Every finding on record at Advanced Health Care of Nashville

Based on policy review, National Weather Service website review, medical record review, facility video footage review, fall investigation documentation review, Facility Reportable Incident investigation review, hospital record review, observation and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent an incident of elopement for 1 of 3 (Resident #62) sampled residents reviewed for wandering/elopement risk. The facility's failure resulted in Immediate Jeopardy on Sunday 12/22/2024 at 7:04 PM, when Resident #62, a vulnerable and cognitively impaired resident with wandering behaviors, eloped from the facility in temperatures of 30 degrees Fahrenheit, without a coat or layered clothing, fell and was subsequently transferred back into his wheelchair by Certified Nursing Assistant (CNA) A prior to a nurse assessment. CNA A returned Resident #62 through the main front doors of the facility in his wheelchair. Resident #62 was transferred and admitted to the hospital where X-ray results revealed Resident #62 sustained an acute transcervical of left femoral neck fracture (a broken hip that happens at the middle part of the thigh below hip joint) and underwent a surgical repair on 12/24/2024. The facility's failure to supervise Resident #62 placed all residents with wandering behaviors in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, serious harm, serious impairment, or death to a resident. An Extended survey was conducted on 8/19/2026 through 8/20/2026. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 8/19/2026 at 5:20 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ began on 12/22/2024 and continued through 1/15/2025. The Immediate Jeopardy was removed on 1/16/2025. The IJ was removed onsite when the facility implemented a corrective action plan. The corrective actions were validated by the surveyor onsite on 8/20/2026. The IJ was cited as past noncompliance for F-689 and the facility is not required to submit a Plan of Correction. The findings include: 1.Review of the facility's policy titled, ELOPEMENT RISK, updated 2/12/2026, revealed .The facility will proactively identify, assess, monitor, and implement individualized interventions for patients at risk of elopement to ensure their safety, dignity, and well-being.Upon admission all patients will have an Elopement Risk Observation completed.For patients identified as moderate or high risk a care plan will be developed with individualized safety interventions. Review of the facility's policy titled, FALL PREVENTION, updated 10/28/2025, revealed .To ensure optimal patient safety while promoting patient independence and maximizing psychosocial well-being.Upon admission each patient will be evaluated for risk of falls utilizing the Fall Risk Observation.If the fall resulted in admission to facility, regardless of score the patient is a high risk.If a fall occurs in the facility an additional Fall Risk Observation will be completed by the Licensed Nurse .The fall will be reviewed by the IDT [Interdisciplinary Team] Team . Review of the facility's undated policy titled, ACCIDENT AND INCIDENT, revealed .Any unusual occurrence or event that may compromise the safety, health or abilities of the patient, staff or others is to be promptly reported so that appropriate action may be taken to protect the health and safety of all concerned.The first responder, witness or inadvertent participant in an accident or incident will ensure immediate safety of those involved.Patients found lying on the floor or other incapacitated position will not be moved until assessed by a Nurse assigned and he/she has provided instruction to do so.The Nurse assigned to the patient at the time of the incident will be immediately notified to perform a physical assessment of patient's condition and take action to direct further monitoring and/or treatment .The nurse shall assess the patient for changes in condition and/or injury related to the incident. Assessment includes but not limited to.Pain.abnormal alignment.swelling.Range of motion. Review of the facility's policy titled, MAINTENANCE OF EQUIPMENT, updated 7/25/2023, revealed .The facility performs routine tests. Checks and maintenance for all equipment.Preventative maintenance records are maintained for all equipment directly related to the health and safety of patients/residents. 2. Review of the National Weather Service.gov website dated 12/22/2024, revealed the temperature was approximately 30 degrees Fahrenheit at 7:00 PM in Nashville, Tennessee. 3. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses including Intracapsular Fracture of Left Femur (left hip fracture), Fracture of Neck of Right Femur, Urinary Tract Infection, Dementia, Hallucinations, Depression, and Falls. Review of the Care Plan for Resident #62 updated 11/14/2024, revealed .Falls .Patient identified at risk for falls related to .History of recurrent falls .Mobility and/or functional deficits .Poor safety awareness .Balance deficits . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #62 scored a 3 on the Brief Interview for Mental Status assessment, which indicate he was severely cognitively impaired. Resident #62 had hallucinations, used a wheelchair for mobility, was not assessed for wandering behaviors or the use of a wander/elopement alarm, had 1 fall within last month, 1 fall in the last 2-6 months, and 1 fall with fracture related to fall in the last 6 months. Review of the Care Plan for Resident #62 updated 11/26/2024, revealed .Problem Start Date .11/26/2024 .Behavioral Problems .Patient wanders, moving with not rational purpose . Review of the Elopement Risk Evaluation & Care Plan for Resident #62 dated 11/27/2024 at 1:50 PM, revealed .Resident is cognitively impaired, poor decision-making skills, and/or pertinent diagnosis (Examples dementia.hallucinations.depression).displays behavior(s) that may indicate an attempt to leave, body language.indicating an elopement may be forthcoming.Elopement Care Plan initiated.Frequent checks.Resident guard device in place. Review of the Care Plan for Resident #62 updated 12/22/2024, revealed .Fall 12/22/2024 . Review of facility's video footage dated 12/22/2024 at 7:04:45 PM, revealed Resident #62 exited the facility through the Physical Therapy egress door exit. Resident #62 was dressed in a long sleeve shirt, pants and gym shoes without layers or coat, no gloves, and no hat. Resident #62 was seen hobbling (walking with an awkward, uneven motion) out of the door holding onto the door and building. At 7:05:09 PM, Resident #62 is seen disappearing around the corner of the building. At 7:05:38 PM, Certified Nursing Assistant (CNA) A responded to the exit alarm and was seen opening the physical therapy egress exit door and taking a few steps out of the door, still holding onto the door, looking around. At 7:06:05 PM, CNA A was observed pulling a wheelchair partially through the door to keep the door open. At 7:06:09 PM, CNA A was seen running towards the corner of the building. At 7:07:05 PM, CNA A walked back to the exit door and obtained Resident #62's wheelchair. At 7:07:11 PM, CNA A was seen disappearing around the corner of the building. On 12/22/2024 at 7:10:28 PM, CNA A was observed bringing Resident #62 through the main front doors in his wheelchair. Review of the facility's Safety Events Fall Incident Event, Risk Observation & Care Plan Update with Event Date of 12/22/2024 at 7:00 PM and a Completion date of 12/23/2024 at 5:04 PM, revealed, .Witnessed Fall.Outside on Facility Grounds.Resident [#62] description Went outside to pee.What was resident doing prior to fall: Sitting at fireplace in wheelchair .Witnessed.[Named CNA A].ALL staff members who responded to fall [Named CNA A].was outside the door of the facility .Does resident exhibit or complain of pain RELATED TO THE FALL: Yes (location) LLE [Left Lower Extremity].level 4 - moderate - distressing, Miserable.pt [patient/Resident #62] stated I am sore.ROM [Range of Motion] painful/limited in lower extremity .no Rotation/deformity/shortening Noted.Alert Wakefulness- Perceives the environment clearly and responds appropriately to stimuli.Left Lower Extremity Movement: weak.Interventions Ineffective: Resident was unable to stay in bed with leg elevated.balance problem.Requires use of assistive device: wheelchair.Active orders: Anesthetics.Narcotics.Psychoactive (anti-depressants, anti-psychotics).Predisposing disease: Osteoporosis.Fractures.Fall Risk Score: 15 Moderate Risk.Physician notified: 12/22/2024 20:05 [8:05 PM]. Resident Representative notified 12/22/2024 19:30 [7:30 PM]. Review of the facility's Safety Events Elopement Incident report with Event Date of 12/22/2024 at 6:25 PM and a completion date of 12/26/2024 at 5:03 PM, revealed .Description .Fall/Elopement .When and where was resident found .Outside the PT [Physical Therapy] gym door.Did resident sustain any injury during elopement period .Yes, patient fell from a standing position while urinating.INTERVENTIONS.Door Alarm Band Applied .Wander guard [a discreet wearable device that tracks movement and triggers automatic security responses when a resident nears a restricted area].RESIDENT GUARD device in place. Verify placement QS [every shift]. Special