attempted to apply the fentanyl patch for the resident, it was not available, and a subsequent search did not locate it. The DON stated that nurses were expected to sign in medications, verify them against the packing slip, and add a log sheet for controlled substances, but this process was not followed for the fentanyl patch, resulting in the missing narcotic and lack of required documentation.
Failure to Complete Significant Change MDS for Hospice Enrollment
Penalty
Summary
The facility failed to complete a significant change in status assessment for a resident who enrolled in hospice care. The resident’s record showed multiple chronic conditions, including COPD, CHF, diabetes mellitus, and peripheral vascular disease, and the MDS documented intact cognition, independence with daily decision making, and dependence on staff for several activities of daily living such as toileting, transfers, showers, lower body dressing, and footwear. The resident also had a history of falls, including one fall with major injury and two falls without injury since the prior MDS assessment. Review of the resident’s care plan showed a focus on fall risk related to impaired mobility, CHF, morbid obesity, DM, and convulsions, but it did not address hospice care. The EMR showed a census change to hospice Medicaid and a hospice progress note documenting that hospice staff came in to complete admit paperwork with the resident. The record also showed that no significant change in status MDS assessment was completed after the resident entered hospice care and before the resident was discharged to the hospital. During interview, the Assistant DON confirmed that a significant change in status MDS assessment should have been completed when the resident enrolled in hospice and also when the resident discontinued hospice. The October 2025 RAI User’s Manual stated that a significant change in status assessment is required when a terminally ill resident elects hospice and again when hospice services are discontinued, and the State Operations Manual guidance likewise identified hospice enrollment and discontinuation as triggers for a significant change in status MDS.
Inaccurate MDS Coding for Hospice and PASRR Conditions
Penalty
Summary
The facility failed to accurately complete MDS assessments for 2 of 10 residents reviewed. For Resident #4, the quarterly MDS assessment scored 15 out of 15 on the BIMS, indicating intact cognition, and listed malignant bladder cancer, but the resident was not coded as receiving hospice care. The care plan documented hospice services, the clinical census record showed the resident entered the facility under hospice care, the hospice plan of care showed hospice was initiated, and the resident reported receiving hospice visits three to five times a week and being satisfied with those services. For Resident #6, the annual MDS assessment scored 5 out of 15 on the BIMS, indicating severe cognitive impairment, and the resident had psychiatric mood disorders including depression, bipolar disorder, and schizophrenia. The MDS did not code the resident for a serious mental illness or related condition, although the PASRR screening identified a PASRR condition involving serious mental illness or related condition and directed the MDS to reflect those findings in sections A1500 and A1510. The care plan also reflected PASRR level II and specialized services needed due to mental illness. During interview, the MDS nurse coordinator confirmed both residents’ MDS assessments were not coded correctly, and the Administrator stated there was no policy on MDS coding and staff were expected to follow the RAI manual.
Care plan participation not documented and hospice care plan not updated
Penalty
Summary
The facility failed to provide the opportunity for Resident #3 to participate in the development, review, and revision of his care plan. Resident #3’s quarterly MDS documented a BIMS score of 11 out of 15, indicating moderately impaired cognition, and listed diagnoses of diabetes and stroke. The care plan noted that the resident had impaired communication related to the stroke, was usually understood but unclear at times, and had a goal for him to be able to communicate for needs to be met. During interview, the resident stated he wanted to go to his care conferences and only recalled attending one a long time ago; he later said he would probably go if invited and stated loudly that he felt they did not want to hear what he had to say. Staff interviews and record review showed limited documentation of care conference participation. The MDS nurse coordinator reported being new to the position and could not explain what had happened previously because of a lack of documentation, but stated the resident’s care conference had been ensured during the survey. The Administrator could locate only three undated form letters over the last year sent to the emergency contact about care conference dates, and only two documents showing meetings occurred. One form dated 5/25/25 indicated the resident was invited and chose not to participate, and another form dated 2/17/26 indicated the meeting took place during survey and the resident chose not to participate. The Administrator stated the meetings should be quarterly, that the process needed work to ensure care conferences were conducted and documented, and that the resident right to participate was understood. The facility also failed to update Resident #1’s care plan after hospice enrollment. Resident #1’s MDS documented intact cognition, independence with daily decision making, and diagnoses including COPD, CHF, diabetes mellitus, and peripheral vascular disease. The record showed a census change to hospice Medicaid and a hospice progress note documenting hospice admission paperwork, but no significant change in status MDS was completed after hospice enrollment and before the resident’s discharge to the hospital. The Assistant DON agreed that a significant change in status MDS was not completed when the resident enrolled in hospice or when hospice ended, and agreed hospice had not been addressed on the individualized care plan. The Administrator stated the facility did not have a hospice policy, and the RAI Manual states an SCSA is required when a terminally ill resident enrolls in hospice to ensure a coordinated plan of care.
