Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Senator Ben Atchley State Veterans' Home during CMS and state inspections, most recent first.
PASARRs were not submitted for Level II evaluation after psychiatric diagnoses were identified for three residents. One resident had PTSD, insomnia, and recurrent depression omitted from the PASARR; another had MDD, adjustment disorder with depressed mood, delirium, PTSD, and nightmare disorder omitted; and a third had hallucinations, other specified mental disorders, adjustment disorder with anxiety, and PTSD omitted. The DON confirmed the missing diagnoses, and the RN/Admissions/Case Manager stated the PASARRs must have been missed.
Medication Storage and Labeling Deficiencies: An LPN and the DON confirmed multiple medication storage problems across 3 medication carts, including dirty cart drawers and bottles, a cup of crushed meds mixed with applesauce left unlabeled in a drawer after a resident refused the dose, partially used insulin pens and a nasal spray without open dates or resident labels, an unlabeled reconstituted Ertapenem vial, and an expired Normal Saline container available for use.
A facility failed to prevent resident-to-resident sexual abuse when a resident with moderate cognitive impairment was found with their hand inside another resident's brief. Both residents had cognitive impairments, and the incident was discovered by CNAs who observed them in a potentially consensual act. The resident with moderate cognitive impairment had a history of a romantic relationship with a previous resident who had recently passed away, which may have contributed to the confusion. Psychiatric evaluations suggested the act was likely consensual, but the cognitive impairments made it difficult to determine consent.
PASARRs Not Submitted for Level II Evaluation After Psychiatric Diagnoses Identified
Penalty
Summary
The facility failed to ensure PASARRs were submitted to the state-designated authority for Level II evaluation after diagnoses of serious mental illness were identified for 3 residents reviewed for PASARRs. Resident #1 was admitted with diagnoses including Anxiety Disorder, Insomnia, PTSD, and Recurrent Depression, but the PASARR submitted prior to admission listed Anxiety Disorder and Mild or Situational Depression and did not include Insomnia or PTSD. The resident’s care plan later documented recurrent depressive disorders, insomnia, generalized anxiety disorder, and PTSD, and the admission MDS showed a BIMS score of 14, indicating cognitive intactness. The record also showed the resident was marked as not having a Level II PASARR for a serious mental illness or related condition. Resident #12 was admitted with diagnoses including Dementia without Behavioral Disturbance, Major Depressive Disorder, Adjustment Disorder with Depressed Mood, Delirium, Anxiety Disorder, PTSD, and Nightmare Disorder, but the PASARR submitted prior to admission listed Dementia/Neurocognitive Disorder and Anxiety Disorder and did not include the other psychiatric diagnoses. The annual MDS showed a BIMS score of 15, and the resident was marked as not having a Level II PASARR. Resident #126 was admitted with diagnoses including Hallucinations, Major Depressive Disorder, Other Specified Mental Disorders, Adjustment Disorder with Anxiety, and PTSD, but the PASARR submitted listed only Major Depression and did not include the other diagnoses. The significant change MDS showed a BIMS score of 14, and the resident was also marked as not having a Level II PASARR. During interviews, the DON confirmed the missing diagnoses on the PASARRs, and the RN/Admissions/Case Manager stated the PASARRs for these residents must have been missed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store medications in 3 of 4 medication carts reviewed. During observation of the C-Front cart, dried debris was seen in the bottom of the liquid medication storage drawer and on the outside of some liquid medication bottles. An LPN stated the carts were cleaned weekly and as needed, and confirmed the drawer and bottles were not maintained in a clean condition. The C-Front cart also contained a 1-ounce cup of crushed medications mixed with applesauce for a resident with dementia, paraplegia, and hypertension. The cup was in a drawer, was not labeled with the resident’s name, date, or time of preparation, and the LPN stated it had been prepared earlier when the resident refused the morning dose and was intended to be given later. The same cart contained a partially used Lantus insulin pen for a resident with diabetes, atrial fibrillation, and chronic kidney disease, and a Fluticasone Propionate nasal spray for a resident with sinusitis, dementia, and hypertension; both were not labeled with an open date. The cart also contained a 100 mL container of Normal Saline 0.9% with an expiration date of 12/28/2025, and the LPN confirmed it had expired and was available for resident use. The C-Back cart contained a partially used Lispro insulin pen for a resident with diabetes, congestive heart failure, and hypertension that was not labeled with the resident’s name or open date and did not have the pharmacy label on the pen. The same cart also contained another partially used Lispro insulin pen for a resident with diabetes, chronic kidney disease, and chronic respiratory failure that was not labeled with a name or open date, and a vial of Ertapenem for a resident with rheumatoid arthritis, chronic kidney disease, and a UTI that had been reconstituted earlier in the day but was not labeled with the resident’s name, date, or time of preparation. The C-Middle cart contained a partially used Lispro insulin pen for a resident with diabetes, dementia, and heart failure that was not labeled with an open date, and a partially used Lantus insulin pen for a resident with diabetes, chronic kidney disease, and dementia that was not labeled with a name or open date. The DON confirmed that cart drawers and liquid medication bottles should be kept clean, resident medications including nasal spray and insulin should be labeled with the resident’s name and the date opened, prepared medications should be administered promptly within the scheduled time frame, refused prepared medications should be discarded, and prepared medications should not be stored in the medication cart.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident sexual abuse involving two residents. The incident occurred when one resident was found with their hand inside another resident's brief. Both residents involved had cognitive impairments, with one resident having a history of wandering and moderate cognitive impairment, while the other had severe cognitive impairment and was new to the facility. The incident was discovered by CNAs who observed the residents in a potentially consensual act, as both residents did not exhibit signs of distress or discomfort at the time. The resident with moderate cognitive impairment had a history of a romantic relationship with a previous resident who had recently passed away. This resident was found in the room previously occupied by their deceased partner, which may have contributed to the confusion and mistaken identity during the incident. The resident with severe cognitive impairment was described as sociable and flirtatious, with no prior history of negative behaviors. Both residents were unable to recall the incident when questioned later, and neither showed signs of psychological or physical distress. Interviews with staff and psychiatric evaluations suggested that the act was likely consensual, although the cognitive impairments of both residents made it difficult to definitively determine consent. The facility's Director of Nursing acknowledged the cognitive impairments and the inability to confirm consent based solely on cognitive assessments. The incident highlighted the challenges in managing residents with cognitive impairments and ensuring their safety and well-being in a long-term care setting.
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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) |
|---|---|---|---|---|
| Wellpark Health And Rehabilitation | 4.6 mi | ★★★★★ | 2 | 0 |
| Legacy Park Health And Rehabilitation | 4.6 mi | ★★★★★ | 7 | 0 |
| West Hills Health And Rehab | 5.2 mi | ★★★★★ | 0 | 0 |
| Diversicare Of Oak Ridge | 7.1 mi | ★★★★★ | 0 | 0 |
| Lyonsview Health And Rehabilitation Center | 7.6 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.