Inspection Reports for
Wellpark Health and Rehabilitation
7512 Middlebrook Pike, Knoxville, TN, 37909
Back to Facility Profile4 CMS Surveys
Inspection Report — Jan 24, 2025
Enforcement
Date: Jan 24, 2025
Visit Reason
Statement of Deficiencies (CMS-2567) from a survey completed on 2025-01-24 documenting a misappropriation of a resident's property.
Findings
Survey found the facility failed to protect 1 resident (Resident #84) of 16 residents reviewed from misappropriation of property (F 0602), with Level of Harm assessed as minimal and Residents Affected listed as few. Surveillance and bank/credit card activity identified Housekeeper A as the suspected perpetrator, who was suspended and later terminated; missing gift cards and transactions were reported with estimated losses up to $500.
Citations (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. Housekeeper A was identified via surveillance and credit card activity and was terminated, and missing gift cards and cash with estimated value up to $500 were reported.
Report Facts
Residents reviewed: 16
Residents affected: 1
Estimated loss: 500
Deficiencies cited: 1
Inspection Report — Jan 24, 2025
Enforcement
Date: Jan 24, 2025
Visit Reason
CMS Statement of Deficiencies (Form CMS-2567) documenting deficiencies identified during a survey completed on 2025-01-24.
Findings
The survey identified multiple F-tag deficiencies with Level of Harm noted as minimal/potential for actual harm affecting few residents, covering dignity, assessment accuracy, care planning, wound care, dialysis communication, medication security, documentation, infection control, and COVID-19 vaccination offering. Deficiencies were documented across several residents including Resident #11, #22, #28, #31, #34, #10, #134, #135, #136 and #139.
Citations (11)
F0550: A sign reading 'No B/P to R Arm' was posted above Resident #11's bed and visible to anyone entering the room although the resident and medical record did not request the sign.
F0641: MDS assessments were inaccurate for residents reviewed, including Resident #31's discharge location recorded incorrectly and Resident #22's admission MDS failing to document a fall.
F0656: The facility failed to develop a comprehensive care plan timely for Resident #11's pressure ulcers, with the care plan not initiated until 01/21/2025 (35 days after MDS completion).
F0657: The care plan was not revised timely to include new interventions after Resident #22's falls, and the gait-belt intervention was not added until 01/21/2025.
F0684: Physician-ordered wound treatments were not followed for Resident #11; a daily betadine order to the right heel was discontinued in error and not administered from 01/04/2025–01/22/2025 before being resumed.
F0692: Resident weights were inaccurately recorded and not monitored; Resident #28 had inconsistent weight entries (e.g., 231.0 then 177.4) and discrepancies were not re-weighed or reported, delaying recognition of significant weight loss.
F0698: Dialysis communication records for Resident #11 were incomplete or missing for multiple dates between 12/13/2024 and 01/22/2025, and several returned forms lacked required pre/post data.
F0761: A medication cart on 200/300 hall was left with keys accessible in the outer lock while the assigned nurse was absent, and the nurse admitted failing to keep the keys on her person.
F0842: The facility failed to maintain accurate medical records for Resident #11's wound care; TAR entries for Santyl treatment on 01/10–01/13/2025 and 01/15/2025 were blank although staff later reported they had provided treatments.
F0880: Enhanced Barrier Precautions and hand-hygiene practices were not implemented correctly; staff changed Resident #10's linens without donning a required gown, Resident #34 had open thigh pressure ulcers without EBP signage or PPE, and five residents were not offered hand hygiene prior to meals.
F0887: The facility did not offer or screen residents (#10, #134, #139) for up-to-date COVID-19 vaccination per current CDC guidance despite last documented doses being older than six months.
Report Facts
Residents reviewed for dignity: 30
Residents reviewed for MDS assessments: 11
Residents reviewed for wounds: 4
Residents reviewed for weight loss: 4
Medication carts observed: 2
Residents reviewed for EBPs: 5
Days wound treatment missed: 19
Days late care plan: 35
Weight loss percent: 9.96
Weight loss days: 49
Missing dialysis communication dates: 12
Inspection Report — May 25, 2022
Enforcement
Date: May 25, 2022
Visit Reason
CMS Statement of Deficiencies (Form CMS-2567) issued following a survey completed on 2022-05-25.
Findings
The facility was cited for F0684 for failure to follow physician orders and provide required treatments/lab work for three residents (Residents #65, #110, and #112). The facility was also cited for F0727 for failing to provide the required RN coverage of 8 consecutive hours on seven days during the review period.
Citations (2)
F 0684: Provide appropriate treatment and care according to orders; the facility failed to follow physician orders and obtain required lab work or schedule medications as ordered for Residents #65, #110, and #112.
F 0727: Have a registered nurse on duty 8 hours a day; the facility failed to provide RN coverage for the minimum requirement of 8 consecutive hours on seven days between 5/7/2022 and 5/25/2022, including two days with no RN coverage.
Report Facts
Deficiencies cited: 2
Residents affected: 3
Residents reviewed for physician orders: 9
Days with insufficient RN coverage: 7
Inspection Report — May 22, 2019
Enforcement
Date: May 22, 2019
Visit Reason
Statement of Deficiencies (CMS-2567) documenting deficiencies cited following a survey completed on 2019-05-22 regarding certified nursing assistant (CNA) in-service training.
Findings
The facility failed to ensure the mandatory annual 12 hours of CNA in-service training was completed for four of seven CNAs reviewed (CNA #1, CNA #3, CNA #5, and CNA #7), and required dementia and abuse prevention training was not provided. The deficiency is cited as F-0947 with Level of Harm noted as minimal or potential for actual harm and Residents Affected listed as many.
Citations (1)
F 0947: Ensure nurse aides have required skills; the facility failed to ensure the mandatory annual 12 hours of CNA in-service training was completed for CNA #1, CNA #3, CNA #5, and CNA #7 and the training did not include required dementia and abuse prevention topics.
Report Facts
CNAs not completing required annual in-service: 4
CNAs reviewed: 7
Loading inspection reports...