Instructions: Elopement prevention order dated 12/23/2024. Review of the Nurses' Note dated 12/22/2024 at 7:04 PM (Recorded as Late Entry on 12/26/2024 at 4:50 PM), revealed the prior Director of Nursing (DON) documented, .Follow up -investigation .Patient [Resident #62] was sitting at the fireplace in the lobby according to staff before incident. [Named CNA A] heard the Wander-guard Alarm alerting at the nurses [nurse's] station. He walked to the alarm system to see where the open door was alarming. He Immediately noted that the alarm was going off in the PT gym. CNA [CNA A] walked to the gym where he noticed the wheelchair was sitting by the door. The door alarm was still sounding, and CNA [CNA A] was able to open the back door. CNA [CNA A] saw the Patient standing with his back to the wall next to the door urinating. When the CNA [CNA A] went to reach for the patient's wheelchair to help the patient back in, he dropped down and fell on his bottom. Patient was then helped to the room. Review of the Nurses' Note dated 12/22/2024 at 7:20 PM, (Recorded as Late Entry on 12/23/2024 at 12:57 AM), revealed licensed practical nurse (LPN) B documented, .Pt [Resident #62] reported by CNA [CNA A] to be found on the ground outside of facility behind Rehab [Physical Therapy] gym. CNA [CNA A] escorted resident [#62] back into facility via [by way of] w/c [wheelchair]. Vital signs and neuro [neurological] checks assessed and WNL [With in Normal Limits]. Pt [Patient] reports soreness. When ROM [Range of Motion] is attempted in LLE pt states The pain shoots down my leg. Review of the Nurses' Note dated 12/22/2024 at 9:18 PM, revealed the prior DON documented, .This Writer was called around 6:45pm [PM] stating the patient [Resident #62] had a fall. Writer conducted interview with staff noting that the patient was caught by the door on outside starting to urinate. While he was urinating, he lost his balance and crouched down and landed on his bottom before the CNA [CNA A] could get to him. The patient was then helped back in the chair, and it was reported to the nurse. Vital signs 143/77, Pulse 75, 98.1 oral temp, 94% [percent]. This writer preformed [performed] ROM on patient, he stated that his left hip was sore. Called on call provider there was no answer, instructed Agency nurse to give PRN [as needed] pain medication and order x ray of left hip. Will follow up with on-call provider through the night. Called and spoke with [Named Resident #64's son]. Explained to him what happened, I explained that he was complaining of pain and we will be obtaining an x ray. Floor nurse will continue to monitor and will follow up with me when x ray results are confirmed. Review of CNA A's handwritten witness statement (related to Resident #62's incidence of elopement) dated 12/22/2024, revealed I was in the breakroom when I had been alerted to the sound of an alarm. I looked down the hallways to see if someone/something had triggered it. I looked at the panel on the wall, and it was signaling from the rehab section of the building. I noticed a wheelchair had been left at the front of the door. I walked outside to find the patient [Resident #62] trying to urinate. Shortly there after [thereafter] falling from a crouched position, and onto his butt. No head contact was made. I then assisted said resident into wheelchair. Through the front door. End of statement. Review of CNA E's handwritten witness statement (related to Resident #62's incidence of elopement) dated 12/22/2024, revealed .at 645 [6:45 PM] [Named Resident #62] was sitting at the fire place [fireplace]. At 7:10 [7:10 PM] [Named CNA A] found resident out side [outside] on the floor [ground]. Resident was last checked at 645 [6:45 PM] when I placed him at the fire place [fireplace] Resident had on skid proof socks. Review of Nurses' Note dated 12/23/2024 at 12:59 AM, revealed .Pt [Resident #62] pain did not subside with PRN pain meds. Continues to climb out of bed and c/o [complaints of] pain shooting down left leg and when ROM is attempted. Emergency services contracted per instructions from On call provider. On call provider notified of pt sent out.[Named patients son] notified as well. Review of the Physician Order for Resident #62 dated 12/23/2024, revealed .Other Test: (X Ray of Left Hip). Review of the Incident Reporting System completed 12/23/2024 at 6:58 AM, by the prior DON revealed .CNA [CNA A] went to check on the alarm in the Physical Therapy gym, patient [Resident #62] was found in door urinating outside the door. When the CNA [CNA A] went to help patient, the patient dropped down in a squatting position and fell on his bottom. The patient was helped back into the wheelchair and brought to his room. Once in his room the nurse performed an assessment, she stated that he complained about being sore, the nurse administered tramadol that is scheduled. This writer [prior DON] went into the facility. Patient family was called and this writer completed another assessment, Patient stated that he was still sore. On- call was called, received order for x ray .Patient was sent to ED [Emergency Department] due to not being able to get x ray to come out stat. Son was agreeable. Patient was seen in ED and was confirmed by ED nurse to have a Left femoral fracture at 05:30AM.patient was on one on one care until sent out to hospital.Witnesses information: Staff CNA [CNA A] stated he heard him urinating at the door and when he went to go help him sit he squatted down and fell on his bottom. Staff member stated he helped him to the wheelchair, and the nurse then completed her assessment. Review of the State Agency Facility Reportable Incident Intake Report received on 12/23/2024 at 9:53 AM, revealed .CNA [CNA A] responded to alarm and found resident [Resident #62] urinating outside physical therapy door, resident lost balance and fell from squatted position onto his butt, resident was helped into his wheelchair and brought back into building to his room where he was accessed [assessed] and complained of being sore .one on one care provided .On call ordered PRN [as needed] Oxycodone 5 mg to be given and x-ray obtained .sent to emergency room due to x-ray unable to be performed stat [immediately] .Emergency department nurse confirmed Left Femoral Fracture at 5:30 AM . Review of the Incident Reporting System of the facility reportable incident 5-day follow-up completed on 12/28/2024 by the prior Administrator, revealed .Patient sent to the hospital, as noted in initial report. Imaging in the ER [Emergency Room] showed a displaced sub capital femoral neck fracture left hip. [Named Resident #62] was admitted to the hospital where his family decided to proceed with surgical intervention, for palliative comfort. He underwent hip hemiarthroplasty [partial hip replacement surgery] on 12/24 [12/24/2024]. [Named CNA A] acknowledged during investigation the patient had made it outside the door of the PT GYM. He noted patient was standing up against the building and urinating. He noted when he went to grab the wheelchair the patient began to become unsteady and he dropped down before he could reach him.The fall/elopement was verified by staff interviews.During the investigation the alarm for the WG [Wander Guard] system was activated; however, the magnet on the door failed. This is noted when we went to test the door after the fall. We have since had all the doors inspected by a third-party company and the magnet has been fixed. Also, we have a log was created to note the daily door checks that are required to be done by the weekend managers and the Director of Environmental services.The patient should have been stabilized and accessed before moving.Education and Training is being provided for the use of gait belts/transfers and the proper steps in which we respond to falls. During an interview on 8/18/2026 at 2:35 PM, the Physical Therapy Director was asked if the doors to the Physical Therapy department were locked. The Physical Therapy Director stated, .no, we are usually finished with therapy no later than 6:00 PM and the doors are closed, we don't have a way to lock them.The Exit door in the PT gym the resident [Resident #62] went out of has a keypad to unlock it or if the bar is pressed on for 15 seconds, the door will be released.the alarm will continue until someone comes and turns it off.The door also has a wander guard sensor on it that I don't think was working.it was supposed to alarm and lock the door if a resident with a wander guard got close to [the] exit door. During an interview on 8/18/2026 at 2:48 PM, the Administrator was asked why there was no lock on the Physical Therapy Department entrance double doors. The Administrator stated, .talked with the Regional Maintenance Director, and he thinks it has to do with an egress requirement [a safety rule that ensures a building has enough clear, safe paths and emergency exits in case of fire or other danger] that there is no lock on the Physical Therapy door, He is going to check into it more and let me know.I would feel better if the door was able to be locked. During an interview on 8/19/2026 at 9:15 AM, the Physical Therapy Director was asked if they had been having problems with the therapy exit door. The Physical Therapy Director stated, .The exit door