Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Nhc Healthcare, Ft Sanders during CMS and state inspections, most recent first.
Uncovered urinary drainage bags were observed for two cognitively intact residents with indwelling catheters. Both residents were found in bed with the contents of the drainage bags visible, and for one resident the drainage port was left hanging outside the bag instead of being placed back in the holding pocket. The RN Manager and ADON confirmed catheter bags were expected to be covered to maintain resident dignity.
Dirty Personal Fans in Resident Rooms: Two residents had bedside portable fans with a large amount of gray dust and thick debris on the protective grilles, and one fan also had debris inside the unit. The RN Manager confirmed the buildup should not be present with routine cleaning, and the ESD confirmed housekeeping was responsible for routine cleaning of rooms and contents.
A resident admitted with incomplete quadriplegia and insomnia later received multiple new mental health diagnoses, including PTSD, nightmare disorder, major depressive disorder, and generalized anxiety disorder. Although the resident’s PASRR Level I screen had previously indicated no Level II evaluation was required, the record showed no documentation that a new PASRR was submitted after the added diagnoses, and the MDS nurse confirmed it had not been sent to the state-designated authority.
Failure to provide nail care to a resident with severe cognitive impairment and dependence for personal hygiene and bathing. The resident's care plan included keeping the nails clean and trimmed, but repeated observations showed brown substance under the nails and around the cuticles of both hands. A CNA stated she had not provided nail care, and the NM confirmed the nails had not been cleaned or trimmed.
Medication administration errors occurred when a nurse working with students gave a medication cup to a student and turned away while the student administered another resident’s medications to the wrong resident. One resident with dementia and chronic kidney disease received the roommate’s ordered meds in error, while another resident’s ordered meds were held on the MAR. The DON, ADON, and NP were notified, and the NP confirmed there was no negative outcome from the error.
A resident with diabetes and a history of tube feeding had 2 cases of sodium chloride bags left on a windowsill in the room instead of being stored securely. Surveyors observed the bags on multiple occasions, and the resident stated they had not been removed after tube feeding was no longer needed. The DON confirmed the saline had not been stored correctly and remained in the room for more than 90 days.
Uncovered urinary drainage bags left visible
Penalty
Summary
The facility failed to maintain resident dignity when urinary drainage bags were left uncovered for two residents with indwelling urinary catheters. Resident #14 was admitted with diagnoses including wedge compression fracture of the spine, respiratory failure, and heart failure, and had a BIMS score of 14 indicating cognitive intactness. Although the care plan identified an indwelling catheter and related urogenital issues, observations on 1/20/2026 at 11:30 AM and 4:15 PM showed the resident lying in bed with a urinary drainage bag hanging from the bed frame, uncovered, with the contents visible. Resident #2 was admitted with diagnoses including quadriplegia, neuromuscular dysfunction of the bladder, and liver cirrhosis, and also had a BIMS score of 14 indicating cognitive intactness. The care plan identified a suprapubic catheter. Observations on 1/20/2026 at 11:35 AM and 4:20 PM showed the resident lying in bed with the urinary drainage bag uncovered and the contents in view. On 1/22/2026 at 9:45 AM, the drainage outlet was also hanging out instead of being placed back into the outlet's holding pocket. During interview, the 2nd floor RN Manager confirmed the bag was uncovered and the drainage port was hanging outside the bag, and the ADON confirmed urinary drainage bags were expected to be covered so the contents are not visible to maintain resident dignity.
Dirty Personal Fans in Resident Rooms
Penalty
Summary
The facility failed to provide a clean and sanitary environment by not ensuring cleanliness of personal fans for two residents, Resident #92 and Resident #40, out of 134 residents reviewed for a clean and sanitary environment. Facility policy titled, General Environmental Cleaning Techniques, stated to conduct a visual preliminary site assessment and to clean from cleaner to dirtier and from high to low. Resident #92 was admitted with diagnoses including history of stroke, dysphagia, and diabetes, and Resident #40 was admitted with diagnoses including diabetes, pulmonary disease, and epilepsy. During repeated observations, Resident #92's bedside portable fan had a large amount of gray dust and thick debris resembling clumped gray fibers on the protective grille. Resident #40's bedside portable fan had a large amount of gray dust and thick debris resembling clumped gray fibers on the protective grille and inside walls of the fan. The 2nd floor RN Manager confirmed the debris on both fans and stated it should not be present with routine cleaning. The Environmental Services Director confirmed housekeeping was responsible for ensuring rooms and contents were cleaned routinely.
