Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 1, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to protect residents from neglect and abuse, specifically related to inadequate neurological assessments and monitoring after seizure activity for Resident #3, and failure to timely collect laboratory specimens for Resident #4 experiencing hematuria.
Complaint Details
The complaint investigation substantiated immediate jeopardy related to neglect in failure to perform neurological assessments and monitoring after seizure activity for Resident #3, and failure to timely collect laboratory specimens for Resident #4. The immediate jeopardy was removed after the facility implemented a removal plan including staff in-service training and monitoring compliance.
Findings
The facility failed to perform neurological assessments and monitoring after seizure activity for Resident #3, resulting in immediate jeopardy and subsequent resident death. The facility also failed to timely collect a urinalysis with culture and sensitivity for Resident #4, leading to delayed treatment of a urinary tract infection and hospitalization. Additionally, the facility failed to ensure licensed nurses had appropriate competencies to detect changes in condition and perform necessary assessments.
Deficiencies (3)
Failure to protect residents from all types of abuse including neglect, specifically failure to perform neurological assessments and monitoring after seizure activity.
Failure to timely collect laboratory specimens and notify physician regarding Resident #4's hematuria and subsequent decline.
Failure to ensure nurses and nurse aides have appropriate competencies to care for residents, including performing neurological assessments and monitoring after changes in condition.
Report Facts
Residents reviewed: 5
Residents affected: 2
Neuro-check frequency: 4
Neuro-check frequency: 4
Neuro-check frequency: 5
Neuro-check frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Named in failure to perform neurological assessments and documentation after Resident #3's seizure activity |
| RN A | Registered Nurse | Named in failure to perform neurological assessments and monitoring during shift for Resident #3 |
| RN D | Unit Manager | Named in failure to recall neurological assessments performed post seizure for Resident #3 |
| Director of Nursing | Director of Nursing | Confirmed required nursing actions post seizure and failure of staff to perform neuro assessments |
| Medical Director | Medical Director | Confirmed unacceptable staff documentation and monitoring post seizure activity |
| Nurse Practitioner | Nurse Practitioner | Confirmed lack of communication and monitoring regarding Resident #3's seizure activity |
| Administrator | Administrator | Confirmed staff responsibilities and failure to implement care plans for neurological monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Oct 22, 2021
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident dignity, supervision, wandering, elopement, and medication and safety practices.
Complaint Details
The complaint investigation was triggered by allegations of failure to maintain resident dignity, inadequate supervision leading to elopement, failure to investigate incidents properly, and medication and safety concerns. Immediate Jeopardy was cited due to the elopement of Resident #338 who was found off the facility property unsupervised for approximately 39 minutes.
Findings
The facility failed to maintain resident dignity during care, failed to supervise a confused resident who eloped from the facility, failed to thoroughly investigate the elopement incident, failed to ensure availability and monitoring of Wander Guard devices for residents at risk of elopement, failed to provide appropriate respiratory care by not dating oxygen tubing, and failed to properly label and store medications. Immediate Jeopardy was cited related to resident elopement and supervision failures.
Deficiencies (7)
Failed to ensure staff maintained resident dignity by knocking before entering rooms and addressing residents respectfully during dining.
Failed to supervise a resident with confusion and hallucinations who eloped from the facility and was found off property unsupervised for approximately 39 minutes.
Failed to thoroughly investigate incidents of elopement, including obtaining witness statements and documenting findings.
Failed to provide adequate supervision and monitoring of residents with wandering behaviors and failed to ensure availability and use of Wander Guard devices.
Failed to provide necessary respiratory care when oxygen tubing was not dated or changed weekly for 5 sampled residents.
Failed to ensure medications were labeled and stored appropriately; undated, open, and expired medications were observed and medications were left unattended during administration.
Failed to administer the facility in a manner that effectively and efficiently used resources to protect residents from elopement and wandering risks, including failure of administration to provide oversight and ensure policies were followed.
Report Facts
Residents observed during dignity deficiency: 13
Staff involved in dignity deficiency: 9
Residents affected by dignity deficiency: 13
Distance resident eloped: 459.5
Time resident was unsupervised outside facility: 39
Residents reviewed for wandering and elopement: 6
Residents reviewed for oxygen therapy: 6
Expired Vancomycin vials: 7
Expired Meropenem vials: 16
Residents reviewed for medication pass: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Nurse on duty when Resident #338 eloped; provided witness statement |
| LPN #3 | Licensed Practical Nurse | Nurse on duty when Resident #338 attempted to exit on 9/29/2021 |
| LPN #2 | Licensed Practical Nurse | Left medications unattended during medication pass for Resident #343 |
| Director of Nursing | Director of Nursing (DON) | Confirmed policies and incidents related to Resident #338 elopement and oxygen tubing |
| Executive Director | Executive Director | Facility administrator involved in oversight and investigation of Resident #338 elopement |
| Social Service Director | Social Service Director | Responsible for Wander Guard administration and involved in elopement response |
| Maintenance Director | Maintenance Director | Responsible for door checks and responded to elopement incident |
| Registered Dietician | Registered Dietician (RD) | Witnessed Resident #338 outside facility during elopement incident |
| Pharmacy Consultant | Pharmacy Consultant | Confirmed medication storage requirements |
| RN #1 | Registered Nurse | Confirmed oxygen tubing was not dated for residents |
| [NAME] President | President of Operations | Provided in-service education and oversight for elopement investigations |
Inspection Report
Routine
Deficiencies: 7
Date: Feb 21, 2020
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal nursing home regulations, including resident assessments, care, safety, staffing, medication management, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to timely transmit resident assessments, inaccurate resident assessments, failure to implement fall prevention interventions, inadequate catheter care documentation, incomplete nurse staffing postings, lack of monitoring for psychotropic medication side effects, and lapses in infection prevention and control practices.
