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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Knox County Nursing Home District during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and a mechanically altered diet experienced significant unplanned weight loss while also developing a pressure ulcer. Staff did not re-evaluate the care plan, notify the MD, RD, consultant pharmacist, or representative, or document intake monitoring for ordered Ensure supplements. During observation, the resident ate very little, had dry lips and a sunken appearance, and received no cueing or assistance during the meal.
A resident with chronic back and shoulder pain, reduced mobility, and severely impaired cognition had repeated episodes of pain that interfered with sleep and activities. Staff documented PRN acetaminophen as not effective or only somewhat effective, but did not record pain scores, notify the charge nurse or provider, or document offering the ordered acetaminophen-codeine after the first medication failed. Interviews confirmed the resident’s pain was ongoing, often worse at night, and that staff were aware of the unresolved pain.
Failure to provide and document ROM and restorative nursing for residents with contractures and mobility impairment. Three residents with stroke-related deficits, hemiplegia, dementia, and contractures had care plans or functional maintenance programs that called for stretching, ambulation, PROM/AROM, and splint use, but records showed long gaps with little or no restorative therapy documented. Observations found contracted hands without splints, and staff and the DON described missed restorative services, missing brace use, and coverage problems because the restorative aide was frequently pulled to work the floor.
Unlabeled insulin products and unsecured controlled medication and cart keys were observed. An LPN administered an open Lantus pen without an open date, an open Humalog vial remained in use beyond the 28-day timeframe, and an open Ozempic pen was also missing an open date. In addition, an Ativan card was left on the med room counter instead of behind two locks, and keys for two med carts were left in a narcotic count binder on top of the carts in a common area where residents and staff passed by.
Incorrect Portion Sizes Served to Residents on Mechanical Soft Diet: Staff served residents with a mechanical soft diet the wrong food portions during lunch, giving a 3-oz serving of ground turkey instead of 4 oz and a 4-oz serving of beef stroganoff instead of the ordered 6-oz portion with noodles. Dietary staff said the diet spreadsheet was not checked before service and the wrong utensils were selected.
Poor Food Quality and Improper Preparation: Residents repeatedly complained that meals lacked flavor, were burnt, hard, undercooked, or mushy, and council minutes documented issues with vinegar-heavy vegetables, burned sandwiches, and tough potatoes. During a meal observation, the turkey appeared freezer burnt and unappetizing and the green bean casserole was runny and unseasoned; dietary staff said the turkey roast had been cooked the day before and reheated, and the vendor had substituted the roast for baked turkey.
The facility failed to follow infection control practices during resident care, wound care, medication administration, and nebulizer treatment. A resident requiring EBP did not receive proper PPE use or hand hygiene during catheter and perineal care, two residents with wounds had dressing changes performed with the same gloves after dirty tasks, and another resident was cared for with soiled gloves during toileting and transfer. In addition, staff used an inappropriate wipe to clean a multi-resident glucometer, did not clean insulin pen tips before attaching needles, and did not disinfect nebulizer equipment after use.
Call system communication was not reliably audible at the nurses’ desk or along resident halls, and call lights were not answered within the expected timeframe for three residents. A resident with stroke-related weakness and assistance needs reported waits of 30 to 45 minutes, another resident said nighttime call lights took a long time to be answered, and a third resident reported waits up to 30 minutes and staff not returning after turning off the light. Call light logs documented repeated prolonged response times, including waits of 19 to 47 minutes.
The facility failed to return resident funds for three residents after discharge or death. One resident died with $28.29 in petty cash still held by the facility, and two residents discharged home with $45.28 and $20.00 remaining, respectively, but the balances were not refunded within the required timeframes. The AA said she was not aware of the deadlines for returning resident money, and the Administrator said the facility was waiting for a family member to sign for the funds and had not considered sending a check to the resident, representative, or estate.
Failure to Complete SCSA for Two Residents: The facility did not complete federally required SCSA MDS assessments for two residents after significant changes in condition. One resident had new pneumonia, a new wound that was later observed as an open pressure ulcer, worsening pain, weight loss, new dementia, and multiple ADL declines. The other resident had major changes in cognition, behaviors, mobility, ADLs, and skin status, including a healed pressure ulcer and new pneumonia/UTI, but no SCSA was completed.
