Quality Center Rehab: Abuse Reporting Failure - TN
The resident suffered bilateral leg fractures on May 5, 2024, at Quality Center for Rehabilitation and Healing. Emergency medical services told the hospital that the patient "complained of pain after using the lift to get her up to a chair."
The facility's investigation consisted of typed statements that staff members never signed. When inspectors asked the administrator why staff didn't sign the statements, she responded: "They don't sign it."
No timeline was created. No staff members were questioned in person about what they witnessed.
The administrator told inspectors the incident was "pathological, no way to pinpoint" and claimed she "did not believe it was an injury of unknown origin." When asked if such injuries should be reported to the state agency, she acknowledged: "Report within 2 hours." No report was filed.
The resident arrived at the hospital as a Level 1 trauma activation around 5:05 AM with systolic blood pressure in the 80s. Dr. MD #3, the admitting physician, said the facility provided no information about how the injuries occurred.
"I was not notified by the facility which is not uncommon," Dr. MD #3 told inspectors during an October videoconference. "EMS told me patient complained of pain after using the lift to get her up to a chair. She was confused and she couldn't tell me what happened."
The physician found "pain and tenderness in her lower extremities" during his 20-30 minute examination before trauma services took over her care.
When inspectors asked Dr. MD #3 when he normally sees bilateral leg fractures, he said: "Motor vehicle injuries or with a fall which can cause a force or stress to the bone."
The facility appeared to blame the resident's osteoporosis for the fractures. But Dr. MD #3 explained to inspectors: "Osteoporosis is a weakening of the bone but there has to be some type of external pressure or force that would lead to the fracture."
Dr. MD #2, who treated the resident during her hospital stay, told inspectors: "Nobody referring to staff at Facility #1 gave me evidence of really what happened. Terrible thing that this happened."
He described seeing significant injuries: "Sure her bones were not in alignment. There was a fair amount of swelling." When inspectors suggested the facility claimed the fractures were spontaneous, Dr. MD #2 responded: "I don't recall saying this was a spontaneous fracture. It is clear that I can't say what caused the injury."
The resident's family member questioned the injuries, according to Dr. MD #2. "I would have been angry Resident #2's injuries," the physician said, noting he saw the family member both at the hospital and during a follow-up appointment.
When inspectors asked the administrator what education was provided to staff after the incident, she replied: "Nothing in particular."
The facility's charge nurse policy, according to staff interviews, required calling the administrator, contacting on-call staff, notifying family, and completing a skin assessment when injuries occur. None of these steps appeared to include investigating how the injury happened.
The resident's fractures were healing by the time of the follow-up appointment, Dr. MD #2 confirmed. But the facility's failure to investigate left fundamental questions unanswered about what force caused both legs to break during what should have been a routine transfer.
Federal inspectors cited the facility for failing to ensure accidents and incidents were thoroughly analyzed and that corrective action was taken to prevent recurrence. The violation was classified as minimal harm with few residents affected.
The administrator's admission that there was "no way to pinpoint" what happened stands in stark contrast to the medical evidence that some external force was required to cause bilateral leg fractures, even in a resident with osteoporosis.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Quality Center For Rehabilitation and Healing LLC from 2025-10-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
QUALITY CENTER FOR REHABILITATION AND HEALING LLC in LEBANON, TN was cited for abuse-related violations during a health inspection on October 2, 2025.
The resident suffered bilateral leg fractures on May 5, 2024, at Quality Center for Rehabilitation and Healing.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.