was working to my knowledge.there is a light over that exit door and lights down the walkway to main/front parking lot. During a telephone interview on 8/19/2026 at 10:13 AM, CNA A was asked if he could recall the incident with Resident #62. CNA A stated .I guess it was nighttime, and I don't think he was assigned to me.I heard the alarm that a door was opened so I went to see what door was opened.I realized the doors were not open and I realized it was the PT room and no one was in there, but the door was opened, so I went to look and it was 30 degrees outside.so I was already cautious of what I may find. I went out the door to see what was going on because it was unusual that the door was open, as I got closer to the corner, I heard a noise that sounded like a water hose and then I turned the corner and I see him [Resident #62] on the floor. CNA A was asked how far away from the door was Resident #62. CNA A stated . not too far, just around the corner, you wouldn't have seen him if you did not go out the door .I had to round the corner to see him. CNA A was asked if he saw the resident fall. CNA A stated, .No, he was already on ground. CNA A was asked what did you do to get assistance. CNA A stated, .It was 30 degrees outside, so I got him off the ground, I assisted him to the wheelchair. CNA A was asked did you bring the Resident back through the front door or the door in PT. CNA A stated, .I don't recall. CNA A was asked if he would have known the code to the PT door. CNA A stated .At the time, yes. CNA A was asked if he was familiar with this resident at all. CNA A stated, .Yes. CNA A was asked if Resident #62 had a history of trying to get out of the building. CNA A stated, .That was the first time. CNA A was asked was Resident #62 complaining of pain when he found the Resident or got him up off the ground. CNA A stated, .I can't recall, I suppose he was. During a telephone interview on 8/19/2026 at 10:31 AM, CNA E stated she had previously worked at the facility for a little over a year and worked on the 2:00 PM - 10:00 PM shift but was no longer employed at the facility. CNA E confirmed Resident #62 exited the building out the PT exit door and was found by CNA A. CNA E verified her statement in the facility investigation was true. Observation on 8/19/2026 at 11:45 AM, revealed the Physical Therapy Director used a rolling tape measure to measure the distance from the physical therapy exit door to the approximate location where Resident #62 was found, and it was approximately 20 feet. The Physical Therapy Director measured the distance from the approximate location that Resident #62 was found to the parking lot, it was approximately 87 feet and the distance from the parking lot to the street was approximately 135 feet. During an interview on 8/19/2026 at 3:21 PM, the Maintenance Director confirmed he was the Maintenance Director at the time of Resident #62's elopement. The Maintenance Director was asked did he have problems with the PT exit doors prior to the night of Resident #62's elopement. The Maintenance Director stated, .No.I have my checklist here, at the time of incident. The Maintenance Director was asked prior to the incident were doors being checked. The Maintenance Director stated, .Yes .we didn't have TELS [a digital platform used in healthcare settings that allows for real-time tracking of tasks and maintenance activities] then. I was documenting and checking doors and auditing .Yes, I check every day.the doors, mag locks [a locking mechanism that holds to a certain degree closed for 15 seconds, then it will release] I make sure the wander guard works with it, sending a signal. I check when closed that the mag lock closes. The Maintenance Director was asked did Resident #62 have a wander guard prior to the incident. The Maintenance Director stated, Don't know. The Maintenance Director was asked after the incident, did you have a company come in and look at the doors. The Maintenance Director stated, .I don't know all those details.I do have [the] checklist here with me. The Maintenance Director was asked about the missing wander guard audits from October 2024 to January 2025. The Maintenance Director stated .I can't, I will take a look at my logs, this is what I have available. The Maintenance Director asked about the training on January 15th, 2025, for the wander guard. The Maintenance Director stated .basically eye opener process how it works.had actual device and how to check.what I do daily.using precautions to watch patients and know which patients have the wander guards.the area where the alarms trigger and know where that is. The Maintenance Director was asked where the alarm/monitoring panel for the exit doors is located. The Maintenance Director stated .close to the fire alarm annunciator, close to [the] med [medication] room, across from [the] nursing station area.was explained where each individual sensor is as well. The Maintenance Director was asked if that alarm sounded would it be heard on the other side of the building. The Maintenance Director stated .it may . The Maintenance Director was asked do you conduct elopement drills. The Maintenance Director stated .I try to add them into the fire drills, when an alarm is tripped. During an interview on 8/19/2026 at 3:41 PM, the Sales Technician for (Named Healthcare Technologies Company) was shown an invoice for equipment and labor dated January 14th, 2025. The Sales Technician stated, .it was a Sunday . The Sales Technician was asked were you the technician that came to the facility on 1/14/2025. The Sales Technician stated .No, we work Monday through Friday. The Sales Technician was asked do you know anything about the incident we are investigating. The Sales Technician stated, .That some man pushed on the door and got out. The Sales Technician was asked do you remember anything about that day. The Sales Technician stated, .No . The Sales Technician was asked to look at the invoice dated 1/14/2025, the first line says equipment door guardian panel, what does that mean in lay terms. The Sales Technician stated, . No wander [guard] management.the transmitters that the patients wear will not work.This panel, if it's locked, hold for 15 seconds it is required that the door drops [opens] for safety issues . The Sales Technician was asked do you know which doors these are for. The Sales Technician stated, .I am not sure. I looked today at the door [in the PT department] and it had the egress door that will open after 15 seconds.Once it opens an alarm sound. There is also an annunciator by the nurse station that lets you know which door is alarming . The Sales Technician was asked would it have been replaced if the door was working. The sales Technician stated, .No, we wouldn't replace it unless something was wrong. The Sales Technician was asked if all the doors in the building are egress doors. The Sales Technician stated, .Yes. The Sales Technician was asked what doors have the wander guard feature. The Sales Technician stated, .the front doors and the doors to the courtyard. The Sales Technician was asked what adult transmitters are. The Sales Technician stated, .the wander guard themselves. The Sales Technician was asked if there were 10 wander guards bought in [DATE]. The Sales Technician stated, .Yes, ma'am . The Sales Technician was asked in April 2025, were more door panels put in. The Sales Technician stated, .We replaced the panel. During an interview on 8/19/2026 at 3:57 PM, the Administrator stated, .[Named Regional [NAME] President] and [Named prior Administrator] were under the impression that the PT door was a wandering door, and it was not .The only doors with the wander guard system are the main front door and the door to the courtyard. The Administrator was asked if there had been any other incidents of elopement since the incident in 2024. The Administrator stated, .No . During an interview on 8/19/2026 at 4:56 PM, the Administrator and DON were asked what is your understanding of the complaint investigation. The Administrator stated, .The elopement involving [Named Resident #62]. There was a facility reportable in 2024, Resident got out of the door and had an injury. The Administrator was asked would you say that was a major injury. The Administrator stated, .It was a major injury. The Administrator was asked how often the door alarms should be checked. The Administrator stated, .The ones we have been talking about Weekly, that's what the manufacturer recommends. The Administrator was asked if they could provide documentation the maglocks for the wander guard system were checked from 11/1/2024 to 1/1/2025. The Administrator stated, .No, the only other thing I can think of is go into the basement and check the overflow records. We have checked everything digitally. The DON was asked should a resident who falls be assessed prior to movement and transfer. The DON stated, .It depends on the status of the patient. If the patient was outside in the cold and was moving around, ambulatory, it may be best to bring inside to assess. Best practice. The DON was asked what education and in-services were provided. The DON stated, .Wander guard education, fall prevention. The DON was asked if there was an order for the wander guard prior to the fall. The DON