Medication Administration Error Resulting in ICU Admission
Penalty
Summary
A medication administration error occurred when a nurse gave a resident both her prescribed morning medications and, in error, administered another resident's medications as well. The nurse had completed the initial medication pass for the resident, who had severe cognitive impairment and multiple diagnoses including stroke, kidney disease, diabetes, dementia, anxiety, and depression. Shortly after, the nurse prepared medications for a different resident but mistakenly called out to the first resident, who responded by opening her mouth, and the nurse administered the second set of medications to her. The error was realized approximately five minutes later when the nurse reviewed the medication records. Following the administration of the incorrect medications, the resident became unresponsive within minutes. Staff assessed the resident, notified the on-call provider, and were instructed to monitor vital signs and provide fluids. The resident was found unresponsive to verbal and physical stimuli, prompting immediate emergency intervention, including administration of Narcan and calling 911. Emergency medical services arrived, and the resident was transported to the hospital, where she was admitted to the ICU with diagnoses of toxic encephalopathy and cardiogenic shock secondary to the medication error. The resident's medical record indicated she had no swallowing disorder and was on multiple medications, including antianxiety, antidepressant, anticoagulants, hypoglycemics, and anticonvulsants. The care plan directed staff to administer medications as ordered and monitor for side effects. The incident resulted in the resident requiring intensive medical intervention, including ICU admission, and she subsequently developed severe dysphagia. Interviews with staff and family confirmed the sequence of events and the impact of the medication error.
Failure to Treat Resident with Dignity and Respect During Care
Penalty
Summary
A resident with moderate cognitive impairment and multiple psychiatric diagnoses, including paranoid schizophrenia, delusional disorders, anxiety disorder, and major depressive disorder, was dependent on staff for activities of daily living (ADLs). During an incident, an LPN with nearly 30 years of experience, along with two CNAs, attempted to assist the resident with dressing. The resident became agitated, refused assistance, and exhibited physical resistance by yelling, hitting, and biting staff. Despite the resident's distress and refusal, the LPN continued to attempt care and responded by calling the resident degrading names and using offensive language. Staff interviews confirmed that the LPN used demeaning language in the resident's presence and attempted to physically restrain the resident's hands instead of disengaging from the situation. Other staff present during the incident reported feeling uncomfortable with the LPN's actions and language, and both CNAs reported the incident to the Director of Nursing (DON) on the same day. The LPN later confirmed using degrading words, though she believed the resident did not hear them. The administrator stated that staff are expected to step away and allow time before reattempting care if a resident refuses, and to try a different staff member if needed. The facility did not have a specific policy for Resident Rights/Dignity but stated they followed regulations and standards of care.
Failure to Maintain Clean, Orderly, and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a clean, orderly, and well-repaired environment, with multiple observations of detached or damaged baseboard guards in resident bathrooms and hallways, exposing boiler pipes and leaving unfinished, jagged walls. Maintenance staff relied on other staff to report issues through an app, and several maintenance concerns were identified but not yet addressed at the time of the survey. These environmental deficiencies were directly observed in specific rooms and common areas. Persistent urine odors were noted in several rooms and hallways, despite regular cleaning efforts. Housekeeping staff acknowledged that some furniture, such as bed stands, were in poor condition and could not be adequately cleaned, with some items described as dirty and rusty. Staff interviews revealed ongoing challenges in controlling odors, particularly in rooms with residents who were incontinent or uncooperative with care, and there was confusion regarding responsibility for cleaning certain items like wheelchairs and bed stands. Multiple residents with significant medical histories, including Alzheimer's disease, dementia, stroke, and incontinence, were observed in unclean environments. Specific observations included residents lying in beds with urine-soaked linens, food debris on sheets and floors, dirty dishes left in rooms, and dark, unkempt living spaces. In some cases, residents refused removal of dirty items, and staff reported difficulties in maintaining cleanliness due to resident behaviors and the condition of facility furnishings.
Facility Fails to Honor Residents' Rights to Self-Determination
Penalty
Summary
The facility failed to honor residents' rights to make choices about significant aspects of their lives, specifically regarding smoking breaks and resting schedules. Five residents who were smokers reported that their smoking breaks were denied as a form of punishment for behaviors such as yelling, swearing, or being disruptive. These actions were documented in the residents' care plans and health status notes, indicating that smoking was considered a privilege that could be revoked by staff for behavioral issues. Residents expressed feelings of belittlement, anger, and dehumanization when their smoking breaks were taken away. Additionally, the facility did not allow a resident with Alzheimer's and dementia to lie down upon request, instead making him wait until after supper. This decision was based on a routine schedule rather than the resident's immediate needs, as confirmed by staff interviews. The facility's policy on residents' rights stated that residents should have the right to make choices about their activities and schedules, including sleeping and waking times, which was not adhered to in this case. Interviews with staff and the administrator revealed a systemic practice of using smoking breaks as a behavioral management tool, which contradicted the facility's policy on residents' rights. Staff members, including a Registered Nurse and a Nurse Specialist, justified the denial of smoking breaks as a necessary measure to manage resident behavior, despite acknowledging that residents have rights. The administrator confirmed that this practice had been in place for three years, indicating a long-standing issue with respecting residents' rights to self-determination.