Failure to Maintain and Use PASARR Level II Information: The facility failed to keep a copy of a resident’s PASARR Level II assessment and did not incorporate the PASARR findings into the care plan or assessment data. The resident had dementia, major depressive disorder, intellectual disability, seizure disorder, and severe cognitive impairment, with records showing unclear speech and behavioral changes, but the chart contained no PASARR documentation and the SSD said she did not know the Level II PASARR needed to be reviewed.
The facility failed to complete a Level 1 PASARR screening for a resident with major depressive disorder and borderline personality disorder. The resident’s EHR and MDS contained no documentation of a PASARR, and the SSD stated she believed the screening was only required for Medicaid residents rather than for all admissions.
A resident with stroke-related hemiplegia/hemiparesis developed a worsening wound behind the left knee that staff repeatedly documented as a skin tear instead of a pressure injury. The record showed missed risk assessments, no documented root-cause evaluation, no care plan updates, and no documented evaluation of the wheelchair cushion or leg support even though the resident, LPN, DON, and NP all linked the wound to constant pressure and rubbing from the wheelchair. The area progressed, reopened multiple times, and later showed infection requiring antibiotics.
Insulin Pen Administration Error: An LPN failed to prime a resident’s Humalog and Lantus insulin pens before dosing and did not hold the pens in place after injection as required by the manufacturer. The resident had diabetes mellitus and orders for scheduled Humalog, sliding-scale Humalog, and Lantus insulin. The LPN stated he/she had never been trained to prime insulin pens or to hold them against the skin after administration.
Failure to Monitor and Respond to Significant Weight Loss
Penalty
Summary
The facility failed to monitor and respond to significant unplanned weight loss for one resident who had a history of hemiplegia, anxiety, COPD, chronic pain syndrome, and cerebral infarction, and who was on a mechanically altered therapeutic diet with Ensure twice daily. The resident’s weight dropped from 124.5 lbs. to 117.5 lbs. in 28 days, a 5.6% loss, and later remained at 118.0 lbs. and 118.5 lbs., reflecting continued significant loss. The resident also developed a pressure ulcer on the right gluteal crevice/coccyx area during the same period. Despite the significant weight loss, the resident’s nutrition care plan was not re-evaluated and no new interventions were initiated. The medical record showed no evidence that the physician, dietitian, consultant pharmacist, or resident representative were notified of the weight loss. The Registered Dietitian did not identify the loss until later record review, and the resident’s care plan continued without documented changes after the weight loss was identified. The resident’s quarterly MDS also reflected significant unplanned weight loss, but the record still showed no corresponding care plan revision. Observation of the resident during a meal showed dry lips, a sunken face, dry skin, and very poor intake. The resident stated he/she could not see well, was given an unidentified food item, and ate less than 10% of the meal without staff cueing or assistance during the meal. The resident’s POA stated the facility had not recently held a care plan meeting and had not notified him/her of the weight loss, and expressed concern that the resident needed assistance, cueing, or feeding to maintain nutrition. Staff interviews confirmed that supplement consumption was not being recorded, that the resident had not been monitored for intake because staff were unaware of the weight loss, and that the significant weight loss had been missed by the facility.
Failure to Manage Resident Pain and Use Ordered PRN Medication
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident with chronic pain and impaired cognition. Resident #15 had diagnoses including right shoulder pain, rhabdomyolysis, reduced mobility, muscle weakness, and a history of falling. The resident’s care plan directed staff to monitor for pain, report pain to the charge nurse, and reassess after pain medication was given. The resident’s MDS showed severely impaired cognition, pain in the past five days, occasional limitation of daily activities from pain, and pain that occasionally made it hard to sleep. The resident had PRN orders for acetaminophen and acetaminophen-codeine, but the MAR showed repeated administrations of acetaminophen alone for pain with documentation that it was not effective or only somewhat effective. On multiple occasions, staff did not document a pain score at the time of administration or follow-up, did not document notifying the charge nurse when the medication was not effective, and did not document offering, administering, or the resident declining the ordered acetaminophen-codeine after acetaminophen did not relieve the pain. Staff interviews showed the resident’s pain was ongoing, often worse at night, and affecting sleep and activity. Observation and interviews further showed the resident had been up all night with back pain and had received Tylenol and warm towels without relief. The resident stated Tylenol was not helping, pain interfered with walking, doing things, and sleeping, and the family representative said the resident had frequent pain and sometimes could not tell staff about it. Staff interviews confirmed awareness of the resident’s pain and the Tylenol 3 order, but the LPN who documented ineffective pain relief said she did not notify the physician and had never given the resident Tylenol 3, while the DON and NP stated they would expect unresolved pain to be addressed with the available acetaminophen-codeine order and physician notification if pain remained unresolved.
