Inspection Reports for Willow Branch Health and Rehabilitation
415 Pace St, McMinnville, TN 37110, United States, TN, 37110
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
16% better than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Census: 68
Deficiencies: 5
Date: Apr 30, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility environment, medication storage, care planning, food service sanitation, and facility-wide assessments.
Findings
The facility was found deficient in maintaining a homelike environment for residents, revising care plans to reflect current code status, proper medication storage, sanitary kitchen conditions, and accurate facility-wide assessments including resident communication needs.
Deficiencies (5)
Failed to maintain a comfortable, well-kept, and homelike environment on 4 of 4 hallways for 4 residents.
Failed to revise a comprehensive care plan to reflect the resident's current code status for 1 resident.
Failed to store an insulin pen appropriately for 1 resident on 1 medication cart.
Failed to ensure kitchen equipment and environment was maintained in a sanitary condition and failed to ensure a dietary aid wore a protective hair covering.
Failed to ensure the languages used by residents in the facility assessment was accurate to include sign language for 1 resident.
Report Facts
Residents reviewed for homelike environment: 68
Residents affected by homelike environment deficiency: 4
Residents reviewed for care planning: 20
Residents affected by care planning deficiency: 1
Residents reviewed for medication storage: 3
Residents affected by medication storage deficiency: 1
Residents affected by kitchen sanitation deficiency: 68
Residents reviewed for facility assessment: 17
Residents affected by facility assessment deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Named in medication storage deficiency and communication with Resident #12. |
| Director of Nursing | Director of Nursing | Confirmed medication storage deficiency and communication with Resident #12. |
| Certified Dietary Manager | Certified Dietary Manager | Observed kitchen sanitation deficiencies and dietary aide attire. |
| Dietary Aide A | Dietary Aide | Observed not wearing facial hair covering during food preparation. |
| Maintenance Director | Maintenance Director | Confirmed facility environment deficiencies and kitchen sanitation issues. |
| Care Plan Coordinator | Care Plan Coordinator | Confirmed care plan deficiency for Resident #46. |
| Certified Nursing Assistant C | Certified Nursing Assistant | Communicated with Resident #12 using sign language. |
| Administrator | Administrator | Verified communication method for Resident #12 and facility assessment deficiency. |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 23, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations related to accident hazard prevention, infection control practices, and appropriate care interventions following resident falls.
Findings
The facility failed to implement appropriate care plan interventions after falls for cognitively impaired residents, specifically instructing them to use call bells. Additionally, infection control practices were not consistently followed, including failure to don PPE in isolation rooms and inadequate hand hygiene during meal tray delivery.
Deficiencies (2)
Failed to implement appropriate care plan interventions after falls for 2 residents, instructing cognitively impaired residents to use call bells.
Failed to ensure infection control practices were followed for 3 of 8 rooms observed for transmission-based precautions and failed hand hygiene during meal tray delivery observations.
Report Facts
Residents reviewed for falls: 14
Rooms observed for transmission-based precautions: 8
Hallways observed for dining: 5
Residents affected by fall intervention deficiency: 2
Residents affected by infection control deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed inappropriate fall intervention and infection control deficiencies |
| Speech Therapist | Speech Therapist (ST) | Observed entering isolation room without PPE and with face mask under nose |
| CNA #4 | Certified Nursing Assistant | Failed to don PPE before entering isolation room |
| LPN #2 | Licensed Practical Nurse | Confirmed PPE requirements for isolation rooms |
| Social Worker | Social Worker (SW) | Observed without PPE in isolation room |
| CNA #2 | Certified Nursing Assistant | Observed failing to perform hand hygiene between meal tray deliveries and patient care |
| LPN #3 | Licensed Practical Nurse | Observed failing to perform hand hygiene during meal tray delivery |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 7, 2019
Visit Reason
The inspection was conducted due to complaints regarding failure to notify physicians and families after resident falls, failure to implement fall prevention care plans, and inadequate supervision to prevent falls.
Complaint Details
The complaint investigation revealed failures in notification after falls, implementation of fall prevention care plans, supervision to prevent falls, and sanitary food handling practices.
Findings
The facility failed to notify the physician and family after a resident fall resulting in pelvic fractures, failed to implement fall prevention interventions for two residents leading to fractures, and failed to provide adequate supervision to prevent falls. Additionally, the facility failed to maintain sanitary food handling practices in the kitchen.
Deficiencies (4)
Failed to notify physician and family after a fall and complaints of pain for Resident #76, resulting in pelvic fractures.
Failed to implement a care plan intervention to prevent falls for Residents #12 and #76, resulting in fractures.
Failed to provide adequate supervision to prevent falls for Residents #12 and #76, resulting in fractures.
Failed to ensure outdated food items were discarded, personal items were separated from food supplies, and sanitary ice handling practices were followed in the kitchen.
Report Facts
Residents reviewed for falls: 5
Residents affected by fall-related deficiencies: 2
Residents affected by food safety deficiency: 85
Date of fall: Jul 4, 2019
Date of survey completion: Aug 7, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Failed to notify physician and family of Resident #76's fall and complaints of pain; failed to initiate fall investigation and implement interventions. |
| LPN #3 | Licensed Practical Nurse | Confirmed fall intervention of Dycem pad was not in place at time of Resident #12's fall. |
| LPN #4 | Licensed Practical Nurse | Was not aware of Resident #76's fall interventions. |
| CNA #2 | Certified Nursing Assistant | Was not aware of Resident #76's fall interventions. |
| Quality Assurance Registered Nurse (RN) #1 | Quality Assurance Registered Nurse | Confirmed failures in notification and fall intervention implementation for Resident #76. |
| Director of Nursing | Director of Nursing | Confirmed failures to notify physician and family, implement fall interventions, and supervise residents to prevent falls. |
| Physical Therapist Manager | Physical Therapist Manager | Confirmed failure to implement Dycem pad intervention resulting in Resident #12's fall and fracture. |
| Dietary Manager | Dietary Manager | Confirmed failures in discarding expired food, separating personal items from food supplies, and sanitary ice handling. |
| Dietary Aide #1 | Dietary Aide | Observed handling ice in an unsafe and unsanitary manner. |
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