Below 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 Quality Center For Rehabilitation And Healing Llc during CMS and state inspections, most recent first.
Nursing staff failed to demonstrate appropriate competency in administering Versed and monitoring residents afterward. Two residents with dementia and severe cognitive impairment received IM Versed for agitation or anxiety after other interventions or PRN Ativan were ineffective. Although reference materials and internal job descriptions required monitoring of vital signs and respiratory status with this benzodiazepine, and a memo from the DON instructed that respiratory status must be monitored, no blood pressure, heart rate, or respiratory rate measurements were documented before or after the injections for either resident. The DON provided only a brief memo without specific monitoring time frames or additional training, and interviews showed inconsistent expectations among leadership and staff regarding required monitoring, resulting in Versed being given without documented vital sign assessment or structured observation.
The facility failed to maintain required controlled substance records for Midazolam (Versed) obtained from the emergency med bank, in violation of its own policies on controlled substances and emergency medications. Several residents with dementia, psychiatric conditions, and other comorbidities received one-time IM Midazolam doses for agitation or anxiety after full vials were pulled from the med bank, but there was no documentation of receipt, wasting, or destruction of the unused portions. In multiple instances, narcotic sheets were not completed or retained, and the DON reported that such sheets were shredded. In one case, a nurse saved Midazolam in a med cart and administered it to a resident days later without a PRN order and without a corresponding med bank pull, further preventing accurate reconciliation of the controlled drug.
A resident with severe cognitive impairment and total care needs developed multiple bruises and bilateral femur fractures of unknown origin. Despite escalating pain, visible injuries, and family concerns, staff did not report the incident to state authorities within the required timeframe. The facility's investigation was incomplete, and the administrator did not consider the injuries to be of unknown origin, resulting in a failure to comply with abuse reporting regulations.
Failure to Monitor Vital Signs and Respiratory Status After Versed Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff had and used the competencies and skills necessary to safely administer midazolam (Versed) and monitor residents afterward. Reference materials reviewed by surveyors, including a National Library of Medicine article and the drug’s Black Box Warning, stated that midazolam is a short-acting benzodiazepine used for sedation and anxiolysis, with known risks of profound sedation, respiratory depression, hypotension, respiratory arrest, hypoxic encephalopathy, coma, and death. These sources emphasized the need for monitoring vital signs such as blood pressure, heart rate, and respiratory rate, especially in older patients, and called for continuous monitoring of respiratory and cardiac function. The facility’s LPN job description and nursing services policy required nurses to observe and evaluate residents’ responses to medications, maintain competency, use critical thinking, and perform pertinent medical assessments such as vital signs as ordered or as needed. The facility issued a memo from the DON stating that Ativan IM was on national back order and that Versed would be used in its place for anxiety/agitation. The memo indicated that Versed is in the benzodiazepine class, FDA-approved for anxiety/agitation in low doses, and that respiratory status would need to be monitored when it was given, instructing nurses to familiarize themselves with the medication. However, the DON did not specify a time frame or parameters for monitoring and acknowledged that no further training was provided beyond this memo. In interviews, the DON stated she would expect staff to monitor for changes in respiratory status and distress but indicated that obtaining vital signs before and after Versed administration would be on a case-by-case basis. The Medical Director stated that staff should monitor using nursing judgment and referenced a three-hour window of monitoring, while an NP and one LPN later acknowledged that residents should have vital signs taken before and after Versed administration and be watched closely for changes in breathing. For Resident #11, who had dementia, Alzheimer’s disease, major depressive disorder, psychosis, and severe cognitive impairment (BIMS score of 5), a nurse practitioner ordered midazolam 2.5 mg IM one time for increased aggression and agitation after the resident refused oral medications. The MAR showed Versed 2.5 mg IM was administered by an LPN, but the weights and vitals summary for that month showed no blood pressure, heart rate, or respirations obtained before or after the injection. For Resident #12, who had dementia, mood disorder, anxiety disorder, and severe cognitive impairment (BIMS score of 6), PRN Ativan was reported as not effective for increased anxiety and combative behavior, and a new order for midazolam 2.5 mg IM one time for anxiety was obtained. The MAR documented administration of Versed 2.5 mg IM by another LPN, and progress notes confirmed the new order and administration, but the weights and vitals summary showed no vital signs taken before or after the dose. In interview, that LPN confirmed no vital signs were obtained when Versed was administered. These actions and inactions demonstrated that nursing staff did not perform the necessary monitoring and assessments associated with Versed administration for two residents.
