Claiborne Healthcare Center

Inspectors wroteBased on record review, observations and interviews the facility failed to ensure residents received adequate supervision to prevent elopement for 1 (#1) of 3 (#1, #2, #3) residents reviewed for elopement. The facility failed to provide adequate supervision for Resident #1 who was a known elopement risk. This deficient practice resulted in an immediate jeopardy situation for Resident #1 on 04/03/2026 at 5:31p.m., when he eloped from the facility through the front door unnoticed by staff while following visitors out of the building. Resident #1 had a history of exit seeking behaviors, had been identified as an elopement risk, and wore a wander guard ankle bracelet. Resident #1 was picked up by a local police officer about 0.9 miles from the facility on the interstate highway. Resident #1 was returned, uninjured, to the facility at approximately 6:45 p.m. on 04/03/2026. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment that promotes or enhances his or her quality of life for 1 (#6) of 6 (1, #2, #3, #4, #5, #6) sampled residents. The facility failed to ensure communication by staff was dignified and respectful while assisting Resident #6 with care.

Inspectors wroteBased on record review and interview the facility failed to develop a comprehensive care plan for 1 (#14) of 1 resident reviewed for urinary tract infection.

Inspectors wroteBased on observations and interviews the facility failed to ensure nurse staffing data information was posted daily and retained for a minimum of 18 months.

Inspectors wroteBased on observations and interviews the facility failed to accommodate the needs of 1(#29) resident of 2 residents reviewed for environment. The facility failed to ensure resident's call light remained within reach.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure the outside dumpster lids were closed.

Inspectors wroteBased on record reviews and interviews the facility failed to protect resident's right to be free from verbal abuse by a staff member for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.

Inspectors wroteBased on record reviews and interviews the facility failed to implement written policies and procedures for 1 (Resident #1) of 2 (Resident #1, Resident #3) residents reviewed with incidents in the past 4 months. An incident report was not completed for a verbal abuse incident involving Resident #1.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet resident's medical and nursing needs for 1 (#265) of 26 sampled residents. The facility failed to ensure: 1.) Resident #265 had an order and was care planned for left knee immobilizer and non-weight bearing to left leg. 2.) Resident #265 received diuretic as ordered by the physician due to diuretic not being reordered timely as per policy.

Inspectors wroteBased on record review, observation and interviews, the facility failed to provide services that met professional standards for 1 (#36) of 26 sampled residents. The facility failed to ensure safe oral medication administration practices by leaving medications at the bedside.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure residents' medical records reflected the resident's wishes for 1 (#20) of 26 residents reviewed for advance directives. The facility failed to ensure Resident #20's medical records were consistent with resident's wishes for DNR (Do Not Resuscitate).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents were free from unnecessary medications for 2 (#5, #29) out of 5 (#5, #28, #29, #45, #265) residents reviewed for unnecessary medications. The facility failed to monitor Resident #5 for bleeding while receiving an anticoagulant and Resident #29 for edema while receiving a diuretic.

Inspectors wroteBased on observations and interview the facility failed to store, prepare, distribute and serve food under sanitary conditions. The facility failed to ensure food was stored properly to prevent cross contamination, utensils were not properly stored when not in use, freezer without a thermometer, and undated food items. This had the potential to affect the 70 residents who received food trays from the kitchen.

Inspectors wroteBased on observation and interviews, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition by failing to ensure 1) dishwasher food trap was cleaned out preventing water from overflowing onto the kitchen floor, 2) refrigerator #1 was not leaking water onto the floor and 3) freezer #1 contained food items maintained at a safe temperature range to keep foods frozen. This deficiency had the potential to affect the health and safety of persons entering or working in the kitchen.