stated, .No, ma'am . The DON was asked if a wander guard was in place prior to the fall. The DON stated, .I wasn't an employee here then. The Administrator was asked what's been put in place since this incident for compliance. The Administrator stated, .Obviously more abundance of caution.replaced hardware of door.when I got here, we did elopement assessments.all windows open only 4-6 inches.reeducated staff.put monitoring in place to make sure if assessment needed.routine elopement drills.QAPI [Quality Assurance and Performance Improvement] and AD HOC [temporary, unplanned, or created on an as-needed basis to handle a specific, immediate task], competencies.check off for gait belt and transfers.added a mechanism to lock Administrator hall door down after the incident. The Administrator was asked what was the Medical Director's role. The Administrator stated, .The Medical Director is a part of the QA [Quality Assurance] committee.he is to be made aware and included in corrective action plans.I would imagine [Named Nurse Practitioner] would have made [the] Medical Director aware.he [Medical Director] is here twice a week. The Administrator was asked if the Medical Director had been spoken with since the surveyors have been onsite. The Administrator stated, .I let him know that you are in the building. The Administrator was asked was the Medical Director notified at the time of the elopement/fall. The Administrator stated, .I would have to look at the event. The DON was asked what is the DON's role related to compliance with the issue of elopement and falls. The DON stated, .on admission an observation triggers if patient is an elopement risk.at that time there is an order set for elopement put into place, that ties into the elopement book.it also triggers the care plan and make sure it is in place. We educate the staff daily in huddles. The Administrator was asked how do you track your QAPI program. The Administrator stated, .we hold QAPI meetings quarterly and as needed, track and trend clinical metrics to clinical benchmarks to see if negative trends, identified cause, and see if action needs to be started.we track those changes to see if they were effective. We also conduct ADHOC QAPI as necessary.certain things we track by default, infections, weight loss, hospitalizations. The Administrator was asked how long they track clinical metrics. The Administrator stated, .if [a] negative trend identified, length would be determined by scope and severity. The Administrator was asked who are the members of QAPI. The Administrator stated, .Administrator, Medical Director, Nurse Practitioner, DON, Clinical Nurse Manager, MDS Coordinator, Physical Therapy Director, Dietary Manager, Registered Dietitian, Pharmacist, Direct Care staff member. The Administrator was asked how often the Medical Director participates. The Administrator stated, .quarterly. During an interview on 8/19/2026 at 6:24 PM, the Medical Director w

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to provide an environment free from the use of physical restraint used for staff convenience, that unnecessarily inhibited a resident's freedom of movement or activity for 1 of 1 (Resident #1) sampled residents reviewed for restraints. On 8/18/2024, a phlebotomist from an outside agency contracted with the facility and Resident #1's private sitter physically restrained Resident #1, while he yelled No during an attempt to obtain blood. The phlebotomist notified Licensed Practical Nurse (LPN) G that she was unable to obtain the blood, and LPN G entered Resident #1's room and observed Resident #1's private sitter holding his arms down across his body. The facility's failure to ensure an environment free from physical restraints for Resident #1 resulted in an Immediate Jeopardy (IJ). An Immediate Jeopardy is a situation in which the provider's noncompliance 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, Director of Nursing, Regional [NAME] President, and Regional Nurse were notified of the Immediate Jeopardy for F-604 on 10/2/2024 at 3:15 PM in the Administrator's office. The facility was cited at F-604 at a scope and severity of J, which constitutes Substandard Quality of Care. The Immediate Jeopardy was effective on 8/18/2024 and is on-going. A partial extended survey was conducted on 9/20/2024 to 10/2/2024. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility policy titled, ABUSE POLICY AND PROCEDURE, updated 7/25/2023, revealed .Any form of resident/patient abuse, mistreatment, neglect, misappropriation, exploitation, or deprivation of goods and/or services will not be tolerated .It is the responsibility of all employees to report resident/patient abuse .Patients will not be subjected to abuse by anyone including staff, other patients, consultants, or volunteers, contract employees or staff from other agencies serving our patients, family members, or legal guardians, friends, or other individuals .All patients will be protected from any and all forms of abuse, mistreatment, neglect, misappropriation, exploitation, or deprivation of goods and/or services .PREVENTION .The Administrator or designee will request verification from the contracting agency or entity of the contract employee/agency personnel's compliance with required background screening and license/certification verification .The Administrator or designee will ensure the contract employee or agency personnel is without and [an] unemployable criminal history and licensure/certification is in good standing .REPORTING AND INVESTIGATING .The person(s) observing the incident of patient abuse or suspecting patient abuse must immediately ensure patient safety then immediately report such incidents to their immediate supervisor and/or the charge nurse .The Administrator or Director of Nursing will then ensure the safety of the patient, begin the investigation, and if necessary, report information to the police . Review of the facility policy titled, USE OF RESTRAINTS, dated 9/28/2022, revealed .Each patient has the right to be free from physical restraints imposed for purposes of discipline or convenience . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Osteomyelitis of vertebra and sacrococcygeal region, Parkinson's disease without dyskinesia (uncontrolled, involuntary muscle movement), Anxiety, and Major Depressive Disorder. Review of the 5-Day Minimum Data Set (MDS) assessment for Resident #1 dated 8/19/2024, revealed a Brief Interview of Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. Review of Comprehensive Care Plan for Resident #1 revealed, .8/5/2024 .Alteration in mood status: ANXIETY .8/15/2024 Patient has identified history of TRAUMA .previous abusive situation at previous SNF [Skilled Nursing Facility] and PTSD [Post Traumatic Stress Disorder] from this . Review of the Facility Reported Investigation dated 8/20/2024, revealed the Director of Nursing (DON) was made aware of the allegation of abuse on 8/20/2024 at 11:30 AM, when Family Member (FM) H reported it. FM H reported, .On 8/18/2024, she was on the speaker phone when Resident #1 .[named Resident #1] attempted to stand up .the private sitter was trying to get him to sit down .[named Resident #1] started to become combative and hit the private sitter .I [FM H] heard the private sitter yelling at him over the phone .I called the private sitter to question her and she became 'loud and belligerent' .she said she had the right to defend herself .FM H stated she called FM N to call CNA F and speak with [named private sitter] .the private sitter yelled at FM N too . FM H made an attempt to speak with the private sitter and had no success due to her yelling. FM H stated, 'I called the private sitter back and asked her to leave' .the private sitter refused .FM H called the front desk to have the private sitter removed .the DON notified the Administrator of the allegation of abuse and she reported to the State Agency .The findings of the Administrator substantiated the abuse . During an interview on 9/5/2024 at 10:52 AM, Licensed Practical Nurse (LPN) G stated, .I worked 100 Hall on the day (8/18/2024) of the alleged abuse .the phlebotomist came and reported to me that she was unable to obtain blood due to [named Resident #1]'s increased agitation .I walked into [named Resident #1]'s room and observed the private sitter restraining Resident #1 by holding his arms across his body .I told her [private sitter] not to hold Resident #1's arms down .the [named private sitter] said Resident #1 had hit her. During an interview on 9/5/2024 at 11:55 AM, the Administrator stated she was notified of the allegation of abuse involving Resident #1 on Tuesday (8/20/2024) after FM H notified the DON. The Administrator stated she initiated an investigation and based on the findings, substantiated abuse. The private sitter was reported to the abuse registry. During an interview on 9/5/2024 at 1:15 PM, the DON was asked when she was made aware of the allegation of abuse. The DON stated she was notified the day after (8/20/2024) the alleged abuse occurred during a meeting with Resident #1's wife, FM H. FM H told the DON she was on speaker phone and heard the private sitter yelling at Resident #1. FM H also stated to the DON that LPN G was in the room too. The DON contacted