Cycle 1
Health 2025-08-13 · Fire 2024-05-31
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Knoxville, TN
Legacy Park Health And Rehabilitation
1-star overall rating with 2-star inspections with $184,672 in total fines with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
7424 Middlebrook Pike, Knoxville, TN
(406) 606-0026
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
176
Certified beds
Average residents
120
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1973-03-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.49
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.27
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
69%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,334
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9900
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.78
Baseline 19.36% · Performance 20.14% · Measure score 2.78 · Achievement 2.78 · Improvement 0
Healthcare-associated infections
4.61
Baseline 5.71% · Performance 6.46% · Measure score 4.61 · Achievement 4.61 · Improvement 0
Total nurse turnover
5.29
Baseline 45.59% · Performance 42.05% · Measure score 5.29 · Achievement 5.29 · Improvement 1.21
Adjusted total nurse staffing
1.95
Baseline 5.21 hours · Performance 3.63 hours · Measure score 1.95 · Achievement 1.95 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.2% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 8.65% · Lower 95% interval 7.3% |
| Discharge to community | 46.54% |
50.57%
4 pts worse
|
No Different than the National Rate · Eligible stays 101 · Observed rate 39.6% · Lower 95% interval 36.47% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.22% |
95.27%
2 pts better
|
Numerator 70 · Denominator 72 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 72 |
| Discharge self-care score | 36% |
53.69%
17.7 pts worse
|
Numerator 18 · Denominator 50 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 20 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 1.41% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 71 · Adjusted rate 1.45% |
| Healthcare-associated infections requiring hospitalization | 6.46% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 4.48% · Lower 95% interval 3.31% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 124 |
| Staff flu vaccination coverage | 50% |
42%
8 pts better
|
Numerator 68 · Denominator 136 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 25 · Denominator 50 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 5.26% |
25.2%
19.9 pts worse
|
Numerator 2 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.6
1 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 79.5% |
89.9%
10.4 pts worse
|
93.4%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.3% · Q2 83.0% · Q3 86.9% · Q4 73.1% · 4Q avg 79.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
94.5%
1.7 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.6%
0.8 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.0% · Q3 2.0% · Q4 1.9% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.7% |
11.8%
2.1 pts better
|
11.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 11.8% · Q3 10.1% · Q4 9.8% · 4Q avg 9.7% |
| Percentage of long-stay residents who lose too much weight | 13.2% |
6.2%
7 pts worse
|
5.4%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 15.1% · Q3 15.9% · Q4 10.8% · 4Q avg 13.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.3% |
32.2%
2.9 pts better
|
19.6%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 28.0% · Q3 31.5% · Q4 29.8% · 4Q avg 29.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.3% |
18.1%
5.8 pts better
|
16.7%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 13.5% · Q3 6.8% · Q4 11.6% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.0% |
19.9%
10.9 pts better
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 7.9% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.6% |
15.3%
6.7 pts better
|
14.9%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 2.9% · Q3 2.7% · Q4 8.2% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.9%
0.3 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 1.8% · Q4 0.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
1.9%
0.9 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 1.0% · Q3 1.0% · Q4 1.9% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.3% |
20.2%
0.9 pts better
|
19.8%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 18.3% · Q3 14.6% · Q4 24.7% · 4Q avg 19.3% |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
5.4%
1.7 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 8.7% · Q3 4.6% · Q4 4.6% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.2% |
79.6%
0.6 pts better
|
81.7%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 74.8% · Q2 77.3% · Q3 81.3% · Q4 87.9% · 4Q avg 80.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
11.2%
2.9 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 8.1% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
1.6%
1.7 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 1.5% · Q3 2.5% · Q4 4.1% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.5% |
79.8%
3.3 pts worse
|
79.7%
3.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.2% |
22.2%
7 pts worse
|
23.9%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 29.7% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-31 · Fire 2020-01-29
19 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2020-01-29 · Fire 2018-11-15
14 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-31
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-17
F · Potential for more than minimal harm
2020-01-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-03-13
F · Potential for more than minimal harm
2018-11-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-12-30
E · Potential for more than minimal harm
2018-11-15
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2018-12-30
E · Potential for more than minimal harm
2018-11-15
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2018-12-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-26
D · Potential for more than minimal harm
2025-08-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-14
D · Potential for more than minimal harm
2025-08-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-14
G · Actual harm
2025-02-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-02-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-27
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-03-28
D · Potential for more than minimal harm
2024-05-31
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-31
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-31
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-31
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-31
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-31
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-31
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-31
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-31
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-31
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-31
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-31
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-03-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-12
G · Actual harm
2023-06-26
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-11
G · Actual harm
2023-06-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-11
G · Actual harm
2023-04-26
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-11
G · Actual harm
2023-04-26
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-05-25
G · Actual harm
2023-04-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-11
D · Potential for more than minimal harm
2020-01-29
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2020-03-09
D · Potential for more than minimal harm
2020-01-29
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2020-03-09
D · Potential for more than minimal harm
2020-01-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-03-09
D · Potential for more than minimal harm
2020-01-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-03-09
D · Potential for more than minimal harm
2020-01-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-03-09
D · Potential for more than minimal harm
2020-01-29
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2020-03-09
D · Potential for more than minimal harm
2020-01-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-03-09
D · Potential for more than minimal harm
2020-01-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-03-09
D · Potential for more than minimal harm
2020-01-29
F849 · Administration Deficiencies
Health
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.
Corrected 2020-03-09
Penalties and ownership
What sits behind the stars
$74,633
2025-02-27
Fine
Fine · fine $74,633
Fine
$0
2025-02-27
Payment Denial
Payment Denial · denial start 2025-03-29 · 16 days
16 day denial
$110,039
2023-04-26
Fine
Fine · fine $110,039
Fine
$0
2023-04-26
Payment Denial
Payment Denial · denial start 2023-05-25 · 47 days
47 day denial
Ownership
Nearby options
Other facilities in reach
#1
Wellpark At Shannondale
Knoxville, TN
3-star overall rating with 3-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
West Hills Health And Rehab
Knoxville, TN
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Lyonsview Health And Rehabilitation Center
Knoxville, TN
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $99,788 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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