Failure to Provide and Document ROM and Restorative Nursing for Residents with Contractures
Penalty
Summary
The facility failed to assess residents with limited range of motion or risk for limited range of motion and failed to provide direction to staff or restorative nursing interventions for three residents with mobility and contracture concerns. The report states that the facility’s policy required residents with limited mobility or ROM to receive treatment and services to prevent avoidable decline, and that the comprehensive assessment and care plan should identify current ROM, mobility status, limitations, risk factors, and specific interventions with measurable goals. Despite those requirements, the records reviewed did not show consistent restorative nursing services, and the facility’s own staff described gaps in restorative coverage because the restorative aide was frequently pulled to work on the floor and the facility had lost another restorative aide. One resident had diagnoses including hemiplegia, muscle weakness, reduced mobility, prior TIA, prior traumatic brain injury, and cerebral infarction. The resident’s care plan and functional maintenance program included stretching the right knee and ankle to prevent contractures and maintaining transfer ability, but the January and February 2026 restorative documentation showed only one day of restorative therapy in January and one day in February, with many days showing no documentation of any restorative therapy. On observation, the resident’s right hand was curled tightly into a ball with fingernails pushing into the palm. The resident stated restorative therapy was not provided several times a week and that the aide was pulled to work the floor a lot. The restorative aide confirmed the resident was ordered for six days a week of restorative therapy but said there was not time to return and ask again if the resident was unavailable. A second resident had diagnoses including stroke, hemiplegia and hemiparesis, cellulitis of the left lower limb, gait and mobility abnormalities, contracture of the left hand and left shoulder, and pain. The resident’s care plan included ambulation, lower body strengthening, and use of a resting hand splint, but the February 2026 MAR showed no documentation that staff applied the splint during the month. The resident’s hand was observed contracted and resting on a side table without a splint on multiple occasions. The resident reported that restorative therapy was not completed often and that the brace had been missing for a long time. Staff interviewed were unaware of the brace or its current status, and the restorative aide stated the resident used to have a brace but it had gone missing and had not been tracked down. A third resident had dementia, arthritis, gait and mobility abnormalities, and a contracture of the right hand. The resident’s functional maintenance program included PROM to the right upper extremity and splinting of the right hand resting splint at bedtime, but the care plan did not address the resident’s severe right-hand contractures, ROM, splinting, or care of the right hand. The resident’s annual and quarterly MDS documented severe cognitive impairment, dependence for many ADLs, limited ROM in one lower extremity, and no therapy or restorative services. On observation, the resident’s right hand was bent at the wrist more than 90 degrees with the fingers in a tight fist, and no washcloth or splint was present. The record did not show ROM or splinting completed, offered, or declined, and the restorative aide stated the resident was not on a restorative program. The DON stated residents with contractures would have restorative nursing for ROM two to three times a week, but she did not know if all residents with contractures or potential contractures were on restorative nursing.
