Legacy Park Health and Rehab: Morphine Dosing Failure - TN
That is what federal inspectors found at Legacy Park Health and Rehabilitation, a nursing facility at 7424 Middlebrook Pike, during a survey completed February 27, 2025. The inspection was classified as causing actual harm to at least one resident.
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See the Derila PillowThe patient, identified in inspection records as Resident 7, was admitted to Legacy Park on a hospice respite stay. Morphine Sulfate oral solution, dosed at 5 mg, had been ordered to be given as needed, meaning only when symptoms required it. Instead, the medication was transcribed as a scheduled drug and administered every two hours, around the clock.
Nobody at the facility tracked what that did to Resident 7.
The director of nursing confirmed to the inspector that Legacy Park's practice for hospice respite patients is narrow by design: staff conduct a skin assessment, administer medications, and carry out treatments. That is the full scope of what the facility does for these patients. No nursing assessments were completed on Resident 7. No vital signs were taken. There was no documentation of any kind showing how receiving 5 mg of morphine on a fixed two-hour schedule, rather than as symptoms demanded, affected this person's condition.
On August 12, 2024, the hospice agency sent a nurse to Legacy Park for a routine visit. That same day, the agency sent someone again, a second visit, this one requested by the family. The family had concerns about Resident 7's behavior and level of consciousness.
The director of nursing did not know any of this had happened.
When the inspector asked her directly why she was unaware that the hospice agency had been in the building twice on the day before Resident 7 was discharged, the director said hospice should have communicated that information to facility staff. They had not, she said. That was the explanation.
It is worth pausing on what that answer means in practice. A family grew concerned enough about their loved one's mental state to call in a second hospice visit in a single day. The hospice team responded. They came. And the nursing home where that patient was physically residing, the staff responsible for that person's moment-to-moment care, had no awareness it had happened. Not that afternoon, not by the time of discharge, not until a federal inspector asked.
A performance improvement plan was put in place following the facility's internal investigation, according to the director of nursing's account to the inspector. The dosing error, the transcription of a PRN order as scheduled, was acknowledged. But the inspection record contains no documentation of what Resident 7 experienced during the period the wrong schedule was in effect. The question of how this patient was affected by receiving a powerful opioid on a two-hour clock rather than in response to symptoms has no documented answer, because no one was measuring it.
The inspection cited deficiencies across four regulatory categories, including medication errors and quality assurance failures.
Resident 7 was discharged. What the morphine schedule did to them during their stay, whether the family's alarm on August 12 was connected to the dosing error, whether anyone ever put those two facts in the same room, the inspection record does not say. The facility's own records don't say either. There was nothing to find, because nothing had been written down.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Legacy Park Health and Rehabilitation from 2025-02-27 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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 14, 2026 · Our methodology
LEGACY PARK HEALTH AND REHABILITATION in KNOXVILLE, TN was cited for violations during a health inspection on February 27, 2025.
The inspection was classified as causing actual harm to at least one resident.
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.