Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fairpark Health And Rehabilitation during CMS and state inspections, most recent first.
Failure to implement a fall intervention for a resident at risk for falls. The resident had severe cognitive impairment, a hx of an unwitnessed fall with major injury, and the care plan included a fall mat to the left side of the bed. During observation, staff confirmed the fall mat was not in place, and the Administrator stated all care-planned fall interventions were expected to be in place.
Meals Served at Improper Temperature: Two cognitively intact residents reported that hot foods were served cold or lukewarm, and a tray test showed meat loaf, fried potatoes, green beans, and corn bread were not at a palatable temperature. The Administrator confirmed the items were not served hot.
Failure to Maintain a Clean, Homelike Environment: Surveyors observed brown substances, debris, broken tile, a broken vanity, and black residue on baseboards and sinks in hallways and resident rooms. A resident with Cerebral Infarction, Pneumonia, and Polyneuropathy reported housekeeping now only mops floors and empties trash, while the Housekeeping Supervisor said rooms and hallways are cleaned daily and deep cleaned monthly.
Inaccurate Weekend PBJ Staffing Submission: The facility submitted weekend staffing data to PBJ that was excessively low for all weekends reviewed. Although daily staffing sheets, time detail reports, and weekend schedules showed adequate RN, LPN, and CNA coverage, the SDC, MDS Coordinator, and DON also provided direct resident care and the PPD ratios were above 2.0. The Administrator stated salaried staff were not changed to hourly status on weekends, resulting in PBJ data that did not reflect the actual hours worked by direct care staff.
Surveyors found that an employee's personal food items were stored in the kitchen cooler with residents' food, and multiple boxes of frozen vegetables in the freezer were not properly sealed, resulting in exposure to air and visible discoloration. The Dietary Manager confirmed these practices did not follow facility policy or professional standards.
A resident with multiple medical conditions was given her roommate's medications after an LPN failed to properly verify her identity and medication details, despite the resident questioning the number of pills. The error was discovered after administration, and the resident experienced no adverse effects.
Sensitive health information was left visible and unattended on a medication cart, including data displayed on a computer screen and a written shift-to-shift communication sheet listing residents' names and medical conditions. An LPN failed to secure this information before leaving the cart, and the ADON confirmed the breach of confidentiality.
A resident with a history of Bipolar Disorder, Depression, and Anxiety, and a documented PASRR Level II outcome for serious mental illness, was not accurately coded for PASRR Level II status on a significant change MDS assessment. The error was confirmed by the RN MDS Coordinator during review, despite facility policy requiring accurate and comprehensive assessments.
Staff failed to perform hand hygiene after serving meal trays to three residents, did not wear required PPE when delivering a meal tray to a resident on contact isolation, and did not offer hand hygiene assistance to a dependent resident before a meal. These actions were confirmed by staff interviews and were not in accordance with facility infection control policies.
The facility failed to maintain a clean and homelike environment in one hallway and five resident rooms. Observations revealed dirty baseboards, scuffed floors, and unsanitary conditions in the rooms and hallway. The Administrator and Environmental Service Manager confirmed these findings.
The facility failed to complete a significant change assessment for a resident with multiple diagnoses who was ordered hospice care. Despite the hospice order, the required assessment was not completed within 14 days, and the resident's MDS assessment did not reflect hospice services. This was confirmed by an MDS RN.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies in documenting anticoagulant use, hospice care, and physical restraints. One resident was incorrectly documented as receiving an anticoagulant, another was not coded for hospice care despite having an order, and a third was inaccurately documented as using physical restraints.
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, admitted with multiple diagnoses including Right Hip Fracture and Dementia, did not have a baseline care plan until 96 hours after admission. This was confirmed by the Area Nurse Director.
The facility failed to follow a physician's order for two residents who were prescribed double protein portions at all meals to promote wound healing. Due to a glitch in a new computer system, the dietary orders were not transferred correctly, leading to the residents not receiving the prescribed portions. Despite being on other protein supplements, the deficiency was confirmed through interviews and observations.
The facility failed to secure hazardous chemicals in a resident bathroom, leaving a bottle of bleach and another of odor control accessible to three residents. Despite the residents' assurances that they would not ingest the chemicals, the unsecured presence of these substances violated the facility's safety policies.