Unlabeled insulin products and unsecured controlled medication and cart keys
Penalty
Summary
Medications and biologicals were not consistently labeled and stored according to facility policy and accepted practice. The facility failed to date an open, in-use Lantus insulin pen for one resident with diabetes, failed to date an open, in-use Ozempic pen for another resident with diabetes, and failed to discard an open, in-use vial of Humalog insulin for a third resident after the manufacturer’s 28-day use period. Facility policies required opened multi-dose insulin products to be dated when first opened and discarded according to manufacturer guidance, and staff acknowledged that without an open date they could not determine whether the insulin pen was expired. For one resident, an open Lantus insulin pen was observed on the licensed nurse treatment cart without an open date, and the nurse administered the insulin from that pen. For another resident, an open Humalog vial was observed in use with a date written on the pharmacy box that staff identified as the date the vial was first used, but the vial remained in use beyond the manufacturer’s 28-day timeframe. For a third resident, an open Ozempic pen was observed in use without an open date on the pen or pharmacy packaging. The facility’s policies stated that when a multi-dose container is opened or accessed, the date opened is to be recorded and the product discarded within the required timeframe. The facility also failed to secure controlled medication and medication cart keys as required. A pharmacy medication card of Ativan for one resident was observed on the medication room counter rather than behind two locked doors, and the nurse stated the card had been left there while waiting for the day shift CMT. In addition, keys for two medication carts were left in the narcotic count binder on top of the carts in an open area between the nursing desk and a resident living area, where residents and staff passed by. A CMT removed the keys from the binder, unlocked the carts and narcotic box, and began the narcotic count. The administrator stated that insulin-like products should be dated when opened, medication cart keys should be kept on the person responsible for them, and narcotics should always be locked behind two locks.
Incorrect Portion Sizes Served to Residents on Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure staff served the correct portion sizes of food items to residents with a physician's order for a mechanical soft diet. The facility census was 39. Review of the facility policy, Portion Control-Portion Sizes, dated 2004, showed that foods were to be served according to standard portion sizes and that portion control equipment such as numbered dippers, scoops, spoodles, and ladles of varying ounce capacities was to be used at all meals. Review of the residents' orders dated 2/22/26-2/23/26 showed six residents had a physician's order for a mechanical soft diet. The diet spreadsheet for lunch on 2/23/26 showed that residents on a mechanical soft diet were to receive either ground baked turkey with gravy as a 4-ounce serving, or ground beef stroganoff over noodles as a 6-ounce serving of beef stroganoff with a 4-ounce serving of noodles. During observation of lunch meal service on 2/23/26 between 11:26 AM and 12:00 PM, Dietary Staff K served residents on a mechanical soft diet either a 3-ounce serving of ground baked turkey instead of a 4-ounce serving, or a 4-ounce serving of ground beef stroganoff over noodles instead of a 6-ounce serving of beef stroganoff over a 4-ounce serving of noodles. Dietary Staff K stated he/she did not check the diet spreadsheet before serving lunch and selected a 3-ounce utensil for the turkey because meat portions were typically 3-ounce servings, and used a 4-ounce scoop for the stroganoff when it should have been a 6-ounce scoop.
Poor Food Quality and Improper Preparation
Penalty
Summary
The facility failed to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature, with residents repeatedly reporting poor food quality and preparation. Review of Resident Council meeting minutes showed complaints that menus and food were not improved, cucumbers and onions were served with pure vinegar, grilled sandwiches were usually burnt, chicken strips were very hard, and sandwiches remained burned at the evening meal. Residents also reported that potato peeling was left on the potatoes, making them tough to chew, and that sauces were placed on everything. During interviews, multiple residents said the food lacked flavor, was not seasoned, and often did not taste good. One resident said vegetables were usually hard and undercooked or sometimes mushy. On observation of the lunch tray on 2/23/26, the turkey appeared freezer burnt, with one half dark brown and the other white, and the texture was stringy and chunky with little flavor; the green bean casserole was runny, thin, unseasoned, and lacked flavor. A resident who received the tray said the turkey did not look like turkey and the casserole did not look like casserole. Dietary staff stated the turkey was a netted roast made of dark and white meat that had been cooked the day before and reheated, and that the green bean casserole started thick but became thinner during cooking. The Dietary Manager stated the baked turkey was unavailable and the vendor substituted the turkey roast in its place, and staff should use a recipe when preparing food items.
