Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Island Home Park Health And Rehab during CMS and state inspections, most recent first.
A resident with an indwelling catheter and moderate cognitive impairment had a foley drainage bag left uncovered and visible to anyone entering the room. The resident had an order for a privacy cover every shift, but repeated observations showed no cover in place, and an LPN confirmed the cover was missing. The DON stated the expectation was that all foley drainage bags would have privacy covers to maintain resident dignity.
PASRR screening was inaccurate for two residents when Level 1 PASRRs stated no mental health diagnosis was known or suspected, despite the medical record and MDS showing active mental health diagnoses. One resident had Alzheimer’s Disease with Anxiety Disorder and severe cognitive impairment, and another had Dementia with Psychotic Disturbance, Insomnia, and Adjustment Disorder with Anxiety, also with severe cognitive impairment. The DON confirmed the PASRRs did not reflect the residents’ current diagnoses.
Failure to Offer Hand Hygiene During Meal Service: A CNA delivered meal trays to three residents, set up each meal, and did not offer hand hygiene before the meal service. The residents had diagnoses including muscle weakness, dysphagia, malnutrition, hypotension, diabetes, and anxiety, and each required staff assistance with meal setup; two were cognitively intact and one had moderate cognitive impairment. The CNA confirmed the omission, and the DON stated hand hygiene was to be offered prior to meals.
The facility did not ensure accurate MDS assessments for three residents, including one with a serious mental illness not properly identified, another receiving dialysis not coded as such, and a third with a sacral wound not documented on the MDS. These inaccuracies were confirmed through staff interviews and medical record reviews.
Two residents with existing mental health conditions were diagnosed with new mental health disorders, but the facility did not refer them to the state PASRR agency as required by policy. Both residents were cognitively intact, and the DON confirmed the failure to make the necessary referrals after the new diagnoses were identified.
A resident with a history of Type 2 Diabetes, swallowing difficulties, and gastrostomy status was no longer receiving enteral feedings, as confirmed by MDS assessment, staff interviews, and direct observation. Despite this significant change, the care plan was not updated to reflect the discontinuation of tube feedings, contrary to facility policy requiring timely care plan revisions when a resident's condition changes.
A resident with Type 2 Diabetes Mellitus and Hypertension experienced physical abuse when a CNA inappropriately touched her chin during an altercation. The resident, who was cognitively intact, became agitated during repositioning, leading to the CNA's inappropriate response. The incident was reported, and the resident was assessed with no injuries found. The facility's investigation confirmed the abuse, resulting in the CNA's termination.
A resident reported $400 missing from their room after a doctor's appointment. The facility's investigation, including interviews with LPNs and a police report, confirmed the misappropriation but could not identify the responsible party. The resident, who was cognitively intact, was reimbursed by the facility.
Failure to Maintain Dignity With Uncovered Foley Drainage Bag
Penalty
Summary
The facility failed to protect a resident’s right to dignity when an indwelling catheter drainage bag was left uncovered and visible to the public. Resident #25 was admitted with diagnoses including obstructive/reflux uropathy and a personal history of malignant neoplasm of the prostate, and a quarterly MDS assessment showed a BIMS score of 9, indicating moderate cognitive impairment. The resident also had a physician’s order dated 2/6/2026 to ensure the foley catheter drainage bag had a privacy cover every shift. During observations on 5/17/2026, 5/18/2026, and 5/19/2026, Resident #25’s foley catheter drainage bag was seen with no privacy cover in place and visible to anyone entering the room. During an observation and interview on 5/19/2026, an LPN confirmed the resident had an order for a privacy cover and did not have one in place. The DON later confirmed it was her expectation that all foley catheter drainage bags would have privacy covers in place to maintain resident dignity.
PASRR Screens Did Not Reflect Current Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that PASRR screening was accurate for two residents after mental health diagnoses were identified. For Resident #13, the Level 1 PASRR dated 8/29/2025 stated that no mental health diagnosis was known or suspected, but the medical record showed the resident was admitted with Alzheimer’s Disease and later received a diagnosis of Anxiety Disorder on 9/12/2025. The quarterly MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment, and further review confirmed the resident had Anxiety Disorder. For Resident #57, the Level 1 PASRR dated 11/7/2025 also stated that no mental health diagnosis was known or suspected, but the medical record showed diagnoses of Dementia with Psychotic Disturbance, Insomnia, and Adjustment Disorder with Anxiety. The quarterly MDS assessment showed a BIMS score of 6, indicating severe cognitive impairment, and documented active diagnoses of Dementia with Psychotic Disturbance, Insomnia, and Adjustment Disorder with Anxiety. During interview on 5/19/2026 at 1:49 PM, the DON confirmed that both residents’ current PASRRs were not accurate and did not reflect their current mental health diagnoses.
Failure to Offer Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to perform appropriate hand hygiene when serving meal trays to three residents on one of four units observed during meal tray distribution. The facility policy titled, Handwashing/Hand Hygiene, stated that all personnel shall follow handwashing/hand hygiene procedures and that hand hygiene products shall be readily accessible before and after eating. During observations on 5/17/2026, CNA B delivered meal service to Resident #11 at 11:37 AM, Resident #23 at 11:43 AM, and Resident #101 at 11:45 AM, set up each resident’s meal, and failed to offer hand hygiene to any of the three residents. Resident #11 had diagnoses including muscle weakness, dysphagia, and anxiety, scored 15 on the BIMS, and required set up or clean-up assistance with ADLs; the care plan directed staff to assist with meal setup. Resident #23 had diagnoses including malnutrition, muscle weakness, and hypotension, scored 13 on the BIMS, and also required set up or clean-up assistance with ADLs; the care plan directed staff to assist with meal setup. Resident #101 had diagnoses including diabetes, muscle weakness, and anxiety, scored 12 on the BIMS indicating moderate cognitive impairment, and required set up or clean-up assistance with ADLs; the care plan directed staff to assist with meal setup. During interview, CNA B confirmed she had not offered hand hygiene while passing the meal service to the three residents, and the DON confirmed hand hygiene was to be offered to residents prior to meals.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, as required by federal regulations. For one resident with a documented serious mental illness per PASRR Level II screening, the annual MDS assessment did not identify the resident as having a serious mental illness, despite confirmation from MDS LPNs that this was inaccurate. Another resident, who had diagnoses including end stage renal disease and was receiving dialysis, was not coded as receiving dialysis on the quarterly MDS assessment, even though the resident, dialysis nurse, and DON all confirmed ongoing dialysis treatments. A third resident, with Alzheimer's disease and severe cognitive impairment, had a wound over a sacral scar documented in the medical record and confirmed by the wound care nurse, but the quarterly MDS assessment failed to indicate the presence of a sacral scar or wound over a bony prominence. In each case, the discrepancies between the residents' actual conditions and the information recorded on the MDS assessments were confirmed by staff interviews and medical record reviews.
Failure to Refer Residents with New Mental Health Diagnoses to PASRR Agency
Penalty
Summary
The facility failed to refer two residents to the state-designated Pre-Admission Screening and Resident Review (PASRR) agency after each was diagnosed with a new mental health condition. According to the facility's policy, any assessment revealing a mental health disorder should be addressed, including referral to the PASRR agency. Medical record reviews showed that one resident, who was already diagnosed with Schizoaffective Disorder, Depression, and Anxiety, received a new diagnosis of Adjustment Disorder, while another resident with a history of Major Depression, Anxiety Disorder, and Insomnia was newly diagnosed with Psychotic Disorder. In both cases, the facility did not make the required referral to the PASRR agency following these new diagnoses. Both residents were found to be cognitively intact based on their Brief Interview for Mental Status (BIMS) scores. The Director of Nursing confirmed during an interview that the facility did not refer these residents to the PASRR agency after the identification of new mental health conditions, despite the facility's policy and regulatory requirements. This lapse was identified through policy review, medical record review, and staff interviews.
Failure to Timely Revise Care Plan After Discontinuation of Enteral Feeding
Penalty
Summary
The facility failed to revise the care plan in a timely manner for one resident after a significant change in the resident's nutritional status. According to the facility's policy, care plans are to be updated as residents' conditions change and reviewed at least quarterly in conjunction with the required MDS assessment. The resident in question was admitted with multiple diagnoses, including Type 2 Diabetes, difficulty swallowing, communication deficit, and gastrostomy status, and initially received enteral feeding via a tube. A review of the resident's quarterly MDS assessment indicated that the resident was no longer receiving nutrition by tube, and multiple staff interviews confirmed that enteral feedings had been discontinued due to an increase in the resident's appetite. Despite this change, the comprehensive care plan was not updated to reflect the discontinuation of enteral feedings. Observations on multiple dates confirmed that the resident was not receiving enteral feedings, and staff acknowledged that the care plan had not been revised when the feedings were stopped.
Failure to Prevent Physical Abuse in LTC Facility
Penalty
Summary
The facility failed to prevent physical abuse for one resident, who was admitted with diagnoses including Type 2 Diabetes Mellitus, Hypertension, and Generalized Muscle Weakness. The resident was cognitively intact, as indicated by a score of 15 on the Brief Interview of Mental Status assessment. The incident occurred when a Certified Nursing Assistant (CNA) attempted to reposition the resident, who then became agitated and screamed at the CNA. In response, the CNA touched the resident's chin, which was acknowledged as inappropriate by the CNA. Following the incident, the CNA reported the event to a Licensed Practical Nurse (LPN), who assessed the resident and found no physical injuries. The resident expressed feeling safe in the facility and did not exhibit signs of distress. The facility's investigation confirmed the CNA's inappropriate action, and the CNA was subsequently suspended and later terminated. The resident later stated to Social Services that she felt safe and did not remember the incident. Interviews with facility staff, including the LPN and the Director of Nursing (DON), corroborated the sequence of events. The Executive Director confirmed that physical abuse had occurred. Despite the absence of physical injuries, the incident was classified as a deficiency due to the failure to protect the resident from physical abuse, as outlined in the facility's policies on resident rights and abuse prevention.
Misappropriation of Resident's Money
Penalty
Summary
The facility failed to protect a resident's rights to be free from misappropriation and/or exploitation when $400.00 was taken from a resident's belongings. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention was reviewed, and it was found that the environment was not maintained as per the policy. The resident, who was cognitively intact as per a recent assessment, reported the missing money after returning from a doctor's appointment. The resident had last counted the money before leaving for the appointment and did not suspect anyone in particular for the theft. The facility conducted an investigation, and the police were notified. Interviews with LPNs revealed that they were informed about the missing money and searched the resident's room with permission, but the money was not found. The facility's administrator confirmed the allegation of misappropriation and stated that the facility reimbursed the resident for the missing amount. However, the facility could not determine who was responsible for the misappropriation of the resident's property.
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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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Nursing homes near Knoxville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holston Health & Rehabilitation Center | 2.5 mi | ★★★★★ | 1 | 0 |
| Fort Sanders Tcu | 2.5 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Ft Sanders | 2.7 mi | ★★★★★ | 7 | 0 |
| Nhc Healthcare, Knoxville | 3.1 mi | ★★★★★ | 0 | 0 |
| Creekview Health And Rehabilitation | 3.6 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.