LPN G for an interview on 8/20/2024 after notification of the abuse. LPN G told the DON she walked into the room and observed the private sitter wrestling with Resident #1 and holding his arms down. The DON asked LPN G why she did not report what she observed immediately. LPN G stated she told the private sitter to stop what she was doing. Continued interview revealed the DON stated LPN G had been previously educated on abuse and had no excuse for not reporting immediately what she had observed. Further interview revealed the expectation of the DON for all staff on any form of abuse was to make sure the resident was safe and report immediately to herself or the Administrator. During a telephone interview on 9/5/2024 at 4:28 PM, RN K stated she witnessed a telephone conversation on 9/4/2024 between the Clinical Nurse Manager and LPN G regarding the alleged abuse. RN K stated LPN G stated she walked into Resident #1's room and the private sitter was holding both wrists down beside his body. RN K asked LPN G why she did not report this immediately. LPN G stated she did not think this was abuse and was more concerned about obtaining blood for labs. During a telephone interview on 9/9/2024 at 10:13 AM, FM H stated she was on the phone when she heard the private sitter yelling in the background, which made Resident #1 more agitated. (Resident #1 had experienced a previous trauma from another facility.) FM H then stated she called the private sitter to try to speak with her, but she continued to yell and be belligerent. FM H told the private sitter not to hold down Resident #1's arms. FM H stated FM N called the private sitter also and she was belligerent to him as well. LPN G was asked if she reported the incident to anyone at the facility and she responded she thought (LPN G) would have reported the incident since she was in the room at the time. During a telephone interview on 9/9/2024 at 3:30 PM, FM N stated he heard the private sitter yelling in the background when he called his father (Resident #1) to try to calm him down. FM N then called the private sitter, and she continued to yell, saying she was not going to be hit. The surveyor attempted to contact Resident #1's private sitter multiple times with no success. During a telephone interview on 9/25/2024 at 2:35 PM, Senior [NAME] President for (named) Lab orchestrated a call between the surveyor and phlebotomist who worked on 8/18/2024. The phlebotomist stated she entered Resident #1's room and observed someone with the patient, .a middle-aged black lady with glasses and short, curly hair who was identified as Resident #1's private sitter . She stated she informed Resident #1, who was alert but confused, that she needed to obtain some blood. The phlebotomist stated she tried to calm Resident #1 down, but he became extra combative. The phlebotomist stated she had one arm, and the private sitter had the other arm. When asked to explain what she meant by having his arms, the phlebotomist stated she put Resident #1's right arm between her legs and the private sitter held his left arm down across his abdomen, but not with force. The phlebotomist stated Resident #1 hit her and became more combative even after she and the private sitter held his arms to try to obtain blood. She stated she was not going to fight with Resident #1 anymore and reported his behavior to LPN G. When asked if Resident #1 refused at any time, the phlebotomist stated, He [Resident #1] was saying no the whole time I was trying to get blood. Continued interview revealed when the phlebotomist left the room, the private sitter remained with Resident #1. During a telephone interview on 9/26/2024 at 4:47 PM, the phlebotomist was asked if a resident did not want treatment, did they have the right to refuse treatment. The phlebotomist responded, Yes. During a telephone interview on 9/30/2024 at 1:58 PM, LPN G was asked what she observed when she entered Resident #1's room. LPN G stated she observed the private sitter holding down Resident #1's arms across his abdomen and chest. She stated she told the private sitter she was unaware of the laws in Tennessee but to release the resident. The private sitter stated Resident #1 was combative and hit her but did release his arms. LPN G was then asked if she left the private sitter alone in the room with Resident #1 after she obtained the blood sample. LPN G stated she did leave the room and left Resident #1 alone with the private sitter. She stated she stayed outside the door for a few minutes and then went up the hallway to give report to the LPN Q. LPN G failed to protect Resident #1 from the likelihood of further abuse after she observed Resident #1's private sitter physically restrain him and then left Resident #1 alone with the private sitter. LPN G failed to protect Resident #1 and failed to report the incident immediately.

Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to report an allegation of abuse for 1 of 4 (Resident #1) sampled residents reviewed for abuse. On 8/18/2024, Resident #1, a moderately, cognitively impaired resident was physically restrained by his private sitter while refusing a venipuncture (a procedure in which a needle is used to take blood from a vein). Licensed Practical Nurse (LPN) G observed the private sitter continuing the physical restraint of Resident #1 after the venipuncture attempt. LPN G failed to report the allegation of abuse to Administration. The facility's failure to ensure all allegations of abuse were reported immediately resulted in an Immediate Jeopardy (IJ). An Immediate Jeopardy is a situation in which the provider's noncompliance 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, Director of Nursing, and Regional [NAME] President were notified of the Immediate Jeopardy for F-609 on 10/2/2024 at 3:10 PM in the Administrator's office. The facility was cited at F-609 at a scope and severity of J, which constitutes Substandard Quality of Care. The Immediate Jeopardy was effective on 8/18/2024 and is on-going. A partial extended survey was conducted on 9/20/2024 to 10/2/2024. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility policy titled, ABUSE POLICY AND PROCEDURE, updated 7/25/2023, revealed .Any form of resident/patient abuse, mistreatment, neglect, misappropriation, exploitation, or deprivation of goods and/or services will not be tolerated .It is the responsibility of all employees to report resident/patient abuse .REPORTING AND INVESTIGATING .The person(s) observing the incident of patient abuse or suspecting patient abuse must immediately ensure patient safety then immediately report such incidents to their immediate supervisor and/or the charge nurse .The Administrator or Director of Nursing will then ensure the safety of the patient, begin the investigation, and if necessary, report information to the police . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Osteomyelitis of vertebra and sacrococcygeal region. Further review revealed Resident #1 had diagnoses which included Major Depressive Disorder and Anxiety. Review of the 5-Day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. Review of the Comprehensive Care Plan for Resident #1 revealed, .8/5/2024 .Alteration in mood status: ANXIETY .8/15/2024 .Patient has identified history of TRAUMA .previous abusive situation at previous SNF [Skilled Nursing Facility] and PTSD [Post Traumatic Stress Disorder] from this . Review of the facility investigation dated 8/20/2024, revealed the Director of Nursing (DON) became aware of the allegation of abuse on 8/20/2024 at 11:30 AM, when family member (FM) H reported it. FM H reported on 8/18/2024 at approximately 7:00 PM, she was on the phone when Resident #1 attempted to stand up and the private sitter tried to make him sit down. Resident #1 became combative and started to hit the private sitter. FM H stated she heard the private sitter start yelling at him over the phone and believed he was restrained. FM H stated she called the private sitter to question her, and the private sitter became loud and belligerent stating she had the right to defend herself. FM H stated she called FM N to call the private sitter and speak with her. The private sitter yelled at FM F, also. FM H call the private sitter back and asked her to leave. The private sitter refused. FM H called the front desk to have the private sitter removed. The DON notified the Administrator of the allegation of abuse, and she reported to the Ombudsman and the State Agency. No physical injury was found. The Administrator substantiated the abuse. During an interview on 9/5/2024 at 10:52 AM, LPN G stated on 8/18/2024, the phlebotomist reported an unsuccessful attempt to obtain a blood specimen due to Resident #1's refusal to cooperate with the procedure. LPN G stated upon entering Resident #1's room, she observed the private sitter restraining Resident #1's arms across his body. LPN G stated Resident #1 was experiencing increased agitation, refusing care, and she directed the private sitter to stop holding the resident down. Continued interview revealed LPN G stated the private sitter then replied, .He hit me . Continued interview revealed LPN G was asked if she reported the alleged abuse and she stated she did not. During an interview on 9/5/2024 at 11:55 AM, the Administrator stated she was notified of the allegation of abuse on 8/20/2024. The Administrator affirmed LPN G should have reported the allegation of abuse immediately. Continued interview revealed the Administrator acknowledged the facility is required to report allegations of abuse within 2 hours of the allegation to the state agency. During an interview on 9/5/2024 at 1:15 PM, the DON was asked when she was made aware of the allegation of abuse. The DON stated she was notified of the allegation of abuse on 8/20/2024 during a meeting by FM H. During a telephone interview on 9/9/2024 at 10:13 AM, FM H stated, .That Sunday [8/18/2024] [named LPN G] called me because [named Resident #1] was refusing to allow blood to be drawn .I was on speaker phone with [named Resident #1] trying to calm him down, when I heard [named private sitter] yelling and being belligerent .