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 West Hills Health And Rehab during CMS and state inspections, most recent first.
A facility failed to provide post-dialysis interventions for a resident with end-stage renal disease. The resident's MAR lacked documentation of the dialysis catheter's location and post-dialysis monitoring. A nurse, unfamiliar with the resident's catheter location, did not document post-dialysis care, and the DON confirmed the oversight. This indicates non-compliance with the facility's dialysis care policy.
The facility failed to resubmit timely PASRR screenings for three residents with mental health diagnoses, leading to deficiencies in compliance. A resident with Major Depressive Disorder and Anxiety Disorder, another with Adjustment Disorder and Unspecified Psychosis, and a third with Schizophrenia, Anxiety, and Depression did not have updated screenings submitted as required. Interviews confirmed the oversight, indicating a lapse in adherence to procedures for mental health assessments.
A resident admitted with Dementia, Age Related Physical Disability, and COVID-19 was receiving humidified oxygen at 2 liters per minute via nasal cannula without a physician's order. Observations from multiple days confirmed the ongoing administration of oxygen therapy. The DON acknowledged the lack of an order and notified the medical provider, resulting in the discontinuation of the therapy and monitoring of the resident.
A resident with a history of depression and other medical conditions was prescribed Sertraline 50 mg daily, but the facility's MAR incorrectly listed the dosage as 25 mg. The error was discovered during a medication pass, and interviews confirmed the transcription mistake, as the MAR was not updated to reflect the new order.
A facility failed to follow infection control practices during medication administration when an LPN did not perform hand hygiene between residents. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with an external fixator, as required. The absence of signage and PPE availability for EBP was confirmed by the Infection Preventionist.
Failure to Document Post-Dialysis Care
Penalty
Summary
The facility failed to provide post-dialysis interventions for a resident who required hemodialysis due to end-stage renal disease. The facility's policy mandates that nursing personnel ensure safe and accurate dialysis care, including post-care assessment and interventions. However, a review of the medical record revealed that the resident's Medication Administration Record (MAR) did not indicate the location of the dialysis catheter or document monitoring of the catheter post-dialysis. Additionally, a nurse's progress note failed to document an assessment of the resident's dialysis catheter after dialysis. During an observation and interview, the resident's nurse admitted she was unaware of the catheter's location as it was her first day caring for the resident, and the resident had left for dialysis before her shift began. The Director of Nursing confirmed that documentation for post-dialysis care was not completed on the specified date. The lack of documentation and awareness of the catheter's location indicates a failure to adhere to the facility's policy for post-dialysis care, potentially impacting the resident's health outcomes.
Failure to Resubmit Timely PASRR Screenings
Penalty
Summary
The facility failed to resubmit timely Level I Preadmission Screening and Resident Review (PASRR) for three residents, leading to deficiencies in compliance with regulatory requirements. Resident #29 was admitted with multiple mental health diagnoses, including Major Depressive Disorder and Anxiety Disorder, but the facility did not submit a new PASRR screening after these diagnoses were documented. Similarly, Resident #47, who was diagnosed with Adjustment Disorder and Unspecified Psychosis, did not have a Level II PASRR submitted after the new diagnosis of psychosis was added. Resident #54, admitted with Schizophrenia, Anxiety, and Depression, had a Level I PASRR indicating a serious mental illness, but the facility failed to submit a new screening by the required 180-day deadline. Interviews with the Director of Nursing and the PASARR Coordinator confirmed the facility's failure to submit the necessary screenings for these residents. The oversight in resubmitting the PASRR screenings for Residents #29, #47, and #54 indicates a lapse in the facility's adherence to the required procedures for monitoring and updating residents' mental health assessments. This deficiency was identified during a review of medical records and interviews, highlighting the need for timely and accurate submission of PASRR screenings to the state-designated authority.
Failure to Obtain Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to obtain physician orders for oxygen therapy for a resident, identified as Resident #301, who was admitted with diagnoses including Dementia, Age Related Physical Disability, and COVID-19. The medical record review and observations indicated that the resident was receiving humidified oxygen at 2 liters per minute via nasal cannula on multiple occasions from 11/9/2024 to 11/15/2024. Despite the continuous administration of oxygen, there was no documented physician order for this therapy. During an interview, the Director of Nursing confirmed the absence of an order and stated that the resident's medical provider had been notified, leading to the discontinuation of the oxygen therapy and monitoring of the resident's condition.
Medication Transcription Error for Resident
Penalty
Summary
The facility failed to accurately transcribe a physician's order for a resident's medication, leading to a discrepancy in the medication administration. The resident, who was cognitively intact and had a history of dysphagia, atrial fibrillation, hypertension, heart failure, and depression, was prescribed Sertraline (Zoloft) 50 mg to be taken once daily. However, the Medication Administration Record (MAR) incorrectly listed the dosage as 25 mg. This error was discovered during a medication administration pass when the resident was observed receiving the correct 50 mg dosage, despite the MAR indicating otherwise. The hospice agency had sent an electronic order for the increased dosage to the pharmacy, and a fax was sent to the facility's nurse's station. However, the facility's staff failed to update the MAR to reflect the new order. Interviews with the hospice RN and the Director of Nursing confirmed the transcription error, as the MAR and physician orders were not updated to match the electronic prescription. This oversight in documentation led to a discrepancy between the prescribed and recorded medication dosages.
Infection Control and EBP Failures in Medication Administration and Resident Care
Penalty
Summary
The facility failed to adhere to infection control practices during medication administration for one resident. Specifically, a Licensed Practical Nurse (LPN) did not perform hand hygiene after administering medication to one resident and before preparing and administering medication to another resident. This lapse in protocol was confirmed by the LPN during an interview, and the Director of Nursing acknowledged that staff were expected to perform hand hygiene between each resident's medication administration. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with an external fixator, which is considered an indwelling medical device. There was no signage indicating the need for EBP, nor was personal protective equipment (PPE) available inside or outside the resident's room. The Infection Preventionist confirmed that the resident required EBP due to the presence of the external fixator, but these precautions were not in place.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Legacy Park Health And Rehabilitation | 0.8 mi | ★★★★★ | 7 | 0 |
| Wellpark Health And Rehabilitation | 0.8 mi | ★★★★★ | 2 | 0 |
| Lyonsview Health And Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Ft Sanders | 5 mi | ★★★★★ | 7 | 0 |
| Senator Ben Atchley State Veterans' Home | 5.2 mi | ★★★★★ | 2 | 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.