QUALITY CENTER FOR REHABILITATION AND HEALING LLC

Nursing Home Inspector

932 BADDOUR PARKWAY
LEBANON, TN 37087
Wilson County
Phone: 615-444-1836
Provider Number: 445154
Last Inspection: 03/29/2017

About the Nursing Home

Number of Beds: 280
Number of Residents: 217
Beds Available: 63
Percent Occupancy: 78%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: For profit - Partnership
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

3

Facility
6

County
14

TN
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

3

2017
6

2016
3

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

3/29/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 4/27/2017
 

3/2/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 3/3/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Isolated : Minimal 3 3/3/2016
 

1/22/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 2/15/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

3/28/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 3/31/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TN State Avg
Number of Residents 217 93.50 85.33
Registered Nurses 0.61 0.67 0.75
Licensed Practical / Vocational Nurses 0.97 1.10 1.05
Certified Nursing Assistants 1.97 2.03 2.17
Total Staff Hours 3.55 3.81 3.97

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% TN State Avg%
of high risk long-stay residents with pressure ulcers 3 8 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 96 98 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 98 93
of long-stay residents experiencing one or more falls with major injury 4 1 3
of long-stay residents who have depressive symptoms 2 4 2
of long-stay residents who lose too much weight 8 8 7
of long-stay residents who received an antianxiety or hypnotic medication 32 31 36
of long-stay residents who received an antipsychotic medication 21 18 17
of long-stay residents who self-report moderate to severe pain 11 5 4
of long-stay residents who were physically restrained 0 0 1
of long-stay residents whose ability to move independently worsened 18 24 21
of long-stay residents whose need for help with daily activities has increased 14 14 15
of long-stay residents with a catheter inserted and left in their bladder 2 3 2
of long-stay residents with a urinary tract infection 4 3 4
of low risk long-stay residents who lose control of their bowels or bladder 76 67 56
of short-stay residents assessed and appropriately given the pneumococcal vaccine 59 75 83
of short-stay residents who had an outpatient emergency department visit 6 7 13
of short-stay residents who made improvements in function 61 67 64
of short-stay residents who newly received an antipsychotic medication 3 1 2
of short-stay residents who self-report moderate to severe pain 31 15 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 72 82 81
of short-stay residents who were rehospitalized after a nursing home admission 17 19 21
of short-stay residents who were successfully discharged to the community 48 57 48
of short-stay residents with pressure ulcers that are new or worsened 0 0 0