Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

LEGACY PARK HEALTH AND REHABILITATION

KNOXVILLE, TN · 176 certified beds · Last Life Safety survey May 31, 2024

CMS Certification Number 445105 · first certified March 1973

Ownership

Independently operated (no chain recorded by CMS) · For profit - Limited Liability company

No change of ownership on CMS record since January 1, 2016, when the records begin.

10
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
7
Inspection & testing records
Of the citations on file

Position within TN

10 citations — more than 60% of the 303 certified nursing homes in TN. Compared within TN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 6 citations; the earlier surveys in the window averaged 2. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: August 2025 to February 2028. This facility’s last Life Safety survey was May 2024. Facilities in TN are typically surveyed 15–44 months after the last one (median 33), measured over 279 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

1 of the 10 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 10 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in TN, and nationally. Surveyors differ markedly between states, so the TN figure is the meaningful one.

This facility10TN median8National median11
Citations on file over three years, compared
MeasureCitations
This facility10
Median facility in TN8
Median facility nationally11

Survey history

Citations at each Life Safety survey
32018-1112020-0162024-05
Citations at each Life Safety survey
Survey dateCitations
November 15, 20183
January 29, 20201
May 31, 20246

Most-cited tags

Most-cited tags at this facility
K-03532K-09181E-00391K-03631K-07121K-02231K-03111K-03451
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0353Inspect, test, and maintain automatic sprinkler systems.22024-05-31
K-0918Have generator or other power source capable of supplying service within 10 seconds.12024-05-31
E-0039Conduct testing and exercise requirements.12024-05-31
K-0363Install corridor and hallway doors that block smoke.12024-05-31
K-0712Have simulated fire drills held at unexpected times.12024-05-31
K-0223Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.12018-11-15
K-0311Have an enclosure around a vertical opening shaft.12018-11-15
K-0345Have approved installation, maintenance and testing program for fire alarm systems.12024-05-31

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 6
  • Emergency Preparedness Deficiencies 1
  • Egress Deficiencies 1
  • Gas, Vacuum, and Electrical Systems Deficiencies 1
  • Other 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies6
Emergency Preparedness Deficiencies1
Egress Deficiencies1
Gas, Vacuum, and Electrical Systems Deficiencies1
Miscellaneous Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

May 31, 2024 — 6 citations

Citations issued on May 31, 2024
TagWhat the surveyor checksStatus
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (June 17, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (May 31, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (June 17, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (June 17, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (June 17, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (June 17, 2024)

January 29, 2020 — 1 citation

Citations issued on January 29, 2020
TagWhat the surveyor checksStatus
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (March 13, 2020)

November 15, 2018 — 3 citations

Citations issued on November 15, 2018
TagWhat the surveyor checksStatus
K-0223Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.Deficient, Provider has date of correction (December 30, 2018)
K-0311Have an enclosure around a vertical opening shaft.Deficient, Provider has date of correction (December 30, 2018)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (December 30, 2018)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.