Allure of Knox County

Inspectors wroteBased on interview, and record review the facility failed to ensure the services of a full-time Director of Nursing who is a Registered Nurse, as identified in the facility's staffing plan. This failure affects all 59 residents who reside at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the quaternary sanitation buckets contained an adequate level of chemical to sanitize kitchen surfaces and ensure all foods located within the refrigerator were labeled with the date opened or prepared. These failures have the potential to affect all 59 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an effective infection prevention and control program by failing to perform surveillance to track and monitor resident and staff illnesses and failed to implement appropriate PPE (Personal Protective Equipment) while handling soiled linens. These failures have the potential to affect all 59 residents residing in the facility.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure residents had an appropriate diagnosis, timely and accurate consent and targeted behaviors to warrant the use of antipsychotic medications and for four of four residents (R4, R7, R17, R53) reviewed for antipsychotic medications in the sample of 33.

Inspectors wroteBased on Interview and Record Review, the facility failed to ensure residents with a new psychiatric diagnosis or significant change in psychiatric status were reevaluated for a level two PASRR (Preadmission Screening and Resident Review) screening, for four of four residents reviewed for PASARR in the sample of 33.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure residents with indwelling urinary catheters were provided drainage privacy bags for three of three residents (R1, R51, R52) reviewed for dignity in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with facility policy and that residents only self-administer medications when a documented assessment and care plan approval were in place for one (R15) of one resident reviewed for self-medication administration in a sample of 33. Findings Include:The facility's Medication Administration policy, not dated, documents. Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines, 19. Observe resident consumption of medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a written Bed Hold Notice was provided to the resident representative and documented in the medical record at the time of hospitalization for one (R59) of one residents reviewed for transfer and discharge requirements in a sample of 33 residents.

Inspectors wroteBased on Interview and Record review, the facility failed to ensure a resident with significant weight loss had a plan of care with measurable outcomes and interventions to address and prevent further weight loss for one of one resident (R4) reviewed for weight loss in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative services were provided for one (R9) of one resident reviewed for range of motion in a sample of 33. Findings Include:The facility's Restorative Nursing Programs policy, not dated, documents, It is the policy of this facility to provide maintenance and restorative services designated to maintain or improve a resident's abilities to the highest practicable level. Definition: Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. Policy Explanation and Compliance Guidelines: 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated, changed weekly, failed to provide a care for plan oxygen use, and failed to correctly identify oxygen use on MDS (medical data set) for one (R2) of one resident observed with oxygen therapy in the sample list of 33. Findings Include: The facility's Oxygen Administration policy, not dated, documents, Policy, oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and residents' goals and preferences. Policy explanation and compliance guidelines, 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the residents' assessment and orders, such as, but not limited to: a. The type of oxygen delivery system, b. [...]

Inspectors wroteBased on interview and record review the facility failed to provide documentation of communication and collaboration with the dialysis facility regarding dialysis care and services for one (R8) of one resident reviewed for dialysis care in a sample of 33. Findings Include:The facility's Hemodialysis policy, not dated, documents, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the residents goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. Purpose, the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatment received at a certified dialysis facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure multi-dose injectable insulin pens were labeled with the date when opened for two of 15 residents (R5 and R56) reviewed for storage and labeling of medications in a sample of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the State Agency survey results were kept in a location readily accessible to residents and visitors and post a notice that survey results are available for review. This failure has the potential to affect all 59 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the daily resident census and direct care staff posting was posted in an area accessible to residents and visitors. This failure has the potential to affect all 59 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to notify R2's Power of Attorney of R2's transfer to the hospital. This failure affects 1 of 1 resident reviewed for transfers. The facility policy, Notification of Changes, document: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. R2's EMR document R2's diagnosis included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide immediate and adequate supervision after a resident's family member notified facility staff of a resident voicing R1 was going to escape out of his window and implement 15-minute visual checks as directed by the plan of care, for a cognitively impaired resident at risk for elopement for one (R1) of three residents reviewed for elopement in a sample of three. These failures resulted in (R1) a cognitively impaired resident with a previous elopement attempt from the facility, exiting the facility through his room window without staff knowledge or supervision on 9/3/25. (R1) was found across the road from the facility, a block away and close to active railroad tracks. These failures resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one resident (R4) was free of significant medication error of three residents reviewed for medications. This failure caused R4 to be visibly uncomfortable and anxious. The Facility's undated Medication Errors policy documents Medications errors, once identified will be evaluated to determine if considered significant or not by utilizing the following three general guidelines: a. Resident's condition: if the resident's condition requires rigid control, such as strict intake and out put measurement, daily weights, or monitoring of lab values. b. Drug category: if the medication is from a category that usually requires the resident to be titrated to a specific blood levels such as a medications with a narrow therapeutic index. c. Frequency of Error: [...]

Inspectors wroteBased on interview and record review the facility failed to assess the pain of a resident who received scheduled medication to control pain for one resident (R4) of three residents reviewed for pain. The Facility's undated Pain Management policy documents The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. Monitoring, Reassessment and Care Plan Revision a. Facility staff will reassess resident's pain management at established intervals for effectiveness and/or adverse consequences such as: i. tolerance 11. Physical dependence iii. increased sensitivity to pains iv. constipation v. nausea, vomiting, and dry mouth vi. sleepiness, dizziness, and/or confusion vii. depression viii. itching and sweating; b. [...]