Infection control failures during resident care and medication procedures
Penalty
Summary
The facility failed to follow infection prevention and control practices during personal care, wound care, medication administration, and respiratory treatment procedures for multiple residents. Resident #6 had diagnoses including UTI, prostate cancer, and need for assistance with personal care, and the care plan required Enhanced Barrier Precautions (EBP) because of an indwelling urinary catheter. During observation, a CNA entered the room, washed hands, and donned gloves but did not wear a gown, then provided catheter care and perineal care while changing between dirty and clean tasks without hand hygiene. The CNA handled soiled items, touched clean items and the resident with soiled gloves and bare hands, assisted with a bed-to-wheelchair transfer while holding the catheter bag, and exited the room without washing hands. Resident #25 had diagnoses including stroke, hemiplegia, hemiparesis, and cellulitis of the left lower limb, with a wound on the posterior left knee and an order for daily wound treatment. During observation, an LPN donned EBP and removed the old bandage, but used the same gloves to measure the wound, apply calcium alginate and Calmoseptine, cover the wound, date the dressing, assist the resident with dressing, and touch the wheelchair. Resident #13 was observed in the shower room with an open, bleeding tailbone wound and fecal contamination during care. A CNA cleaned feces from the resident while keeping the same gloves on and continued holding the resident, and the LPN cleaned and measured the wound and applied dressing supplies without changing gloves or performing hand hygiene before touching clean dressing items. Resident #5, who had severe cognitive impairment and was dependent for personal care and toileting hygiene, was observed being cleaned and dressed by two CNAs who donned gloves without washing hands and continued using the same soiled gloves while touching feces, the resident’s skin, clothing, blankets, and mechanical lift sling, and while transferring the resident and grooming the resident. The facility also failed to follow infection control practices during medication administration and procedures. For Resident #16, who had diabetes and required accu checks, an LPN performed a finger stick and then cleaned the multi-resident glucometer with disinfectant wipes that the manufacturer label did not identify as killing bloodborne pathogens. For Resident #12, who received Humalog and Lantus insulin by pen, an LPN attached needle tips to both insulin pens without cleaning the pen tips with alcohol first. For Resident #29, who received budesonide nebulizer treatments, a CMT set up the nebulizer, left the resident self-administering, then returned and placed the handheld pieces in a cloth bag without disconnecting, rinsing, or disinfecting the equipment as described in facility policy. The report also states the facility did not provide a requested EBP policy.
Call System Not Audible and Call Lights Not Answered Timely
Penalty
Summary
The facility failed to maintain an adequate audible call system in resident bathrooms and bathing areas and failed to ensure call lights were answered in a timely manner for three residents. Survey observations showed the call light monitor at the nurses’ desk had a sign stating the volume must be on at all times, yet no audible sound was heard when call lights were active. Multiple observations on the central, south, and west halls showed call lights remaining on for 10 to 15 minutes without any audible indication to alert staff, including a call light above a resident room door that had no audible sound in the hall. Resident #25 had diagnoses including stroke, left-sided hemiplegia and hemiparesis, cellulitis of the left lower limb, and gait and mobility abnormalities. The resident’s care plan directed staff to keep the call light within reach and provide assistance with ambulation, transfers, showers, repositioning, dressing, toileting, and peri care. The resident was cognitively intact but required varying levels of assistance with toileting, hygiene, transfers, dressing, and showers. The resident reported that call lights took a long time to be answered, often 30 minutes or longer at night and early morning, and said staff had taken 45 minutes to assist in the bathroom. The call light log for this resident showed multiple prolonged waits, including 19 to 35 minutes. Resident #9 was cognitively intact, used a cane, and required partial/moderate assistance with showering and bathing. The resident stated that call lights pressed around midnight were not answered for a long time and that response was much slower during evenings and nights, leading the resident to avoid waiting and instead go to the bathroom independently. The call light log showed waits of 23 and 47 minutes. Resident #20 was cognitively intact and dependent on staff for toileting hygiene, transfers, and bed mobility, with frequent bowel and bladder incontinence. The resident reported waiting up to 30 minutes for call light response and said staff sometimes turned the light off and did not return. The call light log for this resident showed multiple waits of 25 to 31 minutes.
