Willow Branch Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Willow Branch Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF609Jun 3, 2022

  Based on review of a facility policy, medical record review, review of facility incident reports, interviews, and review of facility documentation, the facility failed to report to the State Survey Agency (SSA) an incident of abuse for 1 resident (#6), a cognitively impaired resident who was observed with his hands tied inside his shirt by his shirt sleeves; failed to report injuries of unknown origin for 3 residents (#6, #5, #10) when Resident #6 was observed with multiple bruises to the forearms, Resident #5 was found to have a bruise on the lip, left forearm, and across chest; and Resident #10 had a bruise to the back requiring an X-ray; and failed to report allegations of abuse for 4 residents (#6, #5, #7, #13) of 12 residents reviewed. […]

• Immediate jeopardy, patternF610Jun 3, 2022

  Based on review of a facility policy, medical record review, review of facility incident reports, interview, and review of facility documentation, the facility failed to investigate allegations of physical abuse for 2 residents (#6 and #7) when Resident #6 was observed with his hands tied inside his shirt by his shirt sleeves and Resident #7 was observed being pushed by CNA #1; failed to investigate injuries of unknown origin for 3 residents (#6, #5, #10) when Resident #6 was found with bruising to his arms, Resident #5 was found with a bruise on the lip, left forearm, and across the chest, and Resident #10 had a bruise to the back requiring an X-ray; and failed to investigate an allegation of sexual abuse for 1 resident (#13) of 12 residents reviewed. […]

• Immediate jeopardy, patternF865Jun 3, 2022

  Based on review of a facility policy, review of facility incident reports, medical record review, and interviews, the Quality Assurance Performance Improvement committee failed to identify and correct deficiencies for facility failure of reporting and investigation of abuse and injuries of unknown origin for 5 residents (#6, #5, #10, #7, #13) of 12 residents reviewed. The facility's placed Residents #6, #7, #5, #10, and #13 in immediate jeopardy (IJ) (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator and Director of Nursing were notified of the Immediate Jeopardy on 6/2/2022 at 5:55 PM. […]

• Immediate jeopardy, isolatedF600Jun 3, 2022

  Based on review of a facility policy, medical record review, review of facility incident reports, interview, and observation of photographs, the facility failed to prevent abuse for 2 residents (#6, #13) of 12 residents reviewed. Resident #6 was a cognitively impaired resident who was found with his hands tied in his shirt sleeves. Resident #13 was the victim of sexual abuse perpetrated by Resident #9. The facility's failure to prevent abuse of Resident #6 placed Resident #6 in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). […]

• Immediate jeopardy, isolatedF604Jun 3, 2022

  Based on review of a facility policy, medical record review, interviews, and observation of photographs, the facility failed to ensure 1 resident (#6) of 12 residents reviewed was free from physical restraints used for staff convenience when the resident was observed on 4/3/2022 by 2 staff members with his shirt sleeves tied together with his hands inside. The facility's failure to ensure a resident was free from restraints used for staff convenience placed Resident #6 in Immediate Jeopardy (IJ) (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). […]