Inspectors wroteBased on observation and interviews the facility failed to ensure dependent residents were provided activities of daily living (ADLs) for 1 (#47) of 26 sampled residents. The facility failed to ensure Resident #47's fingernails and toe nails were trimmed.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure all certified nursing assistant (CNA) staff had documented new hire and/or annual competency demonstrations for all skills related to their expected roles for 2 out of 5 personnel files reviewed. This had the potential to affect all 72 residents residing in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee meeting included the required 6 staff members for the facility's last 2 quarterly committee meetings.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were free from accident hazards during transport resulting in a fall for 1 (#1) of 3 (#1, #2, #3) sampled residents who required transportation to appointments. S7Van Driver, S8Van Driver and S4Transportation CNA (Certified Nurse Assistant) failed to ensure Resident #1's mode of transportation was verified by his nurse which led to his fall. This deficient practice resulted in an actual harm for Resident #1 on 04/09/2024 at 1:45 p.m., when S7Van Driver attempted to load Resident #1 via wheelchair onto the facility van for a doctor's appointment when he was required to be transported by ambulance on a stretcher. S7Van Driver reported Resident #1's wheelchair tilted backwards after loading it onto the van lift. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive care plan for 1 (#1) of 3 (#1,#2,#3) sampled residents reviewed. The facility failed to: 1. Develop a care plan for Resident #1's diagnosis of anxiety, and 2. Develop and implement a care plan for Resident #1's transportation mode.

Inspectors wroteBased on record review, interview and video footage review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice by failing to follow the facility's accident policy by moving a resident after a fall and failing to assess 1 (Resident #2) of 2 (Resident #2, #3) residents after a fall. The deficient practice resulted in an Immediate Jeopardy for Resident #2 on 02/14/2024 at approximately 5:35:22 a.m. (per video footage observed) when S3 Van Driver attempted to load Resident #2 on the van lift without following the manufacturer's guidelines for that van lift. S3 Van Driver tried to lift Resident #2's wheelchair over the side of the van lift instead of wheeling Resident #2 on to the front of the lift, as per manufacturer's guidelines. [...]

Inspectors wroteBased on observation, record review, interviews, and video review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for each resident who is transported in the facility's van via wheelchair. The facility's staff failed to follow the guidance of the manufacturer's 'Step by Step Wheelchair Lift Operation Guide' in the loading of wheelchaired residents for 1 (Resident #1) of 2 (Resident #2 and #3) residents reviewed for falls. The deficient practice resulted in an Immediate Jeopardy for Resident #2 on 02/14/2024 at approximately 5:35:22 a.m. (per video footage observed) when S3 Van Driver attempted to load Resident #2 on the van lift without following the manufacturer's guidelines for that van lift. [...]

Inspectors wroteBased on record review, interviews and video footage review, the facility failed to ensure the van driver possessed the competency to load a resident on to the facility van correctly and nursing staff possessed the competency to assess residents after a fall for 1 (Resident #2) of 2 (Resident #2 and #3) residents reviewed for falls. The deficient practice resulted in an Immediate Jeopardy for Resident #2 on 02/14/2024 at approximately 5:35:22 a.m. (per video footage observed) when S3 Van Driver attempted to load Resident #2 on the van lift without following the manufacturer's guidelines for that van lift. S3 Van Driver tried to lift Resident #2's wheelchair over the side of the van lift instead of wheeling Resident #2 on to the front of the lift, as per manufacturer's guidelines. [...]

Inspectors wroteBased on record review, interview and video footage review, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #2) of 2 (Resident #2 and #3) residents after a fall: 1. by failing to ensure a system was in place to safely transport Resident #2 in the facility van; 2. by failing to ensure the van driver possessed the competency to load a resident on to the facility van correctly and nursing staff possessed the competency to assess residents after a fall; and 3. by failing to ensure a system was in place to provide necessary care and treatment in accordance with professional standards of practice to Resident #2 after an incident on 02/14/2024. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's physician/physician's representative was notified after a fall for 1 (Resident #2) of 2 (Resident #2 and #3) reviewed for falls.