Failure to Return Resident Funds After Discharge or Death
Penalty
Summary
The facility failed to convey resident funds after discharge or death for three residents. Resident #43 died, and an observation of a petty cash envelope in the business office showed $28.29 in cash with a transaction log reflecting the same balance, but the facility had not refunded the balance to the resident’s representative within 30 days of death. Resident #44 discharged home, and an observation showed a petty cash envelope labeled for the resident containing $45.28, with the transaction log showing the same balance, but the facility had not refunded the account balance within five days of discharge. Resident #42 also discharged home, and an observation of the resident’s petty cash envelope showed $20.00 in cash with a matching transaction log balance, but the facility had not refunded the account balance within five days of discharge. During interviews, the Administrative Assistant said she was not aware of deadlines for returning resident money, and the Administrator said the facility had not returned the petty cash for Residents #42, #43, or #44 because it was waiting for a family member to come sign for the balances and had not considered sending a check to the resident, representative, or estate.
Failure to Complete Significant Change Assessments for Two Residents
Penalty
Summary
The facility failed to complete significant change in status assessments (SCSA) within 14 days for two residents after changes in condition met the criteria for a federally mandated comprehensive assessment. The report states the facility did not have a specific policy for SCSA completion and instead relied on the RAI manual. The MDS Coordinator said she was new to the position, was still learning the manual, did not know that resident improvements could trigger an SCSA, and did not know that a resident who did not return to baseline within 14 days after illness required an SCSA. For one resident, the annual MDS showed multiple baseline conditions including cognitive intactness, several ADL assist levels, occasional bowel and bladder incontinence, mild depression symptoms, chronic pain, and a weight of 124 pounds. The quarterly MDS later showed a new diagnosis of pneumonia, no signs or symptoms of depression, increased pain frequency affecting sleep, and a weight of 126 pounds. Physician orders and nursing notes also documented a new wound on the right gluteal crevice with yellow slough, maceration, erythema, mild pain, limited mobility, and bowel and bladder incontinence since recent illness. A later observation found an open wound on the right side of the tailbone with bleeding and red granulated tissue exposed, described by staff as a Stage III pressure ulcer. The facility did not complete a comprehensive SCSA after the new dementia diagnosis, decline in several ADLs, weight loss, new pressure ulcer, new antipsychotic pain medication, increased pain, and new behaviors. For the second resident, the annual MDS showed moderately impaired cognition, walker and wheelchair use, multiple ADL assistance needs, frequent bowel and bladder incontinence, several chronic diagnoses, risk for pressure ulcers, and one unhealed Stage II pressure ulcer. The quarterly MDS later showed cognitive intactness, new physical and verbal behaviors, rejection of care, loss of walker use, improvements in several ADLs and transfers, changes in mobility with dependence for wheelchair propulsion, occasional bowel incontinence, new diagnoses of pneumonia and urinary tract infection, and a healed pressure ulcer. A subsequent quarterly MDS also showed continued behavioral symptoms, changes in mobility, mixed ADL changes, and ongoing pain with PRN pain medication use. The facility did not complete an SCSA after the resident had several improvements in ADLs and cognition along with declines in mobility and behaviors.
Failure to Maintain and Use PASARR Level II Information
Penalty
Summary
The facility failed to maintain a copy of the PASARR Level II assessment for one resident with mental illness and intellectual disability, and failed to incorporate the PASARR information and recommendations into that resident’s care plan and assessment data. In a sample of two residents with mental illness, Resident #5 had no documentation of a Level II PASARR assessment in the medical record. The resident’s PASARR Level II assessment, obtained from the state agency, dated 08/19/2015, listed diagnoses including Alzheimer’s dementia, major depressive disorder, intellectual disability, convulsions, and epilepsy, and described the resident as having a brain injury in childhood, never attending school or working, speaking very little with garbled speech, being oriented to person but confused, and having poor concentration, judgment, and insight. The resident’s annual MDS dated 11/11/25 identified PASARR II based on intellectual disability, unclear speech, severe cognitive impairment, and diagnoses including dementia, Alzheimer’s, seizure disorder, depression, panic disorder, and profound intellectual disabilities. The quarterly MDS showed new verbal behaviors directed toward others daily and other behaviors not directed toward others daily. The resident’s record still contained no PASARR documentation, and the care plan dated 01/26/26 did not include information from the PASARR. During interview, the Social Services Director said she was responsible for submitting Level I and Level II PASARRs, was not sure what was on a Level II PASARR, knew the resident had one, was not aware the facility did not have a copy, and did not know someone needed to review the Level II PASARR.