Failure to Maintain Required Controlled Substance Records for Midazolam
Penalty
Summary
The deficiency involves the facility’s failure to maintain required records for receipt, administration, wasting, and destruction of the controlled substance Midazolam (Versed) obtained from the emergency medication supply (med bank), contrary to its own policies on emergency medications, controlled substances, and pharmacy services. Facility policies required an individual controlled substance record for each resident receiving a controlled drug, including documentation of quantity received, number on hand, time of administration, and nurse signatures, as well as two nurses to witness dispensing and wasting from the emergency supply. Despite these requirements, the facility was unable to produce narcotic sheets or other documentation showing proper receipt and disposition of Midazolam for four residents. For one resident with Alzheimer’s disease, COPD, CHF, psychosis, and wandering, who had intact cognition and no noted behaviors on assessment, an order was written for a one-time intramuscular dose of Midazolam for agitation. A 1 ml vial of Midazolam 5 mg/ml was pulled from the emergency med bank, and 2.5 mg (0.5 ml) was administered, but the facility could not provide documentation of the medication’s receipt or the disposal of the unused portion. For another resident with cerebral infarction, vascular dementia, and depression, who had moderately impaired cognition and physical and verbal behaviors interfering with care, two separate one-time IM Midazolam orders were written on consecutive days. Each time, a 1 ml vial was pulled from the med bank and 2 mg (0.4 ml) was administered, yet the facility again lacked documentation of receipt and disposal of the remaining Midazolam. For a third resident with dementia, Alzheimer’s disease, major depressive disorder, and psychosis, who had severe cognitive impairment and no noted behaviors on assessment, a one-time IM Midazolam order for agitation was written, a 1 ml vial was pulled, and 2.5 mg (0.5 ml) was administered, but no documentation of receipt or wasting of the unused medication was available. For a fourth resident with dementia, mood disorder, and anxiety disorder, who had severe cognitive impairment and no noted behaviors on assessment, a one-time IM Midazolam order was written and a 1 ml vial was pulled; however, the MAR showed a higher dose administered than ordered, and the facility could not provide documentation of receipt and reconciliation. A later one-time Midazolam order for this same resident was administered without any corresponding med bank pull, and the DON stated that the nurse had saved the prior Midazolam dose in the med cart for 10 days and then administered it, despite there being no PRN order. Multiple LPNs either did not recall or confirmed that narcotic sheets were not completed, and the DON reported that narcotic sheets were shredded and not retained, leaving no accurate accounting of controlled drug receipt, use, wasting, or destruction for these residents.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an injury of unknown origin was reported to the appropriate agencies immediately, but not later than 2 hours after the injury was noted, as required by both federal and state regulations. The facility's own policy mandates immediate reporting of any incident or suspected incident of resident abuse, neglect, or injuries of unknown source to the Abuse Coordinator and appropriate state agencies. In this case, a resident with severe cognitive impairment and significant physical dependencies was found to have multiple bruises, abrasions, and ultimately, bilateral displaced femur fractures of unknown origin. Despite the presence of these injuries and escalating pain, there was no timely report made to the state agency as required. The resident, who was non-ambulatory and dependent on staff for all transfers and care, began exhibiting increased pain and spasms in her lower extremities. Over the course of several days, staff documented high pain scores, visible bruising, and excoriations, but did not initiate a report of suspected abuse or injury of unknown origin. Family members observed and documented multiple injuries and expressed concerns to staff, but these concerns were not escalated or reported as required. Medical providers and hospital staff later confirmed the presence of acute, displaced fractures and extensive bruising, with no clear explanation for the injuries. Interviews with facility staff, including the administrator and DON, revealed a lack of consensus or clarity regarding the cause of the injuries, with some attributing them to osteoporosis or immobility, despite medical opinions stating that an external force or trauma is required for such fractures. The facility's internal investigation was incomplete, lacking signed statements, a clear timeline, or thorough staff interviews. The administrator did not consider the injuries to be of unknown origin and therefore did not report them to the state agency, contrary to regulatory requirements. There was no evidence of staff education or corrective action in response to the incident at the time of the survey. The failure to report the injuries of unknown origin in a timely manner constituted a violation of both facility policy and federal/state regulations.
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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 Lebanon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lebanon Center For Rehabilitation And Healing, Llc | 2 mi | ★★★★★ | 0 | 0 |
| Pavilion-ths, Llc | 3.4 mi | ★★★★★ | 0 | 0 |
| Cedar Creek Post Acute | 13.4 mi | ★★★★★ | 0 | 0 |
| Hartsville Convalescent Center | 15 mi | ★★★★★ | 1 | 1 |
| The Waters Of Gallatin | 15.8 mi | ★★★★★ | 14 | 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.