Clayberg, The

In the surveyor’s words

From the most serious findings on record at Clayberg, The, in the surveyor’s own words.

• Actual harm, isolatedF686Aug 4, 2026

  Based on observation, interview, and record review, the facility failed to implement pressure ulcer prevention