Knox County Nursing Home District

In the surveyor’s words

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

• Actual harm, isolatedF692Feb 26, 2026

  Based on observation, interview and record review, the facility failed to monitor or identify weight loss, failed to complete assessments or notify the resident's provider or dietitian of significant weight loss, failed to ensure staff adequately monitored consumption of supplements ordered for weight loss and failed to re-evaluate the resident's care plan or initiate interventions to prevent further weight loss for one resident (Resident #13), in a sample of two residents investigated for nutrition concerns. Review of the resident's weight records showed the resident experienced a seven pound (lb.) weight loss, a 5.6 percent (%) significant weight loss in 30 days. The resident had also developed a pressure ulcer. […]

• Actual harm, isolatedF697Feb 26, 2026

  Based on observation, interview and record review, the facility failed to implement interventions to address pain and notify the physician of effectiveness of interventions regarding pain for one resident (Resident #15), in a review of 13 sampled residents. The facility failed to administer available ordered pain medications to address the resident's pain on occasions when other medication was not effective. Staff reported the resident's increased pain was preventing him/her from sleeping and attending activities. […]

• Actual harm, isolatedF686Aug 14, 2025

  Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote healing of a pressure ulcer (a localized injury to the skin and/or underlying tissue that develops as a result of prolonged pressure on an area) for one resident (Resident #10), who was at risk for development of pressure ulcers, in a review of 10 sampled residents. Staff first identified the pressure ulcer on 8/4/25. Licensed staff failed to assess the wound or obtain treatment orders until 8/8/25 when the wound had developed into a Stage III pressure ulcer (full-thickness skin loss, where fat tissue is visible in the wound. […]

• Actual harm, isolatedF684Jul 26, 2021

  Based on interview and record review, the facility failed to follow professional standards of care when staff failed to notify the physicians of two residents, (Residents #1 and #5) of nine sampled residents, when the residents had a change in condition. Resident #5 developed an elevated temperature, irregular heart rate, abnormal respirations, complained of muscle cramping and had significant lower extremity [CONDITION(S)] (swelling). Resident #5's representative requested facility staff send the resident to the hospital for evaluation. Facility staff failed to notify Resident #5's physician of the resident's change in condition or the representative's request for evaluation at the hospital. The resident required hospitalization for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF728Feb 1, 2024

  Based on interview and record review, the facility failed to ensure two nurse aides (NA D and NA N) of two staff reviewed completed a certified nurse aide (CNA) training program within four months of their employment in the facility. The facility census was 36. The facility did not have a specific policy on NA to CNA training. 1. Review of the facility provided list employees hired since last annual inspection showed the following: -NA D's date of hire was 08/21/23; -NA N's date of hire was 12/30/22. 2. Review of NA D's employee file showed no documentation he/she completed a nurse aide training program within four months of his/her hire date. 3. […]