Accura Healthcare of Knoxville: Wrong Medication ICU - IA
The incident at Accura Healthcare of Knoxville triggered an immediate jeopardy finding from federal inspectors, the most serious level of harm the government assigns, reserved for situations where a facility's failures have placed residents in immediate risk of death or serious injury. The inspection was completed October 13, 2025, following a complaint.
The morning began with a medication error that staff recognized almost immediately. Around 7:30 a.m. on October 3, a nurse identified in the inspection report as Staff A called a registered nurse, Staff E, to report what she had done: she had given Resident 1 her own medications, and then given her Resident 3's medications as well. The full contents of another patient's medication regimen, administered to the wrong person.
Staff E told Staff A to monitor Resident 1 every hour and to send her to the emergency room if she showed any changes, including lethargy. Then Staff E hung up and consulted a nurse practitioner, identified as Staff F. The NP directed staff to monitor Resident 1 with increased frequency and to add IV fluids.
Nobody called an ambulance. Not yet.
What followed is not fully detailed in the inspection report, but the outcome is. At some point after the initial call, the assistant director of nursing arrived and found Resident 1 unresponsive. She yelled the resident's name. No response. She tried a sternal rub, pressing knuckles into the resident's breastbone, a technique used to determine whether someone is conscious. Still nothing.
The ADON told staff to get Narcan. A nurse retrieved it from the medication cart. The ADON administered it while another staff member called an ambulance.
Narcan, also known as naloxone, reverses opioid overdose. Its use indicates that among the medications Resident 1 received from Resident 3's list, at least one was an opioid, or that staff suspected as much. The inspection report does not specify which drugs were involved, but the decision to administer Narcan, and the fact that it preceded the ambulance call rather than following it, speaks to how serious the situation had become.
Staff D, who helped prepare the transfer paperwork, confirmed that Resident 1 received both medication lists. The documentation went with her to the hospital.
Resident 1's family member spoke with inspectors on October 8. He said both the facility and hospital staff had told him what happened: his family member had received someone else's medication. He described being forced to make major decisions about treatments to sustain her life.
She required ICU care.
She came out of the hospital with new concerns about her ability to swallow.
She was still receiving evaluation at the time inspectors conducted their interviews.
The facility's own medication administration policy, updated in April 2024, instructs staff to identify the resident before administering medications. It is a foundational step, one of the most basic safeguards in nursing home care, and it did not happen on the morning of October 3.
What the inspection report does not explain is the gap between the first call, at 7:30 a.m., when a nurse reported the error to a superior and was told to monitor and watch for lethargy, and the moment the ADON found Resident 1 unresponsive and reached for Narcan. That interval, whatever it was, is where the immediate jeopardy lives. A woman received a dangerous combination of medications meant for someone else. The people who knew about it first decided to watch and wait.
Her family member told inspectors the situation forced him to make decisions about sustaining her life. She left for the ICU. She came back with problems swallowing that she did not have before.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accura Healthcare of Knoxville, LLC from 2025-10-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 9, 2026 · Our methodology
Accura Healthcare of Knoxville, LLC in Knoxville, IA was cited for violations during a health inspection on October 13, 2025.
The inspection was completed October 13, 2025, following a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.