Claiborne Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to provide written notice to residents and/or their RP (Responsible Party) of the bed hold agreement at time of transfer and update the emergency transfer log (Notice of Discharge to the ombudsman) for 1 (#7) of 2 (#7 & #44) residents reviewed for hospitalizations. Findings:Review of Resident #7's medical record revealed an admission date of 11/05/2024 and diagnoses of unspecified protein-calorie malnutrition, repeated falls, muscle weakness (generalized), and dementia. Review of Resident #7's medical record revealed the following transfer dates: 01/31/2025, 05/22/2025, and 07/10/2025. Review of Resident #7's bed hold agreement form failed to reveal notification to resident/RP was sent at time of transfer for dates 01/31/2025 and 05/22/2025. Further review failed to reveal Resident #7's bed hold agreement was sent at discharge on [DATE]. During an interview on 09/16/2025 at 1:55 p.m. S3 Business Office Manager reported Resident #7's bed hold agreement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and an interview the facility failed to ensure services provided met professional standards of quality for 1 (#5) of 1 resident with a peg (percutaneous endoscopic gastrostomy) tube observed during medication administration. Review of facility's Administering Medications through an Enteral Tube policy (revision date 01/15/2025) revealed in part:Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. Steps in Procedure:6. Verify placement of feeding tube:a. If you suspect improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse or Physician. Review of Resident #5's medical diagnoses revealed the following but not limited to encounter for attention to gastrostomy, unspecified psychosis not due to a substance or known physiological condition, and intractable status epilepticus. Review of Resident #5's September 2025 physician orders revealed: 08/29/2025: Isosource 1.5cal (calorie) at 55ml (milliliters)/hour to total 660ml/990kcal (calorie…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observations and interviews, the facility failed to provide current pharmaceutical services to meet the needs of each resident as evidenced by having expired medications and supplies readily available for resident use on 1 (cart A) of 1 medication cart and in 1 (medication storage room A) of 2 medication storage rooms observed. Findings:Review of the facility's Storage of Medications policy dated 01/15/2025 revealed in part:4. Discontinued, outdated, or deteriorated drugs or biologicals are destroyed. Expiration dates should be used on the manufactured label.An observation on 09/17/2025 at 9:11 a.m. with S4 DON (Director Of Nursing) revealed medication storage room A contained multiple medications available for use with expiration dates of:1.) 3 bottles- UTI (Urinary Tract Infection) Stat dated 06/25/2025 2.) 9 bottles- Iodoform packing strips dated 07/20253.) 2 bottles- Unna-2 zinc paste bandages dated 02/2024 and 01/01/20254.) 1 box (144 packets)- hydrocortisone cream 1% dated 11/2024 (opened)During an interview on 09/17/2025 at 9:12 a.m. S4 DON confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure residents' medical records reflected the resident's advance directive wishes for 1 (#6) of 19 (#1, #6, #7, #9, #10, #17, #18, #24, #27, #28, #29, #32, #36, #37, #38, #39, #90, #92, #240) total sampled residents. The facility failed to ensure the profile page, physician's orders, medication administration records, comprehensive care plan and LaPost (Louisiana Physician Orders for Scope of Treatment) were consistent with the resident's wishes for advance directives. Findings: Review of Resident #6's medical record revealed an admit date of [DATE] and Resident #6's profile page indicated Resident #6's code status to be Full Code: May use AED (automated external defibrillator) unless contraindicated. Review of Resident #6's physician orders revealed an order dated [DATE] for Full Code, may use AED unless contraindicated. Further review revealed an order dated [DATE] admit to hospice. Review of Resident #6's August and [DATE] medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, and interviews, the facility failed to ensure the correct use and the maintenance of bed rails by ensuring residents were care planned for the use of bed rails, assessed for the risk of entrapment from bed rails, and a written order was obtained from the physician for bed rails prior to installation for 4 (#7, #27, #90, #240) out of 5 (#6, #7, #27, #90, #240) residents reviewed for accidents. Findings: Resident #7 Review of Resident #7's medical record revealed an admit date of 09/10/2019 with diagnoses including, but not limited to, chronic obstructive pulmonary disease, dementia with behavioral disturbance, and lack of coordination. Review of Resident #7's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 7 indicating severely impaired cognition and Resident #7 was totally dependent of one staff for bed mobility. Review of Resident #7's medical record failed to reveal a physician's order for bed rails, a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure Enhanced Barrier Precautions (EBP) were in place. This deficient practice had the potential to affect any of the facilities 46 residents. Findings: Review of the facility's policy Enhanced Barrier Precautions with and effective date of 04/01/2024 revealed in part: Definition and Scope: Enhanced Barrier Precautions (EBP) are infection control interventions designed to reduce transmission of multidrug-resistant organisms (MDROs). Example of Use: EBP involve gown and glove use during high-contact resident care activities for residents know to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, and interviews the facility failed to ensure a resident has a right to be free from any physical restraint not required to treat the resident's medical symptoms for 1 (#37) resident out of 2 (#37 and #90) residents investigated for physical restraints. The facility failed to ensure 1.) A written order was in place 2.) A consent for the use of a lap tray was obtained, 3.) A specific reason for the restraint and 4.) An assessment was completed for the use of a lap tray for Resident #37. Findings: Review of the facility's Use of Restraints policy with a revision date of 01/12/2024 revealed in part: Policy Statement: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. Policy Interpretation and Implementation: 1. Physical Restraints are defined as any manual method of physical or mechanical device, material…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews the facility failed to ensure a resident's elopement from the facility was reported to the State Survey Agency in accordance with State law no later than 24 hours for 1 (#1) of 3 (#1, #2, #3) sampled residents. Findings: Review of the current Facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy revealed in part: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown soured is suspected, the suspicion must be reported immediately to the administrator and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the provider failed to ensure a resident's code status was correct for 1(Resident #10) of 1(Resident #10) reviewed for advanced directives/code status. Findings: Record review of Resident #10's EHR (Electronic Health Record) revealed Resident #10 was admitted to the facility on [DATE] with a primary diagnosis of displaced intertrochanteric fracture of left femur, initial encounter for closed fracture. Record review of Resident #10's physician orders in EHR for [DATE] revealed there was no code status ordered. Record review of Resident #10's medical record revealed the following: 1. A red colored paper with STOP DNR (Do Not Resuscitate) for Resident #10 dated [DATE]. 2. A LaPOST (Louisiana Physician Orders for Scope of Treatment) dated [DATE] indicated to do CPR (Cardiopulmonary Resuscitation). Record review of Resident #10's MDS (Minimum Data Set), Section C showed a BIMS (Brief Interview Mental Status) of 12 that would indicate moderately impaired. Record review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (#7) of 2 (#7, #44) sampled residents reviewed for skin conditions and 1 (#12) of 1 (#12) sampled resident reviewed for pressure ulcers. The facility failed to ensure: 1. Resident #7's wound care was conducted as ordered. 2. Resident #12's wound care and Calmoseptine ointment to perineal area was completed daily. Findings: Resident #7: Review of Resident #7's medical record revealed Resident #7 was admitted to the facility on [DATE] and had diagnoses that included, in part, other specified disorders of the skin and subcutaneous tissue, localized edema, Alzheimer's disease, dementia, osteoarthritis, [NAME] tear, unspecified cerebral infarction, and combined systolic (congestive) and diastolic(congestive) heart failure. Review of Resident #7's 05/30/2023 Quarterly MDS (Minimum Data Set) revealed Resident #7 had a BIMS (Brief Interview Mental Status)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interviews, the facility failed to maintain an effective infection control and prevention program designed to provide a safe and sanitary environment by failing to ensure staff performed hand hygiene while serving dietary trays and beverages. The deficient practice had the potential to affect 46 residents according to the Resident Census and Conditions of Residents Report. Findings: An observation on 09/18/2023 at 12:15 p.m. during lunch revealed S6 CNA (Certified Nursing Assistant) began serving the residents' lunch trays and beverages from the dietary cart. S6 CNA served lunch trays and beverages to room a, room b, room c, room d, room e, room f, and room g. The surveyor observed S6 CNA touch the residents' door knobs, overbed tables, and a resident's wheelchair without using hand sanitizer in between each residents' room while he passed their trays. During an interview on 09/18/2023 at 12:30p.m. S6 CNA revealed he only used hand sanitizer in the dining room when he picked up the dietary cart. S6 CNA confirmed he did not use hand sanitizer each time he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews the facility failed to ensure all patient care equipment was maintained in safe operating condition by failing to repair equipment for 3 (#6, #22, #36) residents out of 21 residents with mobility in a chair all or most of the time according to the Resident Census and Conditions of Residents Report. The facility failed to maintain the following patient care equipment: a wheelchair arm rest (#6); a wheelchair arm tray (#22); and brakes on a gerichair (#36). Findings: Resident #6: An observation on 09/18/2023 at 10:00 a.m. revealed Resident #6's left arm rest on his wheelchair was dirty, the material was peeling away and the corners were torn. During an interview on 09/20/2023 at 1:15 p.m. S3 LPN (Licensed Practical Nurse)/ADON (Assistant Director of Nursing) observed and acknowledged Resident #6 was in need of a new left arm rest for his wheelchair. S3 LPN/ADON acknowledged Resident #6's arm rest had tears, peeling material and was dirty. Resident # 22: An observation on 09/18/2023 at 11:35 a.m. and 09/19/2023 at 9:44 a.m. revealed Resident # 22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a Discharge MDS (Minimum Data Set) Assessment and a readmission MDS Assessment was completed after a resident was discharged from and readmitted to the facility. The deficient practice affected 1 (#36) of 2 (#36, #102) residents investigated for hospitalizations. Findings: Review of Resident #1's EHR (Electronic Health Record) revealed an original admission date of 08/18/2012. Review of Resident #36's Nurses Notes dated 08/11/2023 at 11:25 a.m. revealed the ambulance service was called for transportation and the ER (Emergency Room) was notified. Review of Nurses Notes dated 08/11/2023 at 12:02 p.m. revealed an ambulance service transported Resident #36 to a local hospital for further evaluation and treatment. Review of Resident #36's Nurses Notes dated 08/11/2023 at 13:25 p.m. revealed Resident #36 was admitted to the hospital. Review of Resident #36's paper chart revealed Physician Order dated 08/16/2023 to continue previous orders. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a Significant Change in Status Minimum Data Set (MDS) Assessment was completed within 14 days of a resident sustaining a right hip fracture for 1 (#45) of 2 (#7, #45) sampled residents reviewed for falls. Findings: Record review revealed Resident #45 had diagnoses including a history of cerebrovascular accident and a nondisplaced intertrochanteric fracture of the right femur. Record review of Resident #45's Quarterly MDS dated [DATE] revealed he had a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Further review of his functional status revealed he required the following assistance: supervision/set up help only for eating; supervision/1 person assistance for bed mobility, transfer, walk in room/corridor, dressing and toilet use; and limited assistance/1 person assistance for personal hygiene. Record review of Resident #45's Quarterly MDS dated [DATE] revealed he had a BIMS score of 8, which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.