Quality Center for Rehabilitation and Healing LLC

In the surveyor’s words

From the most serious findings on record at Quality Center for Rehabilitation and Healing LLC, in the surveyor’s own words.

• Actual harm, isolatedF684Aug 10, 2023

  Based on medical record review, hospital record review, facility document review, observation, and interview, the facility failed to adequately monitor and implement appropriate interventions for 1 of 1 (Resident #21) resident who was exhibiting self-mutilating behaviors. Between 6/23/2023 and 7/17/2023, Resident #1 began chewing on his fingers which resulted in infection and subsequent partial amputations on 7/18/2023. The facility's failure to adequately monitor and implement interventions resulted in harm. […]

• Actual harm, isolatedF689Mar 22, 2023

  Based on facility policy review, facility documentation review, medical record reviews, observations, and interviews, the facility failed to ensure each resident received adequate assistance devices for 3 out of 9 residents (Residents #9, #41, and #49) reviewed, which resulted in actual harm, (Resident #9 fractured femur and lacerations) and (Resident #41 increase physical pain and anguish) for 2 of the 9 residents. The findings include: Review of the facility's undated policy, Accidents and Incidents-Investigating and Reporting, revealed, .Accidents or incidents involving residents, employees, visitors, vendors, etc. […]

• No harm, potential for more than minimal, isolatedF726Jan 7, 2026

  Based on review of the National Library of Medicine article review, Black Box Warning review, the facility's Licensed Practical Nurse Job Description review, policy review, facility documentation review, medical record review, observation, and interview, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely for 2 of 4 (Resident #11 and #12) sampled residents. The findings include: 1. […]

• No harm, potential for more than minimal, isolatedF755Jan 7, 2026

  Based on facility policy review, Job Description review, medical record review, and interview the facility failed to provide pharmaceutical services that assured a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate account of medication destruction for 4 of 4 (Resident #8, #10, #11, and #12) sampled residents reviewed for drug destruction. The findings include: 1. Review of a facility policy titled, Emergency Medications, dated 4/2007, revealed .The facility shall maintain a supply of medications typically used in emergencies.The emergency medication supply will include medications that are needed in providing treatment in the immediate need per physician's order.Accessing the emergency medications supply requires 2 nurses to be… […]

• No harm, potential for more than minimal, isolatedF609Oct 2, 2025

  Based on facility policy review, medical record review, Emergency Medical Services (EMS) record review, Hospital record review, Facility investigation review, and interview, the facility failed to ensure an injury of unknown origin was reported to the appropriate agencies immediately, but not later than 2 hours after the injury was noted, for 1 of 11 (Resident #2) sampled residents reviewed for abuse. The findings include: 1. Review of the undated facility policy titled, Abuse Reporting, revealed, .All personnel.are required to immediately report any incident or suspected incident of resident abuse, neglect.including injuries of an unknown source.The incident will be reported to the Abuse Coordinator.FEDERAL REGULATION (42 CFR 483.13) requires the reporting of alleged violations of… […]