Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Wellpark Health And Rehabilitation during CMS and state inspections, most recent first.
Missing Physician Order for CPAP Use: A resident with obstructive sleep apnea had nursing notes documenting CPAP compliance, but the order recap did not include a physician order for CPAP use. An admitting LPN acknowledged missing the CPAP during the admission assessment, another LPN did not verify an order was present, and the DON confirmed the resident should have had an order for the CPAP machine.
Incorrect Resident Name Used in Care Plan: A resident with intact cognition and a hip fracture had an activities care plan that incorrectly used another name instead of the resident’s name, preferred name, or nickname. The AD, MDS Coordinator, DON, and ED all acknowledged the name was inaccurate, and the AD stated she did not know how the incorrect name became part of the care plan.
A resident reported missing belongings and unauthorized transactions on her bank accounts. Surveillance footage identified a housekeeper as the perpetrator. The resident's purse was kept in an unlocked cabinet, leading to the misappropriation of property. The housekeeper was terminated for policy violation.
A resident's dignity was compromised when a sign indicating care instructions was posted above their bed without consent. The resident, who was cognitively intact, did not request the sign, and there was no documentation of such a request in their medical record. The DON confirmed that the facility's policy requires care information to be communicated verbally or documented, not through visible signs unless requested.
The facility failed to accurately complete MDS assessments for two residents, leading to deficiencies in documenting falls and discharge locations. One resident experienced a fall that was not recorded in the MDS, while another was inaccurately documented as discharged to the hospital instead of home. These inaccuracies were confirmed by the MDS Coordinator, indicating a failure to adhere to facility policy and CMS guidelines.
A resident at high risk for pressure ulcers did not have a comprehensive care plan developed within the required timeframe, despite having a deep tissue injury and a new stage 2 pressure ulcer. Although interventions were in place and staff were aware of them, the formal care plan was delayed by 35 days, contrary to facility policy.
A resident with a history of falls and medium fall risk experienced multiple falls in a facility. Despite implementing new interventions like using a gait belt and personal safety alarms, the care plan was not updated promptly. Staff interviews confirmed the delay in updating the care plan, which was not revised with new interventions until months later.
A resident with a deep tissue injury on the right heel did not receive prescribed daily betadine treatment for 19 days due to an error in discontinuing the order after a change in facility ownership. Despite the lapse, the wound showed improvement and did not decline. The Wound Care Nurse and DON confirmed the error and the failure to administer the treatment as per physician's orders.
A facility failed to accurately record and monitor a resident's weight, leading to a deficiency in maintaining the resident's health. The resident, with a history of malnutrition and depression, experienced significant weight loss due to inconsistent weighing methods and unreported discrepancies. Despite consuming most meals, the resident's weight fluctuated, and the DON was unaware of the issue until the survey. The resident did not suffer negative outcomes and was above his ideal body weight.
A facility failed to ensure complete documentation of dialysis communication records for a resident with ESRD, Hypertensive Heart and Kidney Disease, and Diabetes. Despite the facility's protocol requiring inspection of these records upon the resident's return from dialysis, several entries were incomplete or missing, as confirmed by interviews with staff, including an RN and the DON.
A medication cart was found with keys left in the lock, unattended by the designated LPN. The facility's policy requires that medication carts be locked and keys secured on the nurse's person. The DON confirmed the lapse in protocol.
A resident with multiple health issues developed a pressure ulcer, and the facility failed to document wound care treatments accurately. Despite treatments being administered, nursing staff did not record the application of Santyl ointment on several occasions. The DON confirmed the expectation for accurate documentation, highlighting a deficiency in maintaining medical records.
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a sacral wound, foley catheter, and ostomy, as staff did not wear required PPE during high-contact activities. Another resident with pressure ulcers lacked EBP signage and PPE availability. Additionally, staff did not offer hand hygiene assistance to five residents during meal service, contrary to facility policy. Interviews confirmed staff were unaware or did not adhere to these infection control measures.
The facility did not offer COVID-19 vaccinations to three residents according to CDC guidelines and its policy. Despite the CDC's recommendation for updated vaccines every six months, the facility failed to screen or offer vaccines to eligible residents, relying on outdated 2021 guidelines. The DON confirmed the oversight, acknowledging the need to follow current recommendations.
Missing Physician Order for CPAP Use
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to ensure a physician order was in place for a CPAP machine for Resident #66. The resident was admitted with intact cognition, had obstructive sleep apnea listed as an active diagnosis on the MDS, and nursing documentation recorded that the resident was compliant with CPAP therapy on 06/20/2025 and 06/21/2025. However, the resident's order recap for 06/01/2025 through 06/30/2025 did not include an order for CPAP use. During interviews, the admitting LPN stated she completed the nursing admission assessment and missed the use of the CPAP machine, which led to missing the physician order for the device. Another LPN stated she knew the resident used CPAP at night but did not verify that an order was present because she did not admit the resident. The NP stated that if a resident arrived with a CPAP device and no orders, nursing should notify him so he could order CPAP at the resident's home settings. The DON reviewed the daily skilled notes and confirmed they showed CPAP use, and stated the resident should have had a physician's order for the CPAP machine.
Incorrect Resident Name Used in Care Plan
Penalty
Summary
The facility failed to ensure the correct resident name was used in a comprehensive care plan for one resident. Resident #59 was admitted on 08/06/2025, had a 5-day MDS with a BIMS score of 14 indicating intact cognition, and had an active diagnosis of hip fracture. The resident’s care plan included a focus area initiated 08/07/2025 for potential alteration in diversional activities related to a preference to initiate activities of choice independently. The interventions in that care plan incorrectly used a different name, not Resident #59’s name, preferred name, or nickname, including directions to invite and encourage group activities, noting that the resident could propel a wheelchair independently, and encouraging the resident to go outside for fresh air when the weather was good. The Activities Director stated she was responsible for initiating activities care plans and did not know how the incorrect name became part of the care plan. The MDS Coordinator stated the care plan was not accurate because it used the wrong name and said she would have changed it if she had noticed it. The DON stated the name was a typo and that her expectation was that there were never typos. The ED stated the name was not accurate and expected the correct name, nickname, or preferred name to be used throughout a care plan.
Failure to Protect Resident's Belongings and Money
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically the wrongful use of the resident's belongings and money. The resident, who was cognitively intact and required partial to moderate assistance with activities of daily living, reported that her wallet was missing and her bank accounts had been cleared out. The resident had kept her purse in an unlocked cabinet in her room. Surveillance footage from a nearby gas station identified the perpetrator as a housekeeper employed by the facility. The resident had received multiple fraud notifications from her bank and credit card companies, indicating unauthorized transactions. The incident was reported to the facility by the resident, who had already contacted local law enforcement. The facility's investigation revealed that the housekeeper had access to the resident's room and was identified as the individual responsible for the theft. The housekeeper was subsequently terminated for violating facility policy. The resident's daughter also reported that several gift cards were missing, with an estimated value of up to $500. The facility's failure to secure the resident's belongings and prevent the misappropriation of property led to this deficiency.
Failure to Protect Resident Dignity by Unauthorized Signage
Penalty
Summary
The facility failed to protect the dignity of a resident by posting a sign above the resident's bed without their consent. The sign, which read 'No B/P [to] R Arm,' was visible to anyone entering the room. The resident, who was cognitively intact, stated that they were unaware of who posted the sign and had not requested it. The facility's policy on dignity, revised in February 2021, specifies that signs indicating a resident's clinical status or care needs should not be openly posted unless specifically requested by the resident or family. However, there was no evidence in the medical record that such a request had been made. The Director of Nursing (DON) confirmed that resident care information should be communicated through verbal reports or documented in the kardex or care plan, and not through visible signs unless requested. During observations and interviews, the DON acknowledged the presence of the sign and confirmed that there was no documentation in the resident's medical record indicating a request for the sign. This oversight in following the facility's policy resulted in a failure to uphold the resident's right to dignity and privacy.
Inaccurate MDS Assessments for Falls and Discharge Locations
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of falls and discharge locations. Resident #22, who was admitted with conditions including Age-Related Osteoporosis with Pathological Fracture and Unsteadiness on Feet, experienced a witnessed fall on 10/5/2024. However, the admission MDS assessment dated 10/7/2025 inaccurately reported that the resident had no falls since admission. This discrepancy was confirmed by the MDS Coordinator during an interview, indicating a failure to reflect the resident's actual status during the observation period. Similarly, Resident #31, admitted with diagnoses such as COVID-19 and Severe Sepsis, was inaccurately documented in the discharge MDS assessment. The assessment indicated a planned discharge to the hospital, while the Discharge Summary revealed the resident was discharged home with a spouse. The MDS Coordinator confirmed this inaccuracy, highlighting a failure to ensure the discharge location was correctly documented based on the medical record review. These inaccuracies in MDS assessments demonstrate a lack of adherence to the facility's policy and CMS guidelines for certifying the accuracy of resident assessments.