The facility failed to provide trauma-informed care for a resident with PTSD, as staff were unaware of the diagnosis and potential triggers. The resident's care plan did not include identified problems or triggers related to PTSD, despite the facility's policy requiring such measures.
The facility failed to maintain dryer lint screens in the laundry room, resulting in a thick layer of lint build-up on the screens and accumulation on the floor. The Lint Trap Clean Out Log was not completed, and the Environmental Services Manager could not confirm when the screens were last cleaned.
Failure to Implement Fall Intervention
Penalty
Summary
The facility failed to implement a care plan intervention related to falls for one resident. The resident was admitted with diagnoses including Congestive Heart Failure, Hepatic Encephalopathy, and Mood Disorder, and a quarterly MDS assessment showed a BIMS score of 6, indicating severe cognitive impairment, along with a history of a fall with major injury. A post-fall investigation report dated 5/21/2026 documented an unwitnessed fall and identified a fall mat to the left side of the bed as an intervention. A comprehensive care plan dated 5/21/2026 identified the resident as at risk for falls and included the intervention of a fall mat to the left side of the bed. However, during an observation on 6/29/2026, the resident was in bed and did not have a fall mat to the left side of the bed. On 6/30/2026, a CNA and an RN both confirmed that the fall mat was not in place. The Administrator stated on 7/1/2026 that it was her expectation that all fall interventions care planned were to be in place.
Meals Served at Improper Temperature
Penalty
Summary
The facility failed to provide meals at a palatable temperature for 2 residents out of 5 reviewed for dietary services. Facility policy titled, Meal Supervision and Assistance Policy, dated 4/2026, stated that residents would be prepared meals and that hot foods are hot. Resident #6, admitted with diagnoses including osteoarthritis, anxiety, and hypertension, had an annual MDS assessment showing a BIMS score of 15, indicating cognitive intactness, and stated during interview that the food was served cold. Resident #26, admitted with diagnoses including cerebral infarction, pneumonia, and polyneuropathy, also had a quarterly MDS assessment with a BIMS score of 15 and stated that hot foods were often served cold or lukewarm. During an observation, a meal tray was tested and the meat loaf, fried potatoes, green beans, and corn bread were not served at a palatable temperature, and the Administrator confirmed the food items were not served hot and at a palatable temperature.
Failure to Maintain a Clean, Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, homelike environment in 2 of 2 hallways observed. Review of facility policies showed expectations for daily room cleaning, restroom cleaning, and housekeeping services to maintain a sanitary and homelike environment, including dusting, mopping, spot cleaning walls and partitions, and cleaning floors and sinks. During observation, surveyors found a significant amount of a brown substance on both sides of a doorway, brown substance and debris on the floor in front of a sink, dark brown and black substance on baseboards in the 200 hallway, broken tile at a doorway with a brown substance covering the missing tile area, a broken vanity, black substance around a sink drain, brown substance along a baseboard from the door to the sink, and brown rings in a sink. Resident #26 was admitted with diagnoses including Cerebral Infarction, Pneumonia, and Polyneuropathy, and had a BIMS score of 15, indicating cognitive intactness. The resident stated that housekeeping used to be better but now staff only mop the floor and empty the trash and do not clean any other part of the room. The Housekeeping Supervisor stated that resident rooms and hallways are cleaned daily and deep cleaned monthly. During the final observation with the Administrator and Housekeeping Supervisor, they confirmed the facility failed to provide a clean, comfortable, and home-like environment on the 100 Hallway, 200 Hallway, and multiple resident rooms.
Inaccurate Weekend PBJ Staffing Submission
Penalty
Summary
The facility failed to submit accurate weekend staffing information to the Payroll Based Journal (PBJ) for 13 of 13 weekends reviewed. Review of the Certification and Survey Provider Enhanced Reporting (CASPER) Report for the second quarter of 2026 showed an "Excessively Low Weekend Staffing" trigger, indicating the submitted weekend staffing data was excessively low. However, review of daily staffing assignment sheets and time detail reports for 1/1/2026 through 3/31/2026 showed adequate RN, LPN, and CNA coverage, and the Staff Development Coordinator (SDC), MDS Coordinator, and DON also provided direct patient care on all 13 weekends reviewed. Review of the employee weekend working schedules for 1/1/2026 through 3/31/2026 showed the PPD ratios were above 2.0 and staff were able to provide adequate care to residents. During interview, the Administrator stated the facility coded payroll data correctly, but Corporate Human Resource did not change the status of salaried employees to hourly employees on weekends when the SDC Coordinator, MDS Coordinator, and DON provided direct resident care, which resulted in inaccurate data submitted to CMS. The Administrator later confirmed the PBJ submission was inaccurate and did not accurately reflect the actual hours worked by direct care staff on weekends for the second quarter of 2026.