Failure to Complete PASARR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a Level 1 PASARR screening for one resident with mental health diagnoses. Resident #27 was admitted on 08/18/23 and had diagnoses that included major depressive disorder and borderline personality disorder. Review of the resident’s EHR showed no documentation of a completed Level 1 PASARR, and the resident’s quarterly MDS dated 02/17/26 also showed no documentation that a PASARR had been completed. The facility’s policy stated that all new admissions and readmissions are to be screened for mental disorders, intellectual disabilities, or related disorders through the Medicaid PASARR process, regardless of payer source. During interview, the Social Services Director stated she was responsible for submitting the Level 1 PASARR, but she was not aware that it had to be completed for all admissions and believed it was only required for Medicaid residents, not private pay residents.
Failure to correctly assess and manage a worsening pressure injury
Penalty
Summary
The facility failed to follow its wound assessment and pressure injury prevention policies for a resident with stroke-related left-sided weakness, hemiplegia, hemiparesis, impaired mobility, and a history of cellulitis. The resident had a care plan identifying risk for pressure ulcers and directing daily skin observation, repositioning every two to four hours, weekly full skin evaluations, and use of a pressure-reducing mattress and wheelchair cushion. The resident’s record also included weekly skin assessment orders, but the documentation showed repeated gaps in assessment, staging, root-cause evaluation, and care plan revision as the wound changed over time. The resident’s left posterior knee area was first documented as a 1.0 cm by 0.3 cm skin tear after staff removed an Opti foam dressing during a shower. The wound was treated with wound wash, skin prep, triple antibiotic ointment, and a non-adherent bandage, but the care plan was not updated after discovery of the wound. Subsequent weekly skin assessments repeatedly documented the area as intact or healed, even though later notes showed the wound reopened, enlarged, and continued to recur. The record did not show that staff completed a risk assessment with each change in condition, evaluated the surrounding skin as directed, or documented the wound measurements and characteristics in the wound section as required by the care plan. The resident’s wound continued to worsen while staff continued to identify it as a skin tear. The wound management record later showed the area reopened with increasing size, changing appearance, and eventually red tissue and purulent drainage, at which point the resident was started on Keflex. During observation, the resident’s left leg extended without a foot or leg rest, and the posterior left leg was rubbing against the wheelchair cushion and seat, with direct pressure noted on the back of the left knee. The resident stated the wheelchair cushion and lack of proper leg support had caused the sore area for months and that the wound had become worse. The wound nurse and DON both acknowledged the wheelchair was causing pressure, and the NP stated she would consider the area a wound rather than a skin tear and believed it was a Stage II pressure ulcer obtained at the facility.
Insulin Pen Administration Error
Penalty
Summary
The facility failed to ensure that a resident with diabetes mellitus was free from significant medication errors during insulin administration. Resident #12 had physician orders for Humalog insulin 20 units three times daily, Humalog insulin per sliding scale three times daily, and Lantus insulin 55 units subcutaneously twice daily. During observation, an LPN checked the resident’s blood sugar and prepared insulin for administration, but did not prime either the Humalog insulin pen or the Lantus insulin pen before dialing up the ordered doses, as directed by the manufacturer instructions. The same observation showed the LPN administered the Lantus insulin in the resident’s right abdomen and did not hold the pen in place for 10 seconds, and administered the Humalog insulin in the resident’s left abdomen and did not hold the pen in place for 5 to 10 seconds. During interview, the LPN stated he/she had never been trained to prime insulin pens or to hold the pen against the resident’s skin after administration. The administrator stated staff were expected to prime insulin pens before dialing up the dose and to hold the pen against the skin after administration as instructed by the manufacturer.
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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.
Illustrative
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Illustrative
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Nursing homes near Edina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Belle Manor Care Center | 12 mi | ★★★★★ | 0 | 0 |
| Country Aire Retirement Center | 19.2 mi | ★★★★★ | 4 | 0 |
| La Plata Nursing Home | 20.6 mi | ★★★★★ | 0 | 0 |
| Twin Pines Adult Care Center | 22 mi | ★★★★★ | 3 | 0 |
| Kirksville Manor Care Center | 22.4 mi | ★★★★★ | 23 | 0 |
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