Accura Healthcare of Knoxville, LLC

Based on staff interview, personnel file review, and facility policy review, the facility failed to designate a person to serve as the director of food and nutrition services who met the minimum qualifications to carry out the food and nutrition services. Findings include: During an interview on 2/16/26 at 9:15 a.m. with the Dining Services Manager, she revealed she had been promoted from cook to Dining Services Manager last month, January 2026. Further interview on 2/17/26 at 10:30 a.m. with the Dining Services Manager revealed she had been hired 9/8/23 as a housekeeper and soon after her hire, she then accepted a position in the facility's kitchen as dietary aide. She then accepted a position as [NAME] in January 2024. She stated another dietary aide and her had managed the dietary department during the month of December 2025, after the previous Dining Services Manager had abruptly quit. During that time she had accepted the role as Director of Dining Services and on January 1, 2026 she was fully in her role as the Dining Services Manager. She stated she was currently completing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual review, the facility failed to complete a significant change in status assessment for one (1) of two sampled residents who had been admitted to hospice care (Resident#1). Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #1 without any memory problems and independent with his cognitive skills for daily decision making, which indicated intact cognition. The MDS listed diagnoses included: chronic obstructive pulmonary disease (a progressive, incurable, yet treatable lung disease that obstructs airflow and makes breathing difficult), congestive heart failure (CHF), diabetes mellitus, and peripheral vascular disease (a progressive condition where plaque buildup reduces blood flow to the legs and feet). The MDS documented the resident had one fall with major injury and two falls with no injury since his prior MDS assessment on 8/26/25. The MDS assessed the Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and resident interview the facility failed to accurately complete a Minimum Data Set (MDS) assessment correctly for 2 of 10 resident's reviewed in the sample (Resident #4 and Resident #6). The facility reported a census of 45 residents.Findings include:1. Resident #4, Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Diagnosis included malignant bladder cancer. Resident #4 was not coded for receiving hospice care. The Care Plan for Resident # 4 initiated 11/20/25 documented the resident received hospice services.The Clinical Census record for Resident #4 documented the resident entered the facility on 11/19/25 under hospice care.The Hospice Plan of Care report for Resident #4 revealed hospice were initiated on 11/14/25. On 2/18/26 at 1:18 PM Resident #4 reported participation of hospice visits three to five times a week, and expressed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, clinical record review, staff interview, the facility failed to provide the opportunity for the resident to participate in the development, review and revision of his care plan for 1 of 1 (Resident #3 ) reviewed for care conferences and failed to update a care plan for 1 of 2 reviewed for hospice (Resident #1 ). The facility reported a census of 45 residents. Findings include: 1. Resident #3 Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating moderately impaired cognition. The MDS further documented the resident had a diagnosis of diabetes and stroke. The Care Plan focus revised on 11/18/25 for Resident #3 revealed the resident would remain in long term care. Care Plan interventions included the following; staff to assist the resident to be independent as possible, resident would participate in activities of choice, staff to invite encourage and remind daily the resident to attend…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, policy review, and staff interviews, the facility failed to carry out a system to receive controlled substances for 1 of 1 residents reviewed for a missing narcotic(Resident #54). The facility reported a census of 45 residents. Findings included: The Minimum Data Set(MDS) assessment tool, dated 8/17/25, listed diagnoses for Resident #54 which included chronic pain syndrome, seizure disorder, and depression. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The facility policy Controlled Substances, updated 11/18/25, stated the facility would ensure staff handled, stored, and disposed of controlled drugs properly and carried out proper record keeping. Resident #54's October 2025 Medication Administration Record(MAR) listed a 9/27/25 order for fentanyl(a powerful synthetic pain medication) transdermal(delivered through the skin) patch 72 hour 25 micrograms(mcg)/hour(hr), apply every 72 hours for chronic pain. A Packing Slip Proof of Delivery document, stated the facility received 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, resident interview, and clinical record review, the facility failed to treat residents with dignity and respect throughout cares provided for 1 of 3 residents reviewed (Resident #1).The facility reported a census of 46 residents.Findings include:Record Review of Resident #1 Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 09 indicating moderate cognitive impairment The MDS reflected Resident #1 diagnosis of Paranoid Schizophrenia, Delusional Disorders, Anxiety Disorder, and Major Depressive Disorder. The MDS further documented Resident #1 dependence on staff for performing activities of daily living (ADLs). A facility reported incident review dated 6/15/25 documented Staff A, Licensed Practical Nurse (LPN), with almost 30 years of experience as an LPN, attempted to assist Resident #1 during ADLs along with two other staff, Staff B, Certified Nursing Assistant (CNA), and Staff C, CNA. Resident #1 was agitated and in distress, and was refusing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to maintain an environment in a clean, orderly condition, in good repair and with all odors kept under control through cleanliness and proper ventilation. The facility reported census was 49. Findings include: 1. During an observation on 4/16/25 at 11:00 a.m. several rooms with cosmetic and baseboard guards detached were detected: room [ROOM NUMBER] bathroom, baseboard guard split open exposing boiler pipe. room [ROOM NUMBER] bathroom had baseboard pulled away from the wall with peeling paint. The 500 hallway baseboard was removed from the wall leaving a jagged unfinished wall. In an interview on 4/16/25 at 2:05 p.m. Staff C, Maintenance, stated he relies on staff, aides and housekeeping to alert him to maintenance needs within the facility. When staff see an issue, they are to input the concern into the Tells app which then goes directly to his phone. From there he will make plans to repair the concern depending on the priority of the need. Staff C…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and resident and staff interviews, the facility failed to ensure residents had the right to make choices about aspects of their lives which were significant to the resident by denying smoke breaks for 5 of 5 smokers reviewed (Residents #6, #7, #17, #27, and #30) and by not allowing a resident to lie down upon request for 1 of 6 residents reviewed for dignity (Resident #28). The facility reported a census of 50 residents. Findings include: 1. The Quarterly Minimum Data Set(MDS) assessment tool, dated 1/12/25, listed diagnoses for Resident #7 which included anxiety, depression, and unspecified intellectual disability. