Knox County Nursing Home

In the surveyor’s words

From the most serious findings on record at Knox County Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 30, 2026

  Based on interview and record review, the facility failed to provide adequate supervision and implement resident-specific fall prevention interventions to prevent accidents/injuries for two (R48 and R92) of six residents reviewed for accidents and supervision in the sample of 106. These failures resulted in actual harm to R92 after a fall forward from the wheelchair sustaining a laceration requiring sutures Findings include:R92's admission record documents R92's medical diagnoses including dementia, metabolic encephalopathy, cognitive communication deficit, unsteadiness on feet, muscle wasting and atrophy, abnormalities of gait and mobility, ataxia, osteoarthritis, and anemia.R92's Physical Therapy Evaluation and Plan of Treatment, dated 1/31/26, documents R92 used a manual wheelchair for… […]

• Actual harm, isolatedF689Aug 31, 2021

  Based on observation, interview, and record review the facility failed to provide sufficient supervision to prevent a fall with major injury for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 walking without her walker or staff assistance causing R1 to fall sustaining a laceration to the forehead, a laceration to the right hand and a fracture to the right proximal phalanx of the little finger and a fracture to the base of the phalanx of the right ring finger. […]

• No harm, potential for more than minimal, widespreadF725Jun 15, 2023

  Based on observation, interview, and record review, the facility failed to provide sufficient staff to care for dependent residents. This failure has the potential to affect all 79 residents residing in the facility. Findings include: The facility Assessment, no date available, documents, Nursing, nutrition services, and housekeeping staffing is evaluated at the beginning of each shift and adjusted as needed to meet the care needs and acuity of the resident population. The facility's Resident Council Minutes/Report, dated 5/18/23, documents, The CNAs (Certified Nursing Assistants) should not be giving showers on Wing 1 when there is only one CNA. On 06/12/23 at 10:45 AM, V12 (R16's family) stated, (R16) was left in pool of urine, the bed, the mattress, and the sheets. […]

• No harm, potential for more than minimal, widespreadF812Apr 28, 2022

  Based on observation, interview, and record review, the facility failed to date opened food, date food received or thawed, date thawed health shakes, clean the convection oven, ensure a covering for a food cart to keep food warm, and failed to wear a hair net in the kitchen. These failures have the potential to affect all 61 residents except R32 who is NPO (nothing by mouth). Findings include: Facility Food Receiving and Storage policy, revised 2017, documents, All foods stored in the refrigerator or freezer will be covered, labeled, and dated ('use by' date). Facility Sanitization policy, revised 2008, documents, The food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas shall be kept clean. […]

• No harm, potential for more than minimal, widespreadF761Feb 11, 2021

  Based on observation, interview and record review, the facility failed to properly store controlled substance medications, ensure a medication cart was locked and date an open in use multi dose insulin vial. These failures have the potential to affect all 55 residents residing in the facility. Findings include: Facility Storage of Medication policy, revised April 2019, documents, Compartments containing drugs and biologicals are locked when not in use. Scheduled II-V controlled medications are stored in separately locked, permanently affixed compartments. […]