Failure to Resubmit PASRR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit a PASRR for Level II Evaluation after new mental health diagnoses were identified for one resident. The resident was admitted with diagnoses including incomplete quadriplegia and insomnia, and the medical record later showed additional diagnoses of Adjustment Disorder with Depressed Mood, PTSD, Nightmare Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, and Personal History of Other Mental and Behavioral Disorders. The resident’s PASRR Level I screen dated 1/11/2024 listed Anxiety Disorder and Adjustment Disorder and indicated that a Level II Evaluation was not required. Review of the resident’s quarterly MDS assessment showed a BIMS score of 15, indicating the resident was cognitively intact. The care plan was revised to include psychiatric/psychotropic medications related to Adjustment Disorder with Depressed Mood, Insomnia, Anxiety, Nightmare Disorder, PTSD, and Major Depressive Disorder. The medical record contained no documentation that a PASRR was submitted for Level II Evaluation after the new mental health diagnoses were identified, and during interview the MDS Nurse confirmed that a new PASRR had not been submitted to the state-designated authority.
Failure to Provide Nail Care
Penalty
Summary
The facility failed to provide nail care to Resident #26, who was admitted with diagnoses including Cerebral Ischemia, Dementia, and Restlessness and Agitation. The admission MDS assessment showed a BIMS score of 3, indicating severe cognitive impairment, and the resident was dependent on staff for personal hygiene and bathing. The care plan included keeping the nails clean and trimmed. During observations on 1/20/2026, 1/21/2026, and 1/22/2026, the resident's nails were observed to be unclean with a brown substance underneath the nails and around the cuticles of both hands. On 1/22/2026, CNA A stated she cared for the resident regularly and had not provided nail care, and NM later inspected the resident's hands and confirmed the nails had not been cleaned or trimmed.
Medication Administration Error and Failure to Follow Physician Orders
Penalty
Summary
The facility failed to follow physician orders for two residents during medication administration. One resident had diagnoses including dementia, cerebral infarct, and hypertensive chronic kidney disease, and had severe cognitive impairment on the BIMS. Another resident had diagnoses including hemiplegia, epilepsy, and hypertensive chronic kidney disease. The deficiency involved medication administration errors and failure to administer ordered medications as prescribed. For the first resident, the MAR showed that diltiazem HCL 120 mg and cholecalciferol 50 mcg were held. A nursing note documented that a medication nurse prepared medications with students and gave the medication cup to the students, then turned toward the hallway while medications were being given to the wrong patient. The note stated the nurse immediately reported the incident to the nurse manager, ADON, and DON, and the NP was notified with new orders. Facility documentation identified the medications involved as aspirin 81 mg, vitamin D3 10 mcg, levetiracetam 500 mg, lisinopril 20 mg, metoprolol 37.5 mg, potassium chloride 20 mEq, and rivastigmine tartrate 1.5 mg. The resident was monitored afterward and remained without adverse effects or change in condition. The event occurred while an RN was working with TCAT students in medication preparation and administration. The nurse stated she scanned the roommate’s medications, handed them to the student, and turned away while preparing the other resident’s medications. She later realized the student had administered the roommate’s medications to the wrong resident. Interviews with the DON and ADON confirmed they became aware of the error that morning, and the NP later confirmed there was no negative outcome from the medications received in error. The report also noted that the facility’s policy required medications to be administered as prescribed, residents to be identified before administration, and the person preparing the dose to be the person administering it.
Improper Storage of Sodium Chloride Bags in Resident Room
Penalty
Summary
The facility failed to ensure medications were stored securely for one resident, who was admitted with diagnoses including diabetes and acute metabolic acidosis and was cognitively intact on the most recent BIMS assessment. The resident’s care plan included risks related to compromised gastrointestinal status, skin integrity, and tube feeding/ileostomy. The medication administration record showed sodium chloride 0.9% ordered for gastric tube administration and flushing, with a start date of 8/11/2025 and an end date of 9/30/2025. During observations on 1/20/2026, 1/21/2026, and 1/22/2026, surveyors found 2 cases containing a total of 48 1000 mL bags of 0.9% sodium chloride resting on the ledge of the windowsill with blinds partially open in the resident’s room. The resident stated she had been on tube feeding and the saline bags had not been removed from her room after she no longer required tube feeding. Further interview confirmed the cases of sodium chloride had remained in the room for greater than 90 days. The DON confirmed the 2 cases of sodium chloride had not been stored correctly and were left in the resident’s room greater than 90 days.
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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) |
|---|---|---|---|---|
| Fort Sanders Tcu | 0.2 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Knoxville | 2.4 mi | ★★★★★ | 0 | 0 |
| Island Home Park Health And Rehab | 2.7 mi | ★★★★★ | 3 | 0 |
| Creekview Health And Rehabilitation | 3.1 mi | ★★★★★ | 12 | 0 |
| Lyonsview Health And Rehabilitation Center | 3.6 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.