Claiborne Health And Rehabilitation Center

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Human Resources (HR) Manager stated he reviewed video surveillance of the incident with security which showed CNA A securing Resident #15's legs with a blanket/towel. The HR Manager stated the video showed the resident moved both legs from side to side but could not move one leg without the other. The HR Manager stated CNA A was interviewed and reported she did not consider it bounding, just tucked. The HR Manager stated .If you look at the video it was more than a tuck .During an interview on 11/19/2025 at 2:15 PM, the Administrator stated the surveillance video showed CNA A wrapping and tucking Resident #15's lower legs with a sheet and covered her legs with a blanket. The Administrator stated Resident #15 was able to move her feet and wiggle her toes. The Administrator reported CNA A stated she wanted to make sure the resident was comfortable because she was constantly moving her legs and she didn't want her to fall. The Administrator stated Resident #15's legs were .wrapped . and the ends of the sheet were tucked in .it wasn't tied .it was tucked .During review of video surveillance and interview on 11/20/2025 at 11:20 AM, the Quality and Regulation Manager was asked if she considered wrapping Resident #15's legs with sheets a restraint. The Quality and Regulation Manager replied .No . because the resident's movement of her legs and feet were unchanged. The Quality and Regulation Manager was asked if she would consider wrapping resident legs with sheets a restraint for a resident who moved their legs independent of each other. The Quality and Regulation Manager replied .Yes . When asked if she would want her legs to be wrapped such as Resident #15's legs were wrapped the Quality and Regulation Manager replied .No .During a telephone interview on 11/20/2025 at 11:43 AM, CNA A stated Resident #15 liked to kick her blankets off and throw them on the floor and stated the resident had kicked her blanket off several times.

CNA A stated it was like playing a game with a toddler. CNA A reported another resident had tried to pick

the blanket up and stated .I was afraid the other resident was going to fall .I took a sheet and wrapped it around the bottom part of the legs [Resident #15's legs] to keep her from kicking it [blanket] off, so no one else fell over it. I had saw other people tuck the blanket under her legs. I had folded it [sheet] and placed it over her legs and tucked under . CNA A stated she did not consider her actions a restraint.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Claiborne Health and Rehabilitation Center

1850 Old Knoxville Road Tazewell, TN 37879

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

next day and the resident's daughter stated, .no, because momma thinks someone sexually touched her .momma thinks it real, and we just want to take her home . The SW confirmed she did not notify administration of the allegation because the family blew it off and the resident's daughter stated she did not want to file a complaint. The SW stated she became aware an allegation of sexual assault against Resident #83 had been reported to the local police department. It was at this time the SW notified the Administrator.

During an interview on 11/20/2025 at 9:07 AM, the RN MDS Coordinator stated on 11/3/2025, Resident #83's daughters came into the MDS and SW office stating they wanted to take their mother home because

she thought someone had touched her inappropriately while she was sleeping. The resident's daughters stated the resident was scared and they want to take her home. RN MDS Coordinator further stated family said she might have been dreaming. RN MDS Coordinator stated at some point the Assistant Director of Nursing (ADON) came into the office and was informed of the dream Resident #83 had. The RN MDS Coordinator stated she did not hear anything else until the police department notified the facility of the allegation of sexual assault. During an interview on 11/20/2025 at 10:26 AM, the Administrator (ADM) stated she was not aware of the alleged of sexual assault for Resident #83 which reportedly occurred 11/2/2025 until the police notified the facility on 11/12/2025. The Administrator confirmed facility staff had knowledge of the allegation of sexual assault prior to receiving notification from the local police department

on 11/12/2025.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Claiborne Health and Rehabilitation Center

1850 Old Knoxville Road Tazewell, TN 37879

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

was true. CNA G stopped what she was doing and went and informed her nurse RN H since there was no management in the building to report to. CNA G stated she did not hear anything else about it until a couple weeks later when she was being questioned by management. CNA G further stated she did not notify anyone else of the alleged allegations. During an interview on 11/19/2025 at 9:33 AM, Registered Nurse (RN) H stated on 11/1/2025 or 11/2/2025, CNA G informed her at the nurse's station around end of shift that Resident #83's daughter was asking if her mom had a vaginal exam. RN H went and talked to the daughter who stated she thought her mom had a bad dream and was confused but just wanted to make sure. RN H further stated she thought CNA G notified the Director of Nursing (DON) of the allegation. RN H stated she did not hear anything else about incident until a couple weeks later.During an interview on 11/20/2025 at 8:30 AM, the SW stated she became aware of the allegations on 11/3/2025, when Resident #83's daughter came to her office to discuss Resident #83's discharge stating they wanted the resident discharged that day. The SW stated she asked if she could wait until the next day and the resident's daughter stated, .no, because momma thinks someone sexually touched her .momma thinks it real, and we just want to take her home . The SW confirmed she did not notify administration of the allegation because

the family blew it off and the resident's daughter stated she did not want to file a complaint. The SW stated

she became aware an allegation of sexual assault against Resident #83 had been reported to the local police department. It was at this time the SW notified the Administrator. During an interview on 11/20/2025 at 9:07 AM, the RN MDS Coordinator stated on 11/3/2025, Resident #83's daughters came into the MDS and SW office stating they wanted to take their mother home because she thought someone had touched her inappropriately while she was sleeping. The resident's daughters stated the resident was scared and

they want to take her home. RN MDS Coordinator further stated family said she might have been dreaming.

RN MDS Coordinator stated at some point the Assistant Director of Nursing (ADON) came into the office and was informed of the dream Resident #83 had. The RN MDS Coordinator stated she did not hear anything else until the police department notified the facility of the allegation of sexual assault. During an

interview on 11/20/2025 at 10:26 AM, the Administrator (ADM) confirmed facility staff became aware of the allegation of sexual assault for Resident #83 on 11/3/2025 but failed to report the allegation to the facility's Abuse Coordinator. The ADM confirmed the facility did not initiate an investigation until 11/12/2025 (9 days

after the allegation was reported to facility staff).

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