Delayed Comprehensive Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop a comprehensive care plan in a timely manner for a resident with pressure ulcers. The facility's policy requires that a comprehensive person-centered care plan be developed within seven days of completing the Resident Minimum Data Set (MDS) assessment. However, for one resident, the care plan addressing pressure ulcers was not developed until 35 days after the MDS assessment was completed, which is significantly beyond the required timeframe. The resident in question was admitted with multiple diagnoses, including a fracture of the right femur, type 2 diabetes mellitus, and end-stage renal disease. Upon admission, the resident was identified as being at high risk for pressure ulcers, with a deep tissue injury on the right heel present at admission and a new stage 2 pressure ulcer developing on the sacrum. Despite these conditions, the comprehensive care plan to address these issues was delayed, although interventions such as seating redistribution cushions, pillows, and turning and repositioning were noted in the resident's records. Interviews with the MDS Coordinator revealed that the staff were aware of the interventions needed to prevent and address pressure ulcers, but the formal care plan was not updated in a timely manner. Observations during the survey period showed that the necessary interventions were in place, and staff were knowledgeable about them. However, the delay in formalizing the care plan represents a deficiency in adhering to the facility's policy for timely care planning.
Failure to Timely Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that a care plan was revised to include new interventions after a fall for a resident. The resident, who was admitted with diagnoses including age-related osteoporosis with pathological fracture and unsteadiness on feet, was identified as being at medium risk for falls. Despite having a history of falls and requiring substantial assistance for transfers, the care plan was not updated in a timely manner to include new interventions after the resident experienced multiple falls. The resident had a witnessed fall on October 5, 2024, during a transfer from a recliner to a wheelchair, which resulted in the implementation of a new intervention to use a gait belt with all transfers. However, this intervention was not added to the care plan promptly. The resident experienced additional falls on October 16, 2024, and November 1, 2024, with the latter fall leading to the implementation of further interventions such as a low bed and personal safety alarms. Despite these incidents, the comprehensive care plan was not updated with the new interventions until January 21, 2025. Interviews with staff, including the MDS Coordinator and the Director of Nursing, confirmed that the care plan was not updated in a timely manner. The MDS Coordinator acknowledged that falls were discussed daily in IDT meetings to determine root causes and appropriate interventions, but the care plan was not updated as required. The Director of Nursing confirmed that the new intervention for the gait belt was not added to the care plan until January 21, 2025, indicating a delay in updating the care plan with necessary interventions to address the resident's fall risk.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to ensure that physician's orders for wound care were followed for a resident with a deep tissue injury (DTI) on the right heel. The resident, who was admitted with multiple diagnoses including a fracture of the right femur, type 2 diabetes mellitus, and end-stage renal disease, had a DTI present on admission. The physician's order was to apply betadine to the right heel daily, but this treatment was not administered from January 4, 2025, to January 22, 2025, due to an error in discontinuing the order. The Wound Care Nurse mistakenly discontinued the order for the daily betadine treatment while reconciling orders after a change in facility ownership. This error led to the absence of the treatment on the Treatment Administration Record (TAR), resulting in the nursing staff not administering the treatment. Despite the lapse in treatment, the wound did not decline, and the resident's condition remained stable, with the wound showing signs of improvement over the period. Interviews with the Wound Care Nurse, Director of Nursing (DON), and other nursing staff confirmed the error in discontinuing the order and the subsequent failure to administer the treatment. The DON and Nurse Practitioner both acknowledged that the wound care orders were not followed as expected, although they noted that the resident did not suffer harm as a result of the missed treatments.
Failure to Accurately Monitor Resident's Weight
Penalty
Summary
The facility failed to ensure accurate recording and monitoring of a resident's weight, leading to a deficiency in maintaining the resident's health. The facility's policy on weighing residents was not followed, as evidenced by inconsistent weighing methods and failure to report significant weight discrepancies. Resident #28, who was admitted with severe protein-calorie malnutrition and other health issues, experienced a 23-pound weight loss over 49 days. The Director of Nursing (DON) was unaware of this weight loss until it was highlighted during the survey, indicating a lapse in communication and monitoring. Resident #28 had a history of acute intermittent porphyria and depression, which contributed to his limited oral intake and intentional weight loss to manage fecal incontinence. Despite consuming 75-100% of meals, the resident's weight fluctuated significantly, with one recorded weight deemed inaccurate. The facility's failure to adhere to its policy for weight monitoring and reporting resulted in the deficiency, although the resident did not experience any negative outcomes such as wounds or infections. The resident was still above his ideal body weight and planned to be discharged home soon.
Incomplete Dialysis Communication Records for a Resident
Penalty
Summary
The facility failed to ensure complete documentation of dialysis communication records for a resident with End Stage Renal Disease (ESRD), Hypertensive Heart and Kidney Disease, and Diabetes. The resident, who was cognitively intact, was admitted to the facility and required regular dialysis appointments. The facility's dialysis contract stipulated the need for the interchange of information necessary for the care of the resident. However, the review of dialysis communication records revealed incomplete documentation on several dates, with missing entries for vital signs such as respiratory rate, temperature, and weight. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed the incomplete and missing documentation. The RN stated that dialysis communication records should be inspected upon the resident's return from the dialysis center, and any missing information should be followed up with the center. Despite this protocol, the records for multiple dates were either incomplete or entirely missing, indicating a failure to ensure proper documentation and communication regarding the resident's dialysis care.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that medications were secured appropriately on one of the two medication carts observed. According to the facility's policy titled 'Medication Labeling and Storage,' all medications and biologicals must be stored in locked compartments, and only authorized personnel should have access to the keys. During an observation, it was noted that the medication cart for the 200/300 hall was locked, but the keys were left in the outer lock of the cart's upper drawer. The nurse responsible for the cart, LPN G, was not present at the nurses' station, although other staff members were present in the hall. Upon returning to the medication cart, LPN D, who was designated to the cart, retrieved the keys and secured them on her person. During an interview, LPN D admitted to forgetting to take the keys with her and confirmed that she failed to secure the medication cart properly. The Director of Nursing (DON) also confirmed that the nurses are required to keep the medication cart keys on their person at all times, acknowledging the lapse in protocol by LPN D.
Failure to Document Wound Care Treatments
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident who was being treated for wounds. The resident, who was admitted with multiple diagnoses including a fracture, diabetes, and end-stage renal disease, developed a stage 2 pressure ulcer that was not present on admission. The medical records revealed inconsistencies in the documentation of wound care treatments, specifically the application of Santyl ointment, which was not recorded on several dates despite being ordered by the physician. Interviews with the nursing staff responsible for the resident's care indicated that the treatments were administered but not documented. The LPNs and RNs involved admitted to either forgetting to document the treatments or being unaware of the omission. The Director of Nursing confirmed that it was expected for treatments to be documented accurately in the medical records and that physician's orders should be followed. The wound care nurse and the nurse practitioner monitored the resident's wound progression, noting changes in the wound's stage and treatment requirements. Despite the lack of documentation, the wound showed signs of improvement over time. However, the failure to document the treatments as per the physician's orders constituted a deficiency in maintaining accurate medical records, as required by the facility's policy.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for Resident #10 and failed to identify the need for EBP for Resident #34. Resident #10, who was admitted with a sacral wound, foley catheter, and ostomy, had a sign posted on their door indicating the need for gloves and gown during high-contact activities such as changing bed linens. However, during an observation, CNA F was seen changing the resident's bed linens wearing only gloves and not a gown, contrary to the posted EBP requirements. CNA F mistakenly believed that a gown was not necessary unless providing direct personal care, despite the clear signage. Resident #34, admitted with pressure ulcers on bilateral posterior thighs, did not have EBP signage on their door, nor was there PPE readily available for staff use. The comprehensive care plan and physician's orders did not include EBP for the resident's open wounds. During an interview, LPN C acknowledged the absence of EBP signage and PPE, and the DON/IP confirmed that residents with chronic wounds requiring treatment should be placed in EBP. Additionally, the facility failed to offer hand hygiene assistance to five residents during meal service. Observations revealed that staff members delivered meal trays to residents without offering hand hygiene assistance, despite the facility's policy emphasizing hand hygiene as a primary means to prevent the spread of infections. Interviews with staff members, including LPN G and [NAME] H, confirmed that they did not offer hand hygiene assistance to the residents, and the DON/IP acknowledged that staff were expected to provide such assistance prior to meals.
Failure to Offer COVID-19 Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to offer COVID-19 immunizations according to CDC recommendations and its own policy for three residents. The facility's policy, revised in July 2023, mandates offering and administering COVID-19 vaccines to eligible residents, screening them upon admission to determine vaccine status and eligibility using current CDC guidelines. However, the facility did not adhere to this policy for three residents who had not been offered or screened for the COVID-19 vaccine despite being eligible. The CDC recommends that everyone aged six months and older, especially those in long-term care facilities, receive the updated 2024-2025 COVID-19 vaccine every six months. Resident #10, admitted in November 2024, had not been offered a COVID-19 vaccine since receiving one in March 2021. Resident #134, admitted with diagnoses including metabolic encephalopathy and acute respiratory failure, had not been offered a vaccine since October 2022. Resident #139, with fractures and chronic obstructive pulmonary disease, had not been offered a vaccine since March 2022. The Director of Nursing confirmed that the facility had been using outdated recommendations from 2021 and acknowledged that the residents should have been offered the vaccine according to current guidelines.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 106 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Knoxville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy Park Health And Rehabilitation | 0.1 mi | ★★★★★ | 7 | 0 |
| West Hills Health And Rehab | 0.8 mi | ★★★★★ | 0 | 0 |
| Lyonsview Health And Rehabilitation Center | 3 mi | ★★★★★ | 0 | 0 |
| Senator Ben Atchley State Veterans' Home | 4.6 mi | ★★★★★ | 2 | 0 |
| Nhc Healthcare, Ft Sanders | 5.8 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Wellpark Health And Rehabilitation.
100% money-back within 48 hours.
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.