Improper Storage of Personal and Frozen Food Items in Kitchen
Penalty
Summary
The facility failed to comply with its own food storage policy and professional standards by allowing an employee's personal food items, specifically a purple lunch box and a carbonated beverage, to be stored in the kitchen reach-in cooler alongside residents' food items. This was confirmed during an observation and interview with the Dietary Manager, who acknowledged that these personal items belonged to a dietary employee and should not have been stored with food intended for residents. Additionally, the facility did not ensure that frozen food items were properly sealed and stored in the reach-in freezer. Observations revealed that boxes of frozen peas, California blend vegetables, and sliced carrots were not sealed properly, resulting in exposure to air and visible discoloration on the food surfaces. The Dietary Manager confirmed that these items were not stored appropriately, as required by facility policy and FDA Food Code guidelines.
Medication Error Due to Failure to Follow Identification Procedures
Penalty
Summary
A medication error occurred when a resident, who was cognitively intact and had diagnoses including cerebral infarction, morbid obesity, and chronic pain syndrome, was administered her roommate's medications instead of her own. The error took place when an LPN prepared the roommate's medications, entered the resident's room, and, after verbalizing the roommate's name, gave the medication cup to the resident who responded. The resident questioned the number of pills, as it was more than she typically received, but ultimately took the medication. The LPN later realized the mistake after verifying the medications and confirmed that the wrong medications had been administered. Facility documentation and interviews confirmed that the medications given in error included Doxepin, Tylenol, Famotidine, Gabapentin, and Senna. The resident did not experience any adverse reactions following the incident. The error was identified and reported immediately to the appropriate staff, including the nurse practitioner, administrator, and director of nursing. The facility's policy required verification of resident identity and medication details prior to administration, but these procedures were not followed, resulting in the medication error.
Failure to Secure Residents' Health Information on Medication Cart
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records as required by its own policy. During an observation, sensitive health information was found displayed on the computer screen of a medication cart located in the 100 hall. Additionally, a written shift-to-shift communication sheet containing residents' names and various medical conditions was stored on top of the same medication cart. Both the computer screen and the communication sheet were left unattended and visible, making the information accessible to unauthorized individuals. The Licensed Practical Nurse (LPN) assigned to the cart left the area without securing or covering the residents' personal and confidential medical information. Upon returning briefly to the cart, the LPN again failed to ensure the information was protected before leaving the cart unattended. The Assistant Director of Nursing (ADON) confirmed during an interview that the residents' sensitive health information was not secured and acknowledged that it was available for public viewing.
Inaccurate MDS Assessment for Resident with PASRR Level II Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident who was reviewed for MDS assessments. Specifically, a resident with a documented PASRR Level II outcome for serious mental illness, including diagnoses of Bipolar Disorder, Depression, and Anxiety, was not accurately coded for their PASRR Level II status on a significant change MDS assessment. The PASRR Level II screening had been completed prior to admission and indicated the need for certain care and services related to serious mental illness. Despite the resident's medical record and psychiatric notes confirming ongoing diagnoses of Bipolar Disorder and Anxiety, the significant change MDS assessment did not reflect the resident's PASRR Level II status. During a review and interview, the RN MDS Coordinator acknowledged the inaccuracy in the assessment. The facility's policy and federal regulations require accurate and comprehensive assessments using the RAI process, but this was not followed in this instance.