Inspectors wroteBased on record review and interview the facility failed to ensure an alleged violation of physical and/or verbal abuse was reported immediately but not later than 2 hours to the State Survey Agency for 1 (Resident #1) of 3 (Resident #1, #2, and #3) residents reviewed for an allegation of abuse.

Inspectors wroteBased on record reviews, interviews, and video footage review the facility failed to ensure a resident's medical record was complete and accurately documented in accordance with accepted professional standards and practices for 1 (#2) of 3 (#1, #2, #3) sampled residents.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice for 1 (#3) out of 4 (#1, #2, #3, & #4) sampled residents. The facility failed to apply immobilizer/ splint to Resident #3's left arm for humerus dislocation/ fracture and ensure assist bars to right side of Resident #3's bed.

Inspectors wroteBased on record review and interviews the facility failed to ensure resident medical records reflected the resident wishes for 1 (#1) out of 3 (#1, #2, #3) sampled residents reviewed for advance directives. The facility failed to ensure Resident #1's physician orders and care plan were consistent with the resident's wishes.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident's plan of care was implemented for 1 (#52) of 1(#52) resident out of total of 35 sampled residents. The facility failed to complete resident #52's lab work and chest x-ray as ordered by the physician.

Inspectors wroteBased on record review, observations, and interviews the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 2 (#19, #34) of 2 residents reviewed for ADL's (Activities of Daily Living) by: 1. Failing to provide nail care for Resident #19 and #34 2. Failing to shave facial hair for Resident #34.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by 1. Failing to give a resident's medication dose as prescribed and 2. Failing to notify the physician of missed doses for 1 (#46) resident out of 5 ( #15, #20, #29, #34, #46) residents observed for med pass and 3. Failing to complete glucometer control testing for 6 glucometer machines. This had the potential to affect any of the 15 diabetics in the building.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure residents were free of unnecessary medications for 1 (#268) out of 6 (#63, #37, #10, #15, #49, #268) residents reviewed for unnecessary medications. The facility failed to monitor edema for Resident #268 who received a diuretic.

Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure drugs were stored and labeled properly in accordance with currently accepted professional principles by failing to monitor the temperatures in the medication storage refrigerator. This had the potential to affect any of the 64 residents as listed on the Resident Census and Condition form.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to store and serve food in accordance with professional standards for food service safety for the 64 residents served a meal tray from the kitchen as reported by the Dietary Manager. The facility failed to ensure: 1. Food items in freezers that had been opened were wrapped securely and dated. 2. Evidence of food temperature checks for each food item at each meal had been obtained. 1. Review of Food Receiving and Storage Policy with date of October 2022 revealed: Policy Statement - Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation . 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) .11. The freezer must keep frozen foods frozen solid. [...]

Inspectors wroteBased on record review, observation and interviews, the facility failed to maintain the building in good condition for 1 (#39) resident out of 64 residents residing in the facility according to the Resident Census and Conditions of Residents dated 12/11/2023. The facility failed to ensure bathroom sink in Resident #39's bathroom was in good repair.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure necessary respiratory care and services was provided in accordance with accepted professional standards of practice for 1 (#268) out of 1 (#268) resident reviewed for respiratory care out of a total of 35 sampled residents. The facility failed to store nasal cannula and hand held nebulizer to prevent contamination.

Inspectors wroteBased on record review and interviews, the facility failed to accurately submit payroll information for direct care staffing as required.

Inspectors wroteBased on record review and interview the facility failed to conduct Quality Assessment and Assurance (QAPI) meetings at least quarterly. The facility total census was 64 according to the Resident Census and Conditions of Residents Report form.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an allegation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency for 1 (#2) of 3 (#1, #2, & #3) residents reviewed for abuse.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure resident's property was not misappropriated. The facility failed to ensure 2 (#6, #7) of 7 (#1, #2, #3, #4, #5, #6, #7) resident's narcotic controlled medications were not diverted. The facility failed to ensure narcotic controlled medications were destroyed according to facility policy.