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Complaint Investigation

Legacy Park Health And Rehabilitation

February 27, 2025 · Knoxville, TN · 7424 Middlebrook Pike
Citations 2
CMS Rating 1/5
Beds 176
Provider ID 445105
Healthcare Facility
Legacy Park Health And Rehabilitation
Knoxville, TN  ·  View full profile →
Inspection Summary

LEGACY PARK HEALTH AND REHABILITATION in KNOXVILLE, TN — inspection on February 27, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF760

F-F760.

445105

Review of the facility's policy titled, Change in a Resident's Condition or Status, dated 2001, revealed . promptly notifies .his or her attending physician .changes in the resident's medical/mental condition and/or status .Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including .information prompted by the Interact SBAR [situation, background, assessment, recommendation] Communication Form .

Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Neuromuscular Dysfunction of Bladder, Hemiplegia/Hemiparesis, and Vascular Dementia.

Review of a baseline care plan dated 11/21/2024, revealed Resident #2 had an indwelling urinary catheter.

Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated moderate cognitive impairment.

Continued review revealed Resident #2 had an indwelling urinary catheter.

Review of a 7:00 PM-7:00 AM shift report dated 12/4/2024, revealed Resident #2's indwelling urinary catheter was changed during the shift.

Review of a nurse's note for Resident #2 dated 12/5/2024 at 11:30 AM, revealed Resident #2 reported the indwelling urinary catheter had been replaced on 12/4/2024 at approximately 11:00 PM.

Review of the medical record for Resident #2 from 11/21/2024-12/5/2024 revealed no documentation the resident's indwelling urinary catheter had been replaced.

Review of the medical record for Resident #2 revealed there was no documentation of the resident's urine output from 11/21/2024-12/5/2024.

Review of the medical record for Resident #17 revealed the resident was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease and Pressure Ulcer of Sacral Region, Unspecified Stage.

445105

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 445105 B.

Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Shannondale Health Care Center 7424 Middlebrook Pike Knoxville, TN 37909

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in KNOXVILLE, TN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LEGACY PARK HEALTH AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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