Facility Fails to Protect Residents from Mental Abuse by Denying Smoke Breaks
Penalty
Summary
The facility failed to ensure residents were free from mental abuse by denying smoke breaks based on resident behaviors. This deficiency was identified for five residents who were smokers and had intact cognition, as indicated by their Brief Interview for Mental Status (BIMS) scores. The residents reported feeling belittled, angry, and dehumanized when their smoking breaks were taken away as a consequence of their behaviors, such as disagreements with staff, yelling, or using derogatory language. The facility's policy allowed staff to deny smoking privileges for safety concerns, but staff interviews revealed that smoking breaks were also withheld as a form of behavior management. Staff members, including CNAs and an RN, confirmed that smoking breaks were taken away when residents exhibited behaviors such as yelling, swearing, or being disruptive. The facility administrator and a nurse specialist also stated that smoking was considered a privilege and could be revoked for inappropriate behaviors. The report highlights specific instances where residents were denied smoking breaks, leading to feelings of punishment and mental abuse. For example, one resident was denied a smoke break after yelling in the hallway, and another was told they could not smoke after an outburst directed at staff. These actions were consistent with the facility's practice of using smoking breaks as a behavioral control measure, which contributed to the deficiency in protecting residents from mental abuse.
Failure to Complete Mandatory Reporter Training
Penalty
Summary
The facility failed to ensure that a staff member, identified as Staff B, met the requirements for Dependent Adult Abuse Mandatory Reporter Training. Staff B, a housekeeper, began employment on 5/29/24, and was required to complete a 2-hour training course on dependent adult abuse identification and reporting by 11/29/24. However, a review of records revealed that Staff B had not completed this mandatory training by the due date. During an interview on 1/29/25, the Administrator acknowledged the oversight and confirmed that Staff B was in the process of completing the training. The Administrator also stated that it was the responsibility of the Business Office Manager to track training completion dates and notify the Administrator when staff were due for training. The facility's policy, updated on 10/19/22, mandates that all employees complete the initial training within six months of hire and a 1-hour recertification every three years thereafter.
Failure to Follow Pre-Op Bathing Orders for Resident
Penalty
Summary
The facility failed to ensure that staff followed physician pre-operative orders for a resident scheduled for a colonoscopy. The resident, who had severe cognitive impairment and required extensive assistance with personal care, was supposed to receive a bath or shower on the morning of the procedure as per the physician's orders. However, there was no documentation indicating that this was done on the day of the procedure. Instead, the resident was found with wet and clumpy powder in her groins upon arrival for the procedure, suggesting that the pre-operative hygiene instructions were not followed. The resident's medical history included ulcerative colitis, Alzheimer's disease, anxiety disorder, and depression, and she was dependent on staff for bathing and personal hygiene. Despite the facility's expectation that staff adhere to physician orders and standards of care, the lack of a specific policy for bathing or following physician's orders contributed to the oversight. The administrator acknowledged the expectation for staff to provide the necessary care but confirmed the absence of formal policies to guide staff actions in this regard.
Improper Food Storage Practices
Penalty
Summary
The facility failed to maintain sanitary practices by improperly storing food, as observed during kitchen inspections. On multiple occasions, surveyors found various food items in the facility's freezers and refrigerators that were unlabeled and undated. Specific findings included unlabeled bags of meat, chopped meat, dough-like slices, and other food items in different units of the kitchen. Additionally, a metal pan with casserole-like contents and a used ladle stored on top was found in the refrigerator, along with an undated plastic tub of sour cream and other unlabeled items. The dry goods room also contained an opened, undated bag of bread crumbs and unlabeled plastic containers with cereal-like contents in a cabinet. During a follow-up observation, similar issues were noted, including unlabeled and undated bags of various food items in the freezers and refrigerators. The facility's policy on food storage, dated 2021, mandates that all containers or storage bags must be legible, covered, and accurately labeled and dated. However, these guidelines were not followed, leading to the identified deficiencies. The Administrator confirmed that all stored food should be dated and labeled, indicating a lapse in adherence to the facility's own policies.
Lack of Certified Dietary Manager
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not having a certified dietary manager. The facility, with a census of 51 residents, had a Dining Manager who was not certified and had no formal coursework training in food safety and nutrition. The Dining Manager had only 1.5 years of experience as an assistant dietary manager at another facility. The Administrator planned to enroll the Dining Manager in a six-month course starting in April. The facility had a contract dietitian who was present only on Tuesdays. The facility did not have a policy addressing Dietary Manager certification, and the Facility Assessment indicated that a Dietary Supervisor should be involved in completing the assessment, with an average daily resident census of 47.
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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 Knoxville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Ridge Specialty Care | 1.5 mi | ★★★★★ | 3 | 0 |
| Accura Healthcare Of Pleasantville, Llc | 10.5 mi | ★★★★★ | 1 | 0 |
| The Cottages | 11.4 mi | ★★★★★ | 15 | 0 |
| Oskaloosa Care Center | 22.1 mi | ★★★★★ | 11 | 1 |
| Crystal Heights Care Center | 22.4 mi | ★★★★★ | 1 | 0 |
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