[named private sitter] was screaming, 'He [Resident #1] tried to hit me so I held him .I know what I'm doing' . FM H stated the private sitter's behavior increased Resident #1's anxiety. FM H stated, .I tried to explain to [Named private sitter] that she needed to calm down .I told her not to hold [Named Resident #1] down .she [private sitter] kept yelling that she had a right to defend herself .I asked her [private sitter] to leave, and she refused to leave . When asked if she reported the incident to the facility, FM H responded, .I assumed, because [named LPN G] called me and was present in the room, that she would pass it on . During a telephone interview on 9/9/2024 at 3:30 PM, FM N stated (named FM H) called him (8/18/2024) because the private sitter would not leave the facility. FM N stated that he called and attempted to talk with the private sitter, and she continued to yell, .I am not going to be hit . FM N stated the private sitter refused to continue talking and hung up the phone. The facility's failure to ensure timely reporting of the allegation of abuse/physical restraint of Resident #1, increased the likelihood that additional abuse could occur and compromise or impede the protection of all residents residing in the facility.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to protect the resident's right to be free from neglect by facility staff for 1of 4 (Resident #1) sampled residents reviewed for abuse. On 8/18/2024, LPN G witnessed Resident #1's private sitter restraining his arms across his abdomen after an attempt to obtain a blood sample while the resident yelled No. Licensed Practical Nurse (LPN) G witnessed the private sitter's behavior escalate to crying and yelling before she left Resident #1 and the private sitter alone in the room. LPN G failed to protect Resident #1 from further potential abuse when she left Resident #1 alone in the room with the private sitter after she obtained the blood sample, which resulted in Immediate Jeopardy (IJ) for Resident #1. An Immediate Jeopardy is a situation in which the provider's noncompliance 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, Director of Nursing, and Regional [NAME] President were notified of the Immediate Jeopardy for F-600 on 10/2/2024 at 3:10 PM in the Administrator's office. The facility was cited at F-600 at a scope and severity of J, which constitutes Substandard Quality of Care. The Immediate Jeopardy was effective on 8/18/2024 and is on-going. A partial extended survey was conducted on 9/20/2024 to 10/2/2024. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility policy titled, ABUSE POLICY AND PROCEDURE, updated 7/25/2023, revealed .Any form of resident/patient abuse, mistreatment, neglect, misappropriation, exploitation, or deprivation of goods and/or services will not be tolerated .It is the responsibility of all employees to report resident/patient abuse .Patients will not be subjected to abuse by anyone including staff, other patients, consultants, or volunteers, contract employees or staff from other agencies serving our patients, family members, or legal guardians, friends, or other individuals .All patients will be protected from any and all forms of abuse, mistreatment, neglect, misappropriation, exploitation, or deprivation of goods and/or services .PREVENTION . Review of the facility policy titled, USE OF RESTRAINTS, dated 9/28/2022, revealed .Each patient has the right to be free from physical restraints imposed for purposes of discipline or convenience . Review of the facility documentation of LPN G's employee record revealed she received an abuse in-service upon hire on 4/19/2024 and on 8/8/2024 at the monthly in-services. Review of the facility documentation of the private sitter's employee record, who was a previous employee, revealed abuse in-service upon hire. The private sitter was terminated on 7/26/2024. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Osteomyelitis of vertebra and sacrococcygeal region. Further review revealed Resident #1 had diagnoses which included Major Depressive Disorder and Anxiety. Review of the 5-Day Minimum Data Set (MDS) assessment dated [DATE], for Resident #1 revealed a Brief Interview of Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. Review of the Comprehensive Care Plan for Resident #1 revealed, .8/5/2024 .Alteration in mood status: ANXIETY .8/15/2024 .Patient has identified history of TRAUMA .previous abusive situation at previous SNF and PTSD [Post Traumatic Stress Disorder] from this . Review of the facility investigation dated 8/20/2024, revealed the Director of Nursing (DON) became aware of the allegation of abuse on 8/20/2024 at 11:30 AM, when Family Member (FM) H reported it. FM H reported that on 8/18/2024 at approximately 7:00 PM, she was on the phone when Resident #1 attempted to stand up and the private sitter was trying to get him to sit down. Resident #1 became combative and started to hit the private sitter. FM H stated she heard the private sitter start yelling at him over the phone and believed that Resident #1 was restrained. FM H stated she called the private sitter to question her, and she became loud and belligerent stating she had the right to defend herself. FM H stated she called FM N to call the private sitter and speak with her. The private sitter yelled at FM N, too. FM H called the private sitter back and asked her to leave, but she refused. FM H called the front desk to have the private sitter removed. The private sitter finally left the facility. The DON notified the Administrator of the allegation of abuse, and she reported to the Ombudsman and the State Agency. The Administrator substantiated the abuse. During an interview on 9/5/2024 at 10:52 AM, Licensed Practical Nurse (LPN) G stated she worked the 100 Hall on the day (8/18/2024) of the alleged abuse. LPN G was told by the phlebotomist that she was unable to obtain blood due to Resident #1's increased agitation. LPN G stated shortly afterwards, she walked into Resident #1's room and observed the private sitter restraining Resident #1 by holding his arms across his body. LPN G stated she told the private sitter not to hold Resident #1's arms down because the law may not permit this. The private sitter responded Resident #1 had hit her. During an interview on 9/5/2024 at 11:55 AM, the Administrator stated she was notified of the allegation of abuse involving Resident #1 on Tuesday (8/20/2024) after FM H notified the DON. The Administrator stated she initiated an investigation and based on the findings, substantiated abuse. During an interview on 9/5/2024 at 1:15 PM, the DON was asked when she was made aware of the allegation of abuse. The DON stated she was notified on 8/20/2024 the alleged abuse occurred during a meeting with Resident #1's wife, FM H. FM H told the DON she was on speaker phone and heard the private sitter yelling at Resident #1. FM H also stated to the DON that LPN G was in the room too. The DON contacted LPN G for an interview on 8/20/2024, after notification of the abuse. LPN G told the DON she walked into the room and observed the private sitter wrestling with Resident #1. The DON asked LPN G why she did not report what she observed immediately. LPN G stated she told the private sitter to stop what she was doing. Continued interview revealed the DON stated LPN G had been previously educated on abuse and had no excuse for not reporting immediately. Further interview revealed the expectation of the DON for all staff on any form of abuse was to make sure the resident was safe and report immediately to herself or the Administrator. During an interview on 9/5/2024 at 4:10 PM, Registered Nurse (RN) J stated he was the supervisor on 8/18/2024 and was not made aware of any allegation of abuse. During a telephone interview on 9/5/2024 at 4:28 PM, RN K stated she witnessed a telephone conversation on 9/4/2024 between the Clinical Nurse Manager and LPN G regarding the alleged abuse incident on 8/18/2024. LPN G had stated she walked into Resident #1's room and the private sitter was holding both wrists down beside his body. RN K stated LPN G said she did not think this was abuse and was more concerned about obtaining blood for labs. During a telephone interview on 9/9/2024 at 10:13 AM, FM H stated she was on the phone with Resident #1 when she heard the private sitter yelling in the background, which made Resident #1 