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35/100LEGACY PARK HEALTH AND REHABILITATION Inspection Report, Violations & Safety Grade (KNOXVILLE, Tennessee)
7424 MIDDLEBROOK PIKE, KNOXVILLE, Tennessee 37909
Phone: 8656903411
CMS Overall:1/5
Overview & Bed Count
Certified Beds
176
Avg Residents/Day
134.2
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Knox
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health2/5
Staffing1/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | Tennessee Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.36 | 0.60 | -0.23 |
| Total Nurse Hours per Resident per Day | 3.40 | 3.82 | -0.42 |
| CMS Staffing Rating | 1/5 | 2.5/5 | - |
| Nursing Staff Turnover | 67.9% | 48.6% | - |
Health Citation History
33 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-08-31 | Resident Rights Deficiencies | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | E – Moderate Harm Potential |
| 2025-08-13 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-08-13 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2025-08-13 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-08-13 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2025-02-27 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | G – Actual Harm |
| 2025-02-27 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E – Moderate Harm Potential |
| 2025-02-27 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2025-02-27 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2025-02-27 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | D – Moderate Harm Potential |
| 2024-05-31 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D – Moderate Harm Potential |
| 2024-05-31 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2024-05-31 | Resident Assessment and Care Planning Deficiencies | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D – Moderate Harm Potential |
| 2024-05-31 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2024-05-31 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-05-31 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2024-05-31 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2024-05-31 | Quality of Life and Care Deficiencies | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | D – Moderate Harm Potential |
| 2024-05-31 | Pharmacy Service Deficiencies | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D – Moderate Harm Potential |
| 2024-05-31 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D – Moderate Harm Potential |
| 2024-05-31 | Quality of Life and Care Deficiencies | Provide routine and 24-hour emergency dental care for each resident. | D – Moderate Harm Potential |
| 2024-05-31 | Nutrition and Dietary Deficiencies | Dispose of garbage and refuse properly. | D – Moderate Harm Potential |
| 2024-05-31 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D – Moderate Harm Potential |
| 2024-03-14 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2020-01-29 | Resident Assessment and Care Planning Deficiencies | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | D – Moderate Harm Potential |
| 2020-01-29 | Resident Assessment and Care Planning Deficiencies | Assure that each resident’s assessment is updated at least once every 3 months. | D – Moderate Harm Potential |
| 2020-01-29 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2020-01-29 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2020-01-29 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2020-01-29 | Nursing and Physician Services Deficiencies | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | D – Moderate Harm Potential |
| 2020-01-29 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2020-01-29 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D – Moderate Harm Potential |
| 2020-01-29 | Administration Deficiencies | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | D – Moderate Harm Potential |
Fire Safety Citation History
10 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2024-05-31 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2024-05-31 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2024-05-31 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2024-05-31 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | D – Moderate Harm Potential |
| 2024-05-31 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | D – Moderate Harm Potential |
| 2024-05-31 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2020-01-29 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F – Moderate Harm Potential |
| 2018-11-15 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2018-11-15 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | E – Moderate Harm Potential |
| 2018-11-15 | Smoke Deficiencies | Have an enclosure around a vertical opening shaft. | E – Moderate Harm Potential |
Total Penalties & Fines
$74,633
Total Fine Amount (CMS)
1
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-02-27 | Fine | $74,633 | - |
| 2025-02-27 | Payment Denial | - | 16 days starting 2025-03-29 |
Need Help Finding Safe Care?
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3-Year Complete Report ($19)
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the KNOXVILLE area at no cost.
Find Safe, Vetted Facilities Near KNOXVILLE
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.