Failure to Perform Hand Hygiene and Use PPE During Meal Service
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies during meal tray distribution, as evidenced by multiple staff omissions in hand hygiene and use of personal protective equipment (PPE). Specifically, the Assistant Director of Nursing (ADON) delivered and set up lunch meal trays for three residents without performing hand hygiene after each interaction, despite facility policy requiring hand hygiene between resident contacts. These residents had varying degrees of cognitive and physical impairment, with some requiring setup or clean-up assistance with eating and personal hygiene. Additionally, the ADON failed to don appropriate PPE when delivering a meal tray to a resident who was on contact isolation, contrary to the facility's transmission-based precautions policy. The resident in question required setup assistance with eating and partial to moderate assistance with personal hygiene. The ADON acknowledged not wearing the required PPE before entering the room, despite being aware of the resident's isolation status. Furthermore, a Licensed Practical Nurse (LPN) did not offer hand hygiene assistance to a resident who was dependent on staff for personal hygiene prior to serving the lunch meal. This omission was confirmed by the LPN during an interview. Both the Infection Preventionist and the Director of Nursing confirmed that staff are expected to perform hand hygiene before and after delivering meal trays, don appropriate PPE for residents on contact isolation, and offer hand hygiene assistance to all residents prior to meals.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in one of its hallways and in five resident rooms. Observations revealed that Resident #37's bathroom had a visibly dirty black mat under the sink, a dusty and dirty fan base, chipped paint on the sink doors, and dirty baseboards. Resident #418's room had dark scuff marks on the floor, broken baseboards, and visible dirt and debris behind the entrance door. Resident #1's room also had dark scuff marks, broken baseboards, and visible dirt and debris behind the entrance door. Resident #39's room had visible dirt, dust, and debris behind the entrance door, while Resident #15's room had a brown substance on the floor, loose particles behind the headboard, and dirty debris near the chest of drawers. Additionally, the 200-hallway had dirty baseboards, scuffed floors, and dirty entrance doors to all resident rooms. The housekeeping cart in the hallway was also found to be dirty and unsanitary, with crusty debris on the dustpan, a dried substance on the locked cabinet, and loose particles and a brown substance on the black tray at the bottom of the cart. During interviews, the Administrator and Environmental Service Manager confirmed the observations and acknowledged that the 200-hallway and the rooms of Residents #37, #418, #1, #39, and #15 were not maintained in a clean, sanitary, and homelike environment. The facility's policy on routine cleaning and disinfection, which aims to ensure a safe and sanitary environment, was not adhered to, leading to the observed deficiencies.
Failure to Complete Significant Change Assessment
Penalty
Summary
The facility failed to complete a significant change assessment for a resident who had a significant change in condition. The resident, who had diagnoses including Diabetes, End Stage Renal Disease, Hypertension, and Anemia, was admitted to the facility and later had hospice care ordered. Despite the order for hospice services being effective on 8/21/2023, the facility did not complete a significant change assessment within the required 14 days. An annual Minimum Data Set (MDS) assessment showed the resident had moderate cognitive impairment but did not indicate the resident was receiving hospice services. This deficiency was confirmed during an interview with an MDS Registered Nurse who acknowledged that the significant change assessment had not been completed within the required timeframe.
Inaccurate MDS Assessments for Anticoagulant Use, Hospice Care, and Restraints
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of anticoagulant use, hospice care, and physical restraints. Resident #39, who was admitted with multiple diagnoses including Diabetes and End Stage Renal Disease, was inaccurately documented as receiving an anticoagulant when the medication prescribed was actually an antiplatelet (Clopidogrel). This error was confirmed by MDS RN #1 during an interview. Resident #36, who had moderate cognitive impairment and was receiving hospice care, was not coded correctly in the MDS assessments to reflect the hospice services, despite having an order for hospice care effective from 8/21/2023. This inaccuracy was also confirmed by MDS RN #1 during an interview. Resident #33, admitted with diagnoses including Cerebral Infarction and Functional Quadriplegia, was inaccurately documented as using physical restraints in the MDS assessment. Observations over several days showed that the resident did not have any restraints in use, which was confirmed by MDS RN #1. These inaccuracies in the MDS assessments indicate a failure by the facility to ensure accurate and complete documentation, which is essential for proper resident care and regulatory compliance.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, who was admitted with diagnoses including Right Hip Fracture, Dementia, Dislocation of Right Hip, Depression, and Adult Failure to Thrive, did not have a baseline care plan developed until 96 hours after admission. This was confirmed during an interview with the Area Nurse Director, who acknowledged the failure to meet the 48-hour requirement for developing a baseline care plan.