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. A 4/7/22 Care Plan entry stated she loved to participate in smoking breaks. A 1/6/25 Smoking Evaluation stated the resident smoked mornings, evenings, and afternoons supervised. On 1/30/25 at 8:44 a.m., Resident #7 stated that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and resident and staff interviews, the facility failed to ensure residents were free from mental abuse by denying smoke breaks based on resident behaviors for 5 of 5 smokers reviewed(Residents #6, #7, #17, #27, and #30). The facility reported a census of 50 residents. Findings include: 1. The Minimum Data Set(MDS) assessment tool, dated 1/12/25, listed diagnoses for Resident #7 which included anxiety, depression, and unspecified intellectual disability. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. A 4/7/22 Care Plan entry stated she loved to participate in smoking breaks. A 1/6/25 Smoking Evaluation stated the resident smoked mornings, evenings, and afternoons supervised. On 1/30/25 at 8:44 a.m., Resident #7 stated that whenever she had a disagreement with staff they took away her smoking break. She stated staff considered smoking a privilege and when this happened she felt belittled. 2.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review and staff interview the facility failed to ensure staff followed physician pre-op orders as directed prior to a resident procedure for 1 of 1 residents reviewed (Resident #43). Resident #43 did not receive a bath/shower the day of the procedure. The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #43 dated 1/12/25 included diagnoses of ulcerative colitis, Alzheimer's disease, anxiety disorder, and depression. The MDS identified a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition. The MDS documented the resident required extensive assistance with bathing, personal hygiene, and transfers and was dependent on staff assistance for toileting. Review of pre-op orders dated 1/20/25 in preparation for a colonoscopy to be completed on 1/24/25, stated the day of surgery, Resident #43 was to receive a shower or bath the morning of the procedure. Resident #43 was noted to have powder in her groins that was wet and clumpy when she arrived for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on personnel file review, staff interview, and policy review, the facility failed to assure 1 of 5 staff reviewed met the requirements for Dependent Adult Abuse Mandatory Reporter Training (Staff B). The facility reported a census of 50 residents. Findings include: Staff B, Housekeeper, had a start date of 5/29/24. Record review revealed Staff B had not completed the 2 hour Dependent Adult Abuse Mandatory Reporter Training that was due 11/29/24. In an interview on 1/29/25 at 1:00 PM, the Administrator acknowledged Staff B had not yet completed the Dependent Adult Abuse Mandatory Reporter Training. She stated the employee was currently in the facility completing the training. She was aware new employees were to complete the training within 6 months. In an interview on 1/30/25 at 2:48 PM the Administrator stated it was the expectation the Business Office Manager use a spread sheet with all staff and the dates they are due to complete or renew their Dependent Adult Abuse Mandatory Reporter Training and the Business Office Manager was to let the Administrator know when the staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing food. The facility reported a census of 51 residents. Findings include: On 3/25/24 at 10:33 AM, a kitchen observation identified the following findings: Unit #1 freezer contained: 1) An unlabeled, undated, tied bag of folded, yellow items. 2) An unlabeled bag of meat links. Unit #2 freezer contained: 1) An unlabeled bag of chopped meat. 2) An unlabeled bag of 1/8 cut dough-like slices. 3) Two unlabeled blocks of sealed meat on shelves. Unit #3 refrigerator contained: 1) An unlabeled, undated metal pan with casserole-like contents and a used ladle stored on top. 2) An unlabeled, undated plastic bag of meat links. 3) An unlabeled bag of chopped, green contents. Unit #4 refrigerator contained: 1) An unlabeled, undated bag of diced, green contents. 2) An undated, plastic tub of sour cream. A cabinet contained two (2) unlabeled, undated plastic containers with cereal-like contents. An opened, undated bag of bread crumbs stored in the dry goods…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on document review and staff interview, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not having a certified dietary manager. The facility reported a census of 51 residents. Findings include: On 3/25/24 at 10:33 AM, Staff A, Dining Manager stated she was not the Dietary Manager because she was not certified. On 3/26/24 at 11:07 AM, Staff A stated she had not had any formal course-work training in food safety and nutrition, but was an assistant dietary manager at another facility for 1½ years. On 3/26/24 at 11:09 AM, the Administrator stated she planned to enroll Staff A in a six-month course in April. She stated the facility had a contract dietitian who was at the facility on Tuesdays. The contract dietitian was not present. On 3/28/24 at 9:23 AM stated the Dietary Manager should be certified within six (6) months of hire. The facility did not have a policy that addressed Dietary Manager certification. The Facility Assessment with updated date of 3/6/24 documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, clinical record review and staff interviews, the facility failed to provide restorative services on 1/18/24 involving 29 residents. The facility reported census was 45. Findings include: In an interview on 1/18/24 at 10:23 a.m. Staff C, Rehabilitation Director, stated when residents complete a physical or occupational program, they will typically get a restorative plan. Staff C stated she reviews the plans and the restorative aides provide the services usually 3-5 times per week. Staff C stated the ADON oversees the restorative program. In an interview on 1/18/24 at 3:00 p.m. the Assistant Director of Nursing (ADON) stated she oversees the restorative program and indicated there were currently 35-40 residents with a program. The ADON stated Staff D was the facilities full time restorative aide and she provides the restorative services Monday through Friday. The ADON stated Staff D also has responsibilities ordering and putting supplies away and assisting with showers Mondays, Tuesdays and Wednesdays. The ADON stated she provided Staff D with a restorative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.