Inspection Reports for
Wellpark Health and Rehabilitation
7512 Middlebrook Pike, Knoxville, TN, 37909
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Census: 16
Deficiencies: 1
Date: Jan 24, 2025
Visit Reason
The inspection was conducted following a complaint regarding misappropriation of property involving Resident #84, who reported her wallet missing and unauthorized transactions on her bank and credit cards.
Complaint Details
The complaint was substantiated. Resident #84 reported her wallet missing and multiple unauthorized transactions on her bank and credit cards. The perpetrator was identified as Housekeeper A, who was terminated. The incident was reported to Adult Protective Services, Ombudsman, state agency, and local law enforcement.
Findings
The facility failed to protect Resident #84 from misappropriation of property by a housekeeper who was identified through surveillance footage and terminated. The investigation was promptly conducted, residents were educated on securing valuables, and authorities were notified.
Deficiencies (1)
F 0602: Protect each resident from the wrongful use of the resident's belongings or money. The facility failed to protect Resident #84 from misappropriation of property by a housekeeper who used the resident's credit cards without consent.
Report Facts
Residents reviewed: 16
Estimated value of missing gift cards: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Identified perpetrator of misappropriation, terminated for policy conduct violation | |
| LPN B | Licensed Practical Nurse | Received initial report of missing wallet from Resident #84 and notified administration |
| Assistant Director of Nursing | Assistant Director of Nursing | Notified of incident and involved in investigation |
| DON | Director of Nursing | Spoke with Resident #84 and confirmed notification of missing wallet and fraudulent transactions |
| Administrator | Administrator | Notified of missing wallet and suspicious credit card activity, involved in investigation |
Inspection Report
Routine
Census: 30
Deficiencies: 11
Date: Jan 24, 2025
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements including resident rights, care planning, wound care, medication management, infection control, and COVID-19 vaccination.
Findings
The facility was found deficient in multiple areas including failure to protect resident dignity, inaccurate resident assessments, delayed and incomplete care planning for wounds and falls, failure to follow physician orders for wound care, inaccurate weight monitoring, incomplete dialysis communication records, unsecured medication cart, incomplete medical record documentation, failure to implement enhanced barrier precautions, failure to offer hand hygiene before meals, and failure to offer COVID-19 vaccinations according to current CDC recommendations.
Deficiencies (11)
F 0550: The facility failed to protect the dignity of Resident #11 by posting a sign above the bed without the resident's or family's request or documentation.
F 0641: The facility failed to ensure accurate Minimum Data Set (MDS) assessments for Resident #22 for falls and Resident #31 for discharge location.
F 0656: The facility failed to develop a comprehensive care plan timely for pressure ulcers for Resident #11, with the care plan initiated 35 days past MDS completion.
F 0657: The facility failed to revise Resident #22's care plan timely to include new interventions after a fall, with updates delayed until 1/21/2025.
F 0684: The facility failed to ensure physician's orders for wound care were followed for Resident #11, with no treatment given for 19 days due to an order discontinuation error.
F 0842: The facility failed to maintain accurate medical records for Resident #11's wound care, including missed documentation of wound treatments and incomplete wound care records.
F 0692: The facility failed to accurately record and monitor weights for Resident #28, with unexplained weight discrepancies and lack of re-weighing for verification.
F 0698: The facility failed to ensure dialysis communication records were completed for Resident #11, with multiple missing and incomplete forms.
F 0761: The facility failed to ensure medications were secured properly, with a medication cart left unlocked and keys unsecured.
F 0880: The facility failed to implement Enhanced Barrier Precautions for Resident #10 and failed to identify the need for EBP for Resident #34. The facility also failed to offer hand hygiene assistance to 5 residents prior to meals.
F 0887: The facility failed to offer COVID-19 vaccinations according to CDC recommendations and facility policy for Residents #10, #134, and #139, who were not screened or offered vaccines despite eligibility.
Report Facts
Residents reviewed for dignity: 30
Weight loss: 23
Days without wound treatment: 19
Missing dialysis communication forms: 12
Residents observed for hand hygiene: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Named in failure to administer and document wound care treatment for Resident #11 and medication cart security failure. |
| RN I | Registered Nurse | Named in failure to administer and document wound care treatment for Resident #11. |
| LPN C | Licensed Practical Nurse | Named in failure to document wound care treatment for Resident #11. |
| Wound Care Nurse | Named in wound care treatment and order discontinuation error for Resident #11. | |
| Director of Nursing | Director of Nursing | Named in multiple interviews confirming expectations and deficiencies. |
| RN K | Registered Nurse | Named in dialysis communication record process. |
| LPN G | Licensed Practical Nurse | Named in medication cart security failure and failure to offer hand hygiene assistance. |
| CNA F | Certified Nursing Assistant | Named in failure to wear gown during Enhanced Barrier Precautions and failure to offer hand hygiene assistance. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 25, 2022
Visit Reason
The inspection was conducted to investigate complaints regarding failure to follow physician's orders and provide appropriate treatment for residents, as well as failure to provide required RN coverage.
Complaint Details
The investigation was complaint-related, focusing on failure to follow physician orders for lab work and medication administration, and failure to provide required RN staffing. The findings confirmed these issues affecting a few residents.
Findings
The facility failed to follow hospital discharge orders for lab work for multiple residents, failed to administer pain medication as ordered, and did not provide the required RN coverage of 8 consecutive hours per day on multiple days during the review period.
Deficiencies (2)
F0684: The facility failed to follow physician's orders and provide treatment for 3 residents by not obtaining ordered lab work and not administering pain medication as scheduled.
F0727: The facility failed to provide a registered nurse on duty for the minimum requirement of 8 consecutive hours a day for 7 days during an 18-day period reviewed.
Report Facts
Days without RN coverage: 2
Days with less than 8 hours RN coverage: 5
Residents reviewed for physician orders: 9
Oxycodone administrations as PRN: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed failure to follow discharge instructions and RN staffing issues |
| Registered Nurse #1 | Registered Nurse | Reported labs were not obtained for Resident #110 and medication mix-up for Resident #112 |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Confirmed RN staffing deficiencies |
| Medical Director | Medical Director | Confirmed expectations for following orders and inability to explain medication order change |
| Pharmacist | Pharmacist | Confirmed admission orders for Resident #112 were written as scheduled |
| Advanced Nurse Practitioner | Advanced Nurse Practitioner | Stated lab work should have been ordered for Resident #65 |
Inspection Report
Deficiencies: 1
Date: May 22, 2019
Visit Reason
The inspection was conducted to assess compliance with mandatory annual Certified Nursing Assistant (CNA) in-service training requirements, including dementia care and abuse prevention education.
Findings
The facility failed to ensure that 4 of 7 CNAs completed the mandatory 12 hours of annual in-service training. Documentation showed these CNAs received only 1.5 hours of training without the required dementia and abuse prevention content.
Deficiencies (1)
F 0947: The facility failed to ensure nurse aides completed the mandatory annual 12 hours of CNA in-service training, including dementia care and abuse prevention. Four CNAs received only 1.5 hours of training without required content.
Report Facts
CNAs reviewed: 7
CNAs non-compliant: 4
Mandatory training hours: 12
Training hours received: 1.5
Viewing
Loading inspection reports...
