Clay Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600May 22, 2025

  Based on record review, and staff interviews, the facility neglected to provide the amount of assistance and supervision needed to prevent a resident from aspiration. On 05/22/25 at 6:00PM, the state agency notified the facility of the finding of past-noncompliance Immediate Jeopardy (IJ) that began on 03/19/25 and ended on 03/24/25. The deficient practices caused actual harm to Resident #16. The facility's neglect of the resident created a case of physical harm. The resident required transfer to the emergency room for evaluation and had to undergo medical testing. Resident identifier: #16. Facility census: 53. Findings included: a) Resident #16 Medical Record Review (MRR) revealed Resident #16 had resided in the facility since 2018. […]

• No harm, potential for more than minimal, widespreadF756Nov 1, 2023

  Based on policy review, medical record review and staff interview, the pharmacist failed to identify an incomplete order for risperidone (atypical antipsychotic with no indication for use). In addition the Medication Regimen Review (MRR) policy lacks specific time frames for the different steps in the review process. This is true for one (1) of five (5) reviewed for unnecessary medications. The policy has the potential to affect all residents in the facility. Resident identifier: #36. Facility census: 55. Findings included: a) MRR Policy The facility's MRR policy # NS 1218-01 lacks time frames for the different steps in the process when an irregularity is identified. […]

• No harm, potential for more than minimal, patternF880May 22, 2025

  Based on observation, medical record review and staff interviews, the facility failed to maintain an effective infection control program. Failed to complete hand hygiene after removing gloves and did not re-glove when providing care for a resident who was on enhanced barrier precautions (EBP). In addition, ten (10) Personnel Protection Equipment (PPE) Storage Bins were sitting directly on the hallway floor. Three (3) wheelchairs were found with cracked arm rests and could not be sanitized. A Nurse Aide (NA) did not perform hand hygiene prior to feeding a resident. These failed practices had the potential to affect more than a limited number of residents. Resident identifiers: #15, #16, and #30. […]

• No harm, potential for more than minimal, patternF755Nov 1, 2023

  Based on the pharmacy services agreement, medical record review and staff interview, the facility failed to ensure routine and emergency medications were available to meet the residents' needs. Paxlovid was not available to treat a Covid positive resident and Tylenol with Codeine was not available to treat a resident's pain after a fall. This is true for one (1) of one (1) reviewed for Covid and one (1) of three (3) residents reviewed for falls. Resident identifiers: R#43 and R#2. Facility census: 55. Findings included: a) Resident (R) #43 A review of the medical record on 10/31/23, found R #43 was Covid positive on 10/27/23. The Nurse Practitioner (NP) prescribed Paxlovid. The order written on 10/27/23 stated: Paxlovid 300/100 oral therapy Pack 20 x 150 milligrams (mg) and 10 x 200 mg. […]

• No harm, potential for more than minimal, patternF695Jun 29, 2022

  Based on record review and staff interview, the facility failed to ensure residents who required respiratory care, was provided that care in accordance with professional standards of practice. Orders for oxygen flow rates did not include a specific rate for providing oxygen to the resident. This was true for four (4) of five (5) residents reviewed for oxygen therapy during the Long-term survey process (LTCSP). Resident identifiers: Residents #21,#9, #101, and #8. Census: 52. Findings included: a) Resident #9 A review of the medical record for Resident #9, noted an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . […]