Claiborne Healthcare Center

In the surveyor’s words

From the most serious findings on record at Claiborne Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF684Feb 22, 2024

  Based 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. […]

• Immediate jeopardy, widespreadF689Feb 22, 2024

  Based 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. […]

• Immediate jeopardy, widespreadF726Feb 22, 2024

  Based 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. […]

• Immediate jeopardy, widespreadF835Feb 22, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689Jun 5, 2026

  Based 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. […]