Clay County Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Clay County Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF882May 1, 2026

  Based on staff interviews, the facility failed to designate a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program. This had the potential to affect all the residents residing in the facility.Findings included:During the Entrance Conference with the Administrator on 4/27/26 at 11:02 AM, he revealed the facility's Infection Preventionist position was currently vacant and the Assistant Director of Nursing (ADON) and Director of Nursing (DON) were performing those duties. […]

• No harm, potential for more than minimal, patternF760May 1, 2026

  Based on record review, staff, Pharmacist, and Medical Director interview, the facility failed to transcribe and implement orders for diabetes care according to the hospital discharge summary for a resident with diabetes. Additionally, the facility failed to transcribe and implement orders for the same resident's Coreg (used to treat heart failure and hypertension) according to the hospital discharge summary. This deficient practice occurred for 1 of 5 residents reviewed for significant medication errors (Resident #23).Findings included.Resident #23 was re-admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF641Feb 27, 2025

  Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of bed rails and diagnoses for 7 of 12 sampled residents reviewed for physical restraints, respiratory care and unnecessary medications (Residents #1, #51, #63, #13, #65, #24, and #47). Findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included history of falling, generalized muscle weakness and left shoulder pain. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had intact cognition and required substantial/maximum assistance with bed mobility. […]

• No harm, potential for more than minimal, patternF756Oct 26, 2023

  Based on record review and interviews with the resident, staff, Consultant Pharmacist, and the Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities and provide recommendations for 1 of 4 residents reviewed for diabetes management (Resident #39). The findings included: Resident #39 was admitted to the facility on [DATE] with diagnosis including diabetes mellitus. Review of physician's orders dated 07/05/23 revealed Resident #39 had an order to receive 10 units of Humalog insulin subcutaneously 3 times daily before meals for diabetes. The order specified holding the insulin when Resident #39's capillary blood glucose (CBG) was lower than 120 milligrams per deciliter (mg/dL). […]

• No harm, potential for more than minimal, patternF760Oct 26, 2023

  Based on record review and interviews with the resident, staff, Consultant Pharmacist, and the Medical Director (MD), the facility failed to prevent significant medication errors when 5 nurses failed to follow the physician's parameter as ordered during insulin administration. As a result, Resident #39 had received 2 doses or unnecessary Humalog insulin and her insulin had been held against the parameter 17 times within 112 days. This affected 1 of 4 residents reviewed for diabetes management (Resident #39). The findings included: Resident #39 was admitted to the facility on [DATE] with diagnosis including diabetes mellitus. The care plan initiated on 06/15/20 indicated Resident #39 had diagnosis of diabetes mellitus. […]