Deficiencies (7)
Failure to complete and transmit an MDS assessment within 14 days of completion for 1 of 38 sampled residents.
Failure to accurately assess residents for bladder and bowel continence, activities of daily living, cognition, and use of antipsychotics for 4 of 38 sampled residents.
Failure to implement fall interventions for 2 of 5 sampled residents reviewed for falls.
Failure to provide care and services to maintain an indwelling urinary catheter for 1 of 2 sampled residents reviewed.
Failure to document total number of actual hours worked by nursing staff on staffing postings and failure to have postings available for 24 of 76 days reviewed.
Failure to ensure residents receiving psychotropic medications were appropriately monitored for side effects and behaviors for 5 of 7 sampled residents.
Failure to ensure infection prevention practices were followed in isolation rooms and during medication administration, including hand hygiene, cleaning of equipment, and protection of feeding tube tips.
Report Facts
Sampled residents for Resident Assessment and transmission: 38
Residents affected by failure to transmit MDS: 1
Residents affected by inaccurate assessments: 4
Residents affected by failure to implement fall interventions: 2
Residents affected by failure to maintain indwelling urinary catheter care: 1
Days with missing or incomplete staffing postings: 24
Residents affected by lack of psychotropic medication monitoring: 5
Isolation rooms with infection control lapses: 2
Nurses with infection control lapses: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator #1 | Interviewed regarding failure to transmit Resident #2's MDS and incomplete cognitive assessment for Resident #87 | |
| MDS Coordinator #2 | Interviewed regarding failure to transmit Resident #2's MDS, inaccurate assessments for Residents #10 and #104 | |
| MDS Coordinator #3 | Interviewed regarding inaccurate assessment for Resident #62 | |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Confirmed no dycem in Resident #71's wheelchair |
| Licensed Practical Nurse (LPN) #2 | Licensed Practical Nurse | Confirmed no landing mat in Resident #71's room and acknowledged care plan interventions |
| Interim Director of Nursing | Interim Director of Nursing | Confirmed catheter care documentation deficiencies and infection control lapses |
| Director of Nursing | Director of Nursing | Confirmed staffing posting inaccuracies and infection control lapses |
| Interim Infection Control Preventionist | Interim Infection Control Preventionist | Confirmed lack of psychotropic medication monitoring and infection control deficiencies |
| Interim Staff Development Coordinator | Interim Staff Development Coordinator | Confirmed lack of psychotropic medication side effect and behavior monitoring |
| Certified Nursing Assistant (CNA) #1 | Certified Nursing Assistant | Observed entering isolation room without PPE |
| Licensed Practical Nurse (LPN) #3 | Licensed Practical Nurse | Observed failing hand hygiene and infection control during medication administration |
| Licensed Practical Nurse (LPN) #4 | Licensed Practical Nurse | Observed failing to clean stethoscope and protect PEG tube tip during medication administration |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Apr 3, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, and data transmission as part of the annual survey of Quince Nursing and Rehabilitation Center, LLC.
Findings
The facility failed to complete comprehensive resident assessments (admission, annual, and quarterly) within required timeframes for multiple residents, failed to timely transmit assessment data to the state for two residents, and failed to develop a comprehensive care plan for one resident. Interviews with MDS Coordinators and the Director of Nursing confirmed these deficiencies.
Deficiencies (4)
Failed to complete comprehensive assessments using the CMS-specified RAI process within regulatory time frames for 9 of 53 sampled residents.
Failed to complete quarterly assessments within regulatory time frames for 19 of 53 sampled residents.
Failed to complete and transmit MDS assessments timely for 2 of 53 residents reviewed for Resident Assessment and transmission.
Failed to develop and implement a comprehensive care plan for 1 of 33 sampled residents.
Report Facts
Residents reviewed for assessment timeliness: 53
Residents with untimely assessments: 9
Residents with untimely quarterly assessments: 19
Residents reviewed for assessment transmission: 53
Residents with untimely transmission: 2
Residents reviewed for care plan completeness: 33
Residents without comprehensive care plan: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator #1 | Confirmed Resident #1's admission assessment was not completed timely and discussed untimely transmission of discharge assessments. | |
| MDS Coordinator #2 | Confirmed multiple residents' MDS assessments were not completed timely and confirmed untimely transmission and scheduling issues. | |
| Director of Nursing | Director of Nursing (DON) | Confirmed expectation that MDS assessments be completed and transmitted timely. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Confirmed Resident #171 did not have a comprehensive care plan. |
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