more agitated. (Resident #1 had experienced a previous trauma from another facility.) FM H then stated she called the private sitter to try to speak with her, but she continued to yell and be belligerent. She stated FM N called the private sitter also, and she was belligerent to him as well. During a telephone interview on 9/9/2024 at 3:30 PM, FM N stated he heard the private sitter in the background when he called his father (Resident #1) to try to calm him down. FM N then called the private sitter, and she continued to yell, saying she was not going to be hit. Multiple attempts were made to contact the private sitter for interview with no success. During a telephone interview on 9/25/2024 at 2:35 PM, Senior [NAME] President (VP) of the (named) Lab was on the call with the phlebotomist. The phlebotomist was asked to recall the day of 8/18/2024 at the facility with Resident #1. The phlebotomist stated she entered the room and found Resident #1 to be alert but confused. She stated she told Resident #1 what she was about to do, and he said okay. The phlebotomist tried to calm Resident #1 down. She stated she held one arm, and the private sitter held the other. The phlebotomist stated the private sitter held the left arm of Resident #1 across his abdomen while she held the right arm between her knees to try to obtain a blood sample, because that was how she was trained to do if a patient was combative. Resident #1 became increasingly combative while refusing and yelling, No. The phlebotomist left the room and notified LPN G she could not obtain the blood sample. The private sitter remained in the room with Resident #1. When asked if she (the phlebotomist) was in the room when LPN G entered, the phlebotomist stated, No. During a telephone interview on 9/26/2024 at 4:47 PM, the phlebotomist was asked if a resident has the right to refuse treatment and she replied, Yes. During a telephone interview on 9/30/2024 at 1:58 PM, LPN G was asked to recall the witnessed abuse incident with Resident #1 on the day of 8/18/2024. LPN G stated when she entered Resident #1's room, the private sitter had his arms held down across his chest. She stated she told the private sitter that she was unaware of the law in Tennessee, but she needed to let Resident #1 go. The private sitter let Resident go after she told LPN G that he had been combative and hit her. LPN G stated she called FM H to try to comfort Resident #1 before trying to obtain the blood sample. There was back and forth conversation going on via speaker phone with the private sitter, FM H, and FM N that led to the private sitter being asked to leave the facility by the family. LPN G stated after she obtained the blood sample, she exited the room leaving Resident #1 and the private sitter alone in the room. LPN G stated she stood in the hallway for a few minutes then went back up the hallway and gave report to the night nurse. Continued interview revealed LPN G did not report the witnessed abuse per the facility policy. During a telephone interview on 9/30/2024 at 4:32 PM, the phlebotomist confirmed the private sitter remained in Resident #1's room when LPN G went to draw blood. The phlebotomist was asked when LPN G left the room, did the private sitter remain with Resident #1. The phlebotomist stated, Yes. Once the blood was obtained, LPN G left the room while Resident #1 remained with the private sitter. During a telephone interview on 10/1/2024 at 10:23 AM, LPN Q, who was the night shift nurse on 8/18/2024, stated FM H called the facility to check on Resident #1 and said she had fired the private sitter. LPN Q was headed to Resident #1's room when she saw the private sitter leaving the facility. When asked the date and time of this call, LPN Q stated she did not remember the date but did recall the time to be approximately 8:00 PM. During an interview on 10/2/2024, the DON stated when she interviewed LPN G, the LPN eventually admitted she witnessed the private sitter holding down Resident #1's arms across his abdomen. LPN G was asked by the DON if she removed the private sitter from the room and LPN G said No, the private sitter was belligerent at that time. When the DON asked LPN G why she did not report the incident, the LPN stated she took care of it and asked her to let go of Resident #1.

Based on facility policy review, medical record review, and interview, the facility failed to conduct a thorough investigation and take appropriate corrective actions for 1 of 1 (Resident #1) sampled residents reviewed for abuse. The findings included: Review of the facility policy titled, ABUSE POLICY AND PROCEDURE updated 7/25/2023, revealed .Any form of resident/patient abuse, mistreatment, neglect, misappropriation, exploitation, or deprivation of goods and/or services will not be tolerated .It is the responsibility of all employees to report resident/patient abuse .Patients will not be subjected to abuse by anyone including staff, other patients, consultants, or volunteers, contract employees or staff from other agencies serving our patients, family members, or legal guardians, friends, or other individuals .All patients will be protected from any and all forms of abuse, mistreatment, neglect, misappropriation, exploitation, or deprivation of goods and/or services .PREVENTION .The Administrator or designee will request verification from the contracting agency or entity of the contract employee/agency personnel's compliance with required background screening and license/certification verification .The Administrator or designee will ensure the contract employee or agency personnel is without and unemployable criminal history and licensure/certification is in good standing .REPORTING AND INVESTIGATING .The person(s) observing the incident of patient abuse or suspecting patient abuse must immediately ensure patient safety then immediately report such incidents to their immediate supervisor and/or the charge nurse .The Administrator or Director of Nursing will then ensure the safety of the patient, begin the investigation, and if necessary, report information to the police . Review of the facility policy titled, USE OF RESTRAINTS, dated 9/28/2022, revealed .Each patient has the right to be free from physical restraints imposed for purposes of discipline or convenience . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Osteomyelitis of vertebra and sacrococcygeal region, Pressure ulcer of sacral region, stage 4, Parkinson's disease without dyskinesia, and Encephalopathy. Review of the 5-Day Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 revealed, a BIMS score of 8 which indicated moderate cognitive impairment. Review of Comprehensive Care Plan for Resident #1 revealed, .8/5/2024 .Alteration in mood status: ANXIETY .8/15/2024 .Patient has identified history of TRAUMA .previous abusive situation at previous SNF and PTSD from this . Review of the facility investigation dated 8/20/2024, revealed the DON was notified of the allegation of abuse by FM H on 8/20/2024. FM H was on speaker phone when she heard the private sitter yell at Resident #1 as he attempted to try to get up from the bed. FM H called the private sitter to try to calm her down but had no success. FM H called FM N and he an attempt to call and speak with the private sitter, but she (private sitter) continued to yell and voice her concern about having the right to defend herself. FM H called the private sitter back and asked her to leave. The private sitter refused at that time but did eventually leave. The DON notified the Administrator, and she (Administrator) initiated an investigation. Continued interview revealed the allegation of abuse was substantiated. During an interview on 9/4/2024 at 4:05 PM, the Administrator stated she was the abuse coordinator. The DON was her backup abuse coordinator. The staff were trained on abuse upon hire, monthly, with any abuse allegation, and annually. She stated she was responsible to report abuse allegations to the state agency within 2 hours of the incident and then do an investigation. She stated the facility found the abuse allegation involving Resident #1 to be substantiated. Continued interview revealed, the Administrator did not notify the police about the allegation of abuse. When asked why the police was not notified, the Administrator stated, .I do not have to report verbal abuse .That is what I substantiated . Further interview revealed the Administrator did not interview the phlebotomist or LPN Q, who was the night nurse on 8/18/2024. Review of the facility investigation dated 8/20/2024, revealed the Director of Nursing (DON) stated, On 8/20/2024, [named Family Member H] [FM] reported Resident #1 had been yelled at and physically restrained on 8/18/2024 .FM H reported she was on speaker phone with Resident #1 .He [Resident #1] tried to stand up the bed .