Willow Branch Health And Rehabilitation
415 Pace Street, McMinnville, TN 37110 · For profit - Limited Liability company · 140 certified beds · (931) 668-2011 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has 3 actual-harm citations
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- about 36% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.3% | 14.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.1% | 6.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.3% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.1% | 13.8% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 3.4% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 34.5% | 17.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 33.0% | 31.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 93.1% | 94.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.6% | 5.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 18.0% | 20.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 14.3% | 16.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 5.0% | 1.7% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 63.8% | 79.8% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 29.7% | 22.6% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.9% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.38 | 1.67 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.10 | 1.56 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
53.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 134 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 39.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 59 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 53.6%CMS range 45.7–63.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.3%CMS range 9.1–16.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 39.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 40.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 25.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 90.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.1%CMS range 3.8–11.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.09 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 140 beds and averages 84.3 residents a day — about 60% occupied, or roughly 56 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.30 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.79 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.93 hrs/resident/day on weekends vs 3.44 on weekdays — 15% thinner on weekends. RN hours go from 0.53 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
11 citations, most serious first — scroll within the box to see all.
- Actual harm · G2019-08-07 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to notify the physician and the resident's family after a fall, and failed to notify the physician of complaints of pain for 1 resident (#76) of 5 residents reviewed for falls, of 20 sampled residents. Resident #76 sustained pelvic fractures, which resulted in Harm. The findings include: Review of the facility's policy Accidents and Incidents, Investigating and Reporting, revised 7/2017, revealed, .all accidents or incidents involving residents .shall be investigated and reported to the Administrator .1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . Continued review revealed, .The following data, as applicable, shall be included on the Report of Incident/Accident form: .g. The time the injured person's Attending Physician was notified .the date/time the injured person's family was notified and by whom . Medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2019-08-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interviews, the facility failed to implement a care plan intervention to prevent falls for 2 residents (#12, #76) of 5 residents reviewed for falls. The facility's failure to implement a fall intervention resulted in actual Harm when Resident #12 and Resident #76 sustained fractures following a fall. The findings include: Review of the facility policy, Care Planning-Interdisciplinary Team revised on 9/2013 revealed .care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team . Medical record review revealed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Chronic Kidney Disease, Coronary Artery Disease, Gout, Hyperlipidemia, Vitamin D Deficiency, Vitamin B12 Deficiency, History of Falling, and Traumatic Brain Injury. Medical record review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2019-08-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to provide adequate supervision to prevent falls for 2 residents (#12, #76) of 5 residents reviewed for falls. Resident #12 sustained a right hip fracture and Resident #76 sustained pelvic fractures, which resulted in actual Harm to Residents #12 and #76. The findings include: Review of the facility policy Accidents and Incidents Investigating and Reporting, revised 7/2017, revealed, .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .The Nurse Supervisor/Charge Nurse .shall complete a Report of Incident/Accident form and submit .within 24 hours of the incident . Review of the facility policy Falls and Fall Risk, Managing, revised on 3/2018, revealed, .identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-04-30 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observations, and interviews, the facility failed to ensure the kitchen equipment and environment was maintained in a sanitary condition and failed to ensure a dietary aid wore a protective hair covering while working in the food preparation area which had the potential to affect 68 of 68 residents. The findings include: Review of the facility's policy titled, Equipment, dated 10/2019, revealed .center policy that all foodservice equipment is clean, sanitary .Dining Services Director ensures that all non-food contact equipment is clean . Review of the facility's policy titled, Staff Attire, dated 10/2019, revealed .the Dining Services Director insures [ensures] .all staff members .facial hair properly restrained . Review of the facility's policy titled, Equipment Cleaning Procedures, dated 7/2022, revealed .all dietary equipment and the environment are cleaned and sanitized in a manner that meets .federal regulations . all equipment should be cleaned as needed .Equipment that becomes soiled between scheduled cleanings must be properly cleaned and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-04-30 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews, the facility failed to maintain a comfortable, well-kept, and homelike environment on 4 of 4 hallways for 4 residents (Resident #7, Resident #15, Resident #39 and Resident #271) of 68 residents reviewed for a homelike environment. The findings include: Review of the facility's policy titled, Safe and Homelike Environment, revised 2/2025, revealed .the facility will provide a safe, clean, comfortable and homelike environment .any environment in the facility that is frequented by residents .rooms, bathrooms, hallways, dining areas .determination of homelike should include the resident's opinion of the living environment .physical environment that is neat and well-kept .maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to revise a comprehensive care plan to reflect the resident's current code status for 1 resident (Resident #46) of 20 residents reviewed for care planning. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 2/2024, revealed .The care planning process will include an assessment of the resident's strengths and needs and will incorporate the residents personal .preferences . Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including Hip Fracture, Compression Fracture, and Diabetes. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #46 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the comprehensive care plan for Resident #46 dated [DATE], revealed .Advanced Directives .Full Code .Resident advanced directives…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-30 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, and interview the facility failed to store an insulin pen appropriately for 1 resident (Resident #3) of 3 residents reviewed for medications on 1 medication cart (200 hall medication cart) of 2 medication carts observed for medication storage. The findings include: Review of the facility's policy titled, Medication storage, revised 2/2025, revealed .all medications housed on our premises will be stored in accordance to the manufacturer's recommendations and ensure proper .temperature .all medications requiring refrigeration are stored in refrigerators . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes, and Obesity. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Review of a Physician's Order for Resident #3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-30 · tag F0838 — failed to assess facility resources and resident needs — isolatedConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observations, and interviews the facility failed to ensure the languages used by residents in the facility assessment was accurate to include sign language for 1 resident (Resident #12) of 17 residents reviewed. The findings include: Review of the facility's policy titled, Facility Assessment, dated 8/2024, revealed .a facility-wide assessment to determine what resources are necessary to care for our residents competently during both day-to-day operations .and emergencies .The facility assessment will at minimum address or include .the care required by the resident population .that consider the types of diseases, conditions .and other pertinent facts that are present within that population . Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Developmental Disorder of Speech and Language, Nonspeaking Deafness, and Weakness. Review of a 5-day admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-23 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy reviews, observations, and interviews, the facility failed to ensure infection control practices were followed for 3 of 8 rooms observed for transmission-based precautions and the facility staff failed to perform hand hygiene during meal tray delivery observations for 2 of 5 hallways observed for dining. The findings include: Review of the isolation signage, undated, posted on the quarantine resident rooms showed, .For all staff Contact Precautions in addition to Standard Precautions Before entering room .Perform hand hygiene .Put on gown or apron .Put on gloves . Review of the facility's policy titled, .Infection Prevention and Control Program ., dated 9/2/2020, showed .Standard Precautions .Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures . Review of the facility's policy titled, .Hand Hygiene ., dated 3/24/2021, showed .All staff will perform proper hand hygiene procedures to prevent the spread of infection .Between resident contacts After handling contaminated objects .during resident care . During an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement a care plan with an appropriate interventions after a fall for 2 residents (#29, #251) of 14 residents reviewed for falls. The finding included: Resident #29 was admitted to the facility on [DATE] with diagnoses including Heart Disease, Major Depressive Disorder, and Anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 scored an 8 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required limited assistance of 1 staff member for bed mobility and transfer. Review of the facility Post Fall Review dated 1/18/2022 revealed Resident #29 had a fall without injury on 1/18/2022. Continued review showed the intervention implemented after the fall to prevent future falls was to instruct the resident to push the call bell for assistance. Review of the Care Plan updated 1/18/2022 revealed Resident #29 was at risk for falls related to Psychotropic Medication, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2019-08-07 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility policy review, observation, and interview, the facility failed to ensure outdated food items were not available for resident use; failed to ensure personal items were not stored with clean food supplies and food; and failed to provide sanitary ice handling practices in 1 of 1 kitchen, potentially affecting 85 of 85 residents. The findings include: Review of the facility policy, Dry Storage Chart, revised 5/12/16 revealed .follow manufacturer's directions and expiration dates .Expiration dates supersede these guidelines . Review of the facility policy, Food Preparation and Service, revised 10/2017, revealed .Food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices .Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness . Observation with the Dietary Manager (DM) on 8/5/19 at 11:14 AM, in the food storage room, revealed on the bread storage racks, on the clean food supply storage rack: A) Three twelve packs of hamburger buns with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to SIMCHA HYMAN & NAFTALI ZANZIPER — 79 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.6 | -0.6 vs chain |
| Health inspection | 3 of 5 | 2.7 | +0.3 vs chain |
| Staffing | 1 of 5 | 2.2 | -1.2 vs chain |
| Quality measures | 2 of 5 | 3.4 | -1.4 vs chain |
The other 78 homes this chain runs (chain average 2.6★, per CMS)
Showing 40 of 78; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SWEET HOME MANAGEMENT LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/01/2021 |
| VUJANOVIC, MICK | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2020 |
| KIRBY, HOMER | Individual | MANAGING CONTROL - GOVERNING BODY; ADP OF THE SNF | since 12/01/2021 |
| CLEARVIEW HEALTHCARE MANAGEMENT TN LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/04/2026 |
| COPE, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/07/2025 |
| HC FAMILY TRUST | Organization | ADP OF THE SNF | since 12/01/2021 |
| ZANZIPER FAMILY TRUST | Organization | ADP OF THE SNF | since 12/01/2021 |
CMS files one row per role, so the 13 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.8M paid to related parties — landlords or management companies under common ownership — equal to about 36% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in TN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Tennessee Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 445216. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.