Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | — | 0 | 0 |
| Nhc Healthcare, Knoxville | 3.1 mi | — | 0 | 0 |
| Creekview Health And Rehabilitation | 3.6 mi | — | 6 | 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 August 2026) and official state health department websites.