[named private sitter] tried to get him [Resident #1] to sit back down .she [FM H] heard the private sitter yelling at him [Resident #1] .FM H called the private sitter to try to calm her down .the private sitter continued to yell and be belligerent .she [private sitter] said she had the right to defend herself .FM N called the private sitter to attempt to speak with her and calm her down .she [FM H] said the private sitter yelled at [named FM N] also .FM H called the private sitter back to ask her to leave .the private sitter refused .FM H called the facility to have the private sitter removed . Continued review revealed the DON notified the Administrator of the allegation of abuse .the Administrator reported to the Ombudsman and the State Agency .the Administrator substantiated the abuse. During an interview on 9/4/2024 at 4:05 PM, the Administrator stated she was the Abuse Coordinator and responsible for reporting and investigating the allegation of abuse. She stated an allegation of abuse was to be reported to the state agency no later than 2 hours after the incident. During an interview on 9/5/2024 at 10:52 AM, LPN G was asked to recall the incident she witnessed on 8/18/2024. LPN G stated the incident occurred on a Sunday. Resident #1 had experienced a change in condition over the weekend, becoming more combative. The physician was called, and labs were ordered. The phlebotomist came to obtain the blood the same afternoon. When the phlebotomist arrived, the private sitter was in the room with Resident #1. Shortly afterwards, the phlebotomist came to me and reported she was unable to obtain the blood sample and Resident #1 had hit and bit her. LPN G stated she called FM H to get permission to give Resident #1 his prn [as needed] antianxiety medication. When LPN G entered Resident #1's room, she observed the private sitter holding his arms down across his body. LPN G told the private sitter not to do that and she [private sitter] stated, .He hit me too . When asked if the private sitter was asked to leave, LPN G stated, .The family asked [named private sitter] to leave and she left about an hour before her shift ended . During an interview on 9/5/2024 at 4:18 PM, the Clinical Nurse Manager (CNM) stated she an RN K did a phone interview on 9/4/2024 with LPN G about the allegation of abuse. The CNM reported LPN G stated she entered Resident #1 ' s room and found the private sitter holding his arms down to obtain blood while FM H was on the speaker phone. During a telephone interview on 9/5/2024 at 4:28 PM, RN K, who was on the phone with the CNM and LPN G, stated LPN G stated she walked into Resident #1's room and saw the private sitter holding both wrists down bedside Resident #1's body. RN K stated she asked LPN G why she did not report what she witnessed, and LPN G responded, .I did not think it was abuse and was more concerned with getting his blood . During an interview on 9/9/2024 at 10:13 AM, FM H stated LPN G had called her to see if she could calm down Resident #1. While on speaker phone, FM H heard the private sitter yelling at Resident #1. The situation escalated and FM H tried to calm down the private sitter with no success. FM H called FM N and FM N tried to call and calm down the private sitter. The private sitter continued to yell and be belligerent while speaking to both family members, who asked the private sitter to leave. The private sitter refused at first, but eventually left. FM H said she did not report the allegation of abuse to anyone until she had a meeting with the DON. FM H felt like LPN G would have reported the allegation of abuse since she was present during the activities that occurred while in the room. During an interview on 9/9/2024 at 3:30 PM, FM N stated when he tried to speak with the private sitter about Resident #1's behavior, she [private sitter] yelled and said she was not going to be hit. FM N felt the private sitter did not receive his feedback and hung up the phone. During a telephone interview on 9/25/2024 at 2:35 PM, the Senior [NAME] President (VP) for (named) lab and the phlebotomist were on a conference call and was asked to recall the events on 8/18/2024 involving Resident #1. The phlebotomist stated she went into Resident #1's room and saw he had some confusion. She attempted the venipuncture when Resident #1 became combative. The phlebotomist stated she put Resident #1's right arm between her legs and the private sitter held down his left arm across his abdomen/chest area but still could not obtain the blood. The phlebotomist went to LPN G and reported she was unable to obtain the blood. When asked is resident #1 refused care, the phlebotomist stated, .He [Resident #1] was yelling 'No' the whole time . During a telephone interview on 9/26/2024 at 4:47 PM, the phlebotomist was asked if Resident #1 had the right to refuse the treatment she tried to give and she stated, Yes. During an interview on 9/30/2024 at 11:56 AM, the Administrator was asked if she interviewed all parties involved in the allegation of abuse, including the phlebotomist. She responded, .I did not interview the lab person [phlebotomist] .I was not sure if she was even in the room at that time . During an interview on 10/1/2024 at 10:23 AM, LPN Q was asked if the Administrator ever interviewed her about the allegation of abuse since she was the night nurse on 8/18/2024. LPN Q stated, No. I was not interviewed. During an interview on 10/2/2024 at 12:10 PM, the DON was asked if she had interviewed the phlebotomist during the investigation. The DON stated, I did not personally interview her [phlebotomist]. The facility's failure to do a thorough investigation of the allegation of abuse/physical restraint of Resident #1, increased the likelihood that additional abuse could occur and compromise or impede the protection of all residents residing in the facility.

Based on facility policy review, facility record review, and interview, the facility failed to do the 5-day follow-up, after the fall investigation had been submitted, for 2 (Resident #3 and Resident #4) of 10 residents reviewed. The finding included: Review of the facility policy titled, Accident and Incident, dated January 15, 2021 and updated September 28, 2022, revealed, .Any unusual occurrence or event that may compromise the safety, health, or abilities of the patient, staff or others is to be promptly reported so that appropriate action may be taken to protect the health and safety of all concerns .Patient found lying on the floor or other incapacitated position will not be moved until assessed by a Licensed Nurse .licensed nurse will immediately be notified to perform a physical assessment of patient's condition .shall assess for change in condition and/or injury related to the fall incident .inquire and/or observe for headache or pain; if present document location, intensity and additional signs and symptoms .Licensed nurse will immediately consult with the Attending Physician .the Licensed nurse with write a narrative description of the incident in the patient's progress .notes .the IDT will review the Event for additional concerns the following day or Monday .subsequent action or follow up may be added to the event .the Director of Nursing will be responsible for monthly tracking of all incidents .the results .will be reported in QAPI [Quality Assurance and Performance Improvement] at least quarterly . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy, Acute Lymphoblastic Leukemia, in remission, and Cirrhosis of Liver. Review of the Admission Minimum Data Set (MDS) assessment, dated 4/27/2023 for Resident #3, revealed, a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Continued review revealed Resident #3 required substantial/maximal assistance with sit to stand, chair/bed to chair transfer. Review of Care Plan for Resident #3, revealed goals and interventions that included, .5/11/2023 .Assist to toilet, commode, bedpan or urinal as needed .at risk for fall .bed in low position while in bed .encourage to keep room door open when not engaged in .Keep pathway clean and free from clutter .5/30/2023 .resident educated to ask staff for assistance with transfers . Review of the Facility Reported Incident revealed Resident #3's incident was submitted to the State Agency on 4/6/2023 at 1:43 PM, with no 5-day follow-up investigation reported. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with a readmission on 6/21/2023, with diagnoses which included Acute Kidney Failure, Bilateral Primary Osteoarthritis of Hip and Severe Protein-Calorie Malnutrition. Resident #4 discharged on [DATE]. Review of the Admission Minimum Data Set (MDS) assessment, dated 6/8/2023 for Resident #4, revealed a BIMS score of 9, which indicated moderate cognitive impairment. Continued review revealed Resident #4 required extensive assistance with bed mobility, transfers, walking in and out of room, locomotion on and off unit, dressing, and toilet use. Continued review revealed Resident #4 had not been steady and required the use of a walker and wheelchair. Review of Care Plan revealed goals and interventions that included, .6/9/2023 .at risk for falls and injury r/t [related to] Mobility and/or functional deficits, poor safety awareness, OA [Osteoarthritis] in bilateral hips w [with]/pain, Bilateral hip effusions . Review of the Facility Reported Incident revealed Resident #4's incident was submitted to the State Agency on 6/14/2023 at 1:18 PM, with no 5-day follow-up reported. During an interview on 3/7/2024 at 10:30 AM, the DON reviewed the Incident Report entry form with this surveyor and acknowledged that the 5-day follow up had not been completed for Resident #3 and Resident #4 and they should have been done.