Failure to Follow Physician's Orders for Double Protein Portions
Penalty
Summary
The facility failed to follow a physician's order for two residents who were prescribed double protein portions at all meals to promote wound healing. Resident #61, who had diagnoses including Hypertension, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and a Pressure Ulcer to the Buttocks, was not receiving the prescribed double protein portions. This was confirmed through interviews with the resident and observations of meal portions. Similarly, Resident #418, who had diagnoses including Cellulitis of the Left Lower Limb, Type 2 Diabetes with Hypoglycemia, Hypertension, and Peripheral Vascular Disease, also did not receive the prescribed double protein portions. Both residents' dietary orders were not transferred correctly to a new computer system implemented by the facility, leading to inaccurate dietary meal tickets. Interviews with the Dietary Aide, Dietary Manager, Regional Dietary Manager, Area Nurse Director, Registered Dietician, and Nurse Practitioner confirmed that the dietary orders for double protein portions were not followed due to a glitch in the new computer system. Despite the residents being on other protein supplements, the failure to provide double protein portions as ordered was identified. The residents' wounds were reported to be stable and had not deteriorated, but the deficiency in following the physician's orders was evident.
Unsecured Chemicals in Resident Bathroom
Penalty
Summary
The facility failed to ensure that chemicals were secured in the bathroom shared by three residents, leading to a potential safety hazard. The facility's policy mandates that chemicals should be locked at all times, but during an observation, a 32-ounce bottle labeled as glass cleaner but containing bleach, and another bottle labeled as odor control, were found unsecured on the sink. Both bottles were confirmed to contain hazardous chemicals, which were accessible to the residents. This was confirmed by both an LPN and the Environmental Service Manager, who immediately removed the bottles upon discovery. Resident #37, who has diagnoses including Type 2 Diabetes and Congestive Heart Failure, was found lying in bed during the observation. Resident #8, diagnosed with Adult Failure to Thrive and Repeated Falls, was observed walking independently with a walker. Resident #41, who has Vascular Dementia and moderate cognitive impairment, was seen independently using a wheelchair. Despite their varying levels of mobility and cognitive function, the unsecured chemicals posed a risk to all three residents. Interviews with staff and residents revealed that the housekeeper had left the chemicals unsecured when she was called away. The residents, when asked, indicated they would not ingest the chemicals if they saw the labels, but the unsecured presence of these hazardous substances still violated the facility's safety policies. Observations over several days confirmed that there were no wandering residents in the hallway, but the failure to secure the chemicals still represented a significant oversight in maintaining a safe environment.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for Resident #54, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, a fracture of the right femur, muscle weakness, and Post Traumatic Stress Disorder (PTSD). Despite the facility's policy requiring screening for trauma history and accounting for residents' experiences and preferences to mitigate triggers, Resident #54's comprehensive care plan did not identify problems or triggers related to PTSD. The resident, who had a BIMS score indicating cognitive intactness, reported a history of PTSD due to childhood abuse but stated that her current medication regimen kept her stable. However, the facility did not inquire about her PTSD or potential triggers upon admission, and no triggered episodes occurred during her stay at the facility. Interviews with various staff members, including CNAs, an LPN, and a Psychiatric Nurse Practitioner, revealed that none were aware of Resident #54's PTSD diagnosis or potential triggers for behavioral episodes. The Social Services Director confirmed that although a trauma-informed screening was completed, it did not include specific triggers, nor were they added to the resident's care plan. The facility's Administrator, Administrator in Training, and Area Nurse Director acknowledged that the facility's trauma-informed care policy had not been followed, leading to the deficiency in providing appropriate care for Resident #54.
Failure to Maintain Dryer Lint Screens
Penalty
Summary
The facility failed to maintain mechanical equipment in a safe operating condition, specifically in the laundry room. During an observation, both dryers were found with a thick layer of lint build-up on the screens and lint accumulation on the floor beneath them. The facility's policy requires lint screens to be cleaned and brushed every hour and after every load, but the Lint Trap Clean Out Log had not been completed for the observed date. The Environmental Services Manager confirmed the lint build-up and the lack of documentation for the cleaning of the dryer screens, noting that the responsible person had left for the day and she could not confirm when the screens were last cleaned.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shannondale Of Maryville Health Care Center | 1 mi | ★★★★★ | 0 | 0 |
| Foothills Transitional Care And Rehabilitation | 1.5 mi | ★★★★★ | 0 | 0 |
| Ocoee Transitional Care Center Llc | 1.9 mi | ★★★★★ | 11 | 0 |
| Asbury Place At Maryville | 2.8 mi | ★★★★★ | 27 | 0 |
| Life Care Center Of Blount County | 6.7 mi | ★★★★★ | 3 | 0 |
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