Inspectors wroteBased on interview and record review the Facility failed to complete post-fall documentation and implement appropriate fall interventions for four Residents (R1, R2, R3 and R4) and monitor for post fall injuries for three Residents (R2, R3 and R4) of four Residents reviewed for Falls in a sample of four.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent resident physical abuse after (R1) displayed increased agitation and aggression and no interventions were implemented to prevent potential resident abuse for two (R2 & R3) of 23 residents reviewed for abuse in the sample of 26. These failures resulted in R1 throwing a walkie talkie at R2's head and R1 physically shoving a trash can in R3's face and R3 sustaining a bleeding laceration to upper and lower lips. These failures have the potential to affect all 19 residents (R2, R3, R9 through R25) residing in the facility's Dementia unit. These failures resulted in an Immediate Jeopardy that began on 4/13/25. While the Immediate Jeopardy was removed on 5/13/25, the facility remains out of compliance at a severity level two. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain consent prior to the use of psychotropic medications for two of three residents (R1 and R2) reviewed for psychotropic medications in the sample of three.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse was scheduled to work eight consecutive hours, seven days a week. This failure has the potential to affect all 44 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure items in the kitchen were clean. This has the potential to affect all 44 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement all components of their Infection Prevention Control Program. This failure has the potential to affect all 44 residents currently residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement their antibiotic stewardship program. This failure has the potential to affect all 44 residents residing in the building.

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were responded to in a timely manner for 8 of 8 residents (R4, R8, R11, R23, R30, R36, R39, and R42) who were in attendance for the Resident Council meeting.

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital, for four of four residents (R6, R9, R29 and R52), reviewed for bed holds, in the sample of 28. Findings Include: The (undated) facility Bed Hold Notice Upon Transfer Policy, directs staff, At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or resident representative written notice which specifies the duration of the bed- hold policy and addresses information explaining the return of the resident to the next available bed. 1. R9's medical record documents that R9 was hospitalized on [DATE], 8/6/24, 8/19/24 and 10/18/24. R9's medical record does not contain documentation of written notice to R9 or R9's resident representative, of the facility bed hold policy. 2. [...]

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to develop a comprehensive care plan for Oxygen for one of one resident (R6) reviewed for Oxygen in the sample of 28.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess a resident's range of motion quarterly, failed to provide necessary equipment to maintain a resident's range of motion and failed to develop a plan of care for a resident's range of motion for one of three residents (R9) reviewed for range of motion in a sample of 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to check placement with venous blood return prior to intravenous (IV) PICC (peripherally inserted central catheter) line medication administration for one of one resident (R47) reviewed for IV medication administration in the sample of 28.

Inspectors wroteBased on observation, interview and record review, the facility failed to address a resident's symptoms of depression and develop a care plan with interventions to recognize and treat symptoms of depression for one of two residents (R47) reviewed for mood in the sample of 28.

Inspectors wroteBased on observation, interview and record review the Facility failed to employ a licensed Administrator. This failure has the potential to affect all 52 Residents residing in the Facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform pressure ulcer risk assessments as directed by the facility's policy, failed to develop and implement pressure relieving interventions, failed to develop pressure ulcer care plans, and failed to assess a pressure ulcer weekly or obtain a treatment once a pressure ulcer was identified for three of three residents (R1, R2, and R3) reviewed for pressure ulcer development in the sample of four. These failures resulted in R1's left hip stage one pressure ulcer being left untreated and deteriorating from a stage one pressure ulcer to a stage four pressure ulcer that required surgical debridement and R2 developing an unstageable facility-acquired necrotic (dead tissue) pressure ulcer to the right heel.

Inspectors wroteBased on record review and interview the facility failed to report an allegation of misappropriation of funds to the administrator, state agency, and the local police department for one of three residents (R1) reviewed for abuse in the sample of four.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free of injury from electrical devices for one of three residents (R40) reviewed for accidents and supervision in the sample of 25. This failure resulted in R40 sustaining a burn injury to R40's left leg/buttock region after R40 was positioned with a cellular phone charging cube that was plugged into an electrical outlet with use of an extension cord directly under R40's upper leg. After R40 was incontinent of urine, R40's cellular charging cube came into direct contact with liquid, causing the electrical appliance to spark and smoke, resulting in the burning of R40's skin. R40's burn injury has required multiple surgical debridements.

Inspectors wroteBased on record review, and interview, the facility failed to provide/have quarterly Quality Assurance & Performance Improvement (QAPI) meetings. This failure has the potential to effect all 53 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure incontinent supplies were available for one of three residents reviewed for dignity (R42) in the sample of 25.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident was free of physical abuse for one (R14) of four residents reviewed for abuse in a sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy for one (R47) of three residents reviewed for abuse in a sample of 25.

Inspectors wroteBased on record review and interview, the facility failed to report the misappropriation of money to the local State Agency for one of four residents reviewed for abuse (R42) in a sample of 25.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation into an allegation of misappropriation of property for two (R47 and R42) of three residents reviewed for abuse in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a smoking careplan for one (R47) of 24 residents reviewed for careplan development in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate residents for smoking safety for one (R47) of two residents reviewed for safe smoking in a sample of 25.

Inspectors wroteBased on interview and record review the Facility failed to respond to Resident call lights in a timely manner and comply with Resident requests for assistance, for four of four Residents (R1, R2, R3 and R4) reviewed for call light response in a sample of four. This failure resulted in urinary bladder pain, worsening skin conditions, resident request for discharge and embarrassment.

Inspectors wroteBased on record review and interview the Facility failed to ensure Resident grievances were promptly responded and resolved for three of four Residents (R1, R2 and R3) reviewed for Grievances in a sample of four.

Inspectors wroteBased on record review and interview the Facility failed to develop a Care Plan for one (R1) of four Residents reviewed for Care Plans in a sample of four.

Inspectors wroteBased on record review and interview the Facility failed to prevent a Pressure Ulcer for one (R1) of four Residents reviewed for skin issues in a sample of four.

Inspectors wroteBased on observation, record review and interviews the facility failed to implement interventions to reduce the risk of falls for one of three residents (R1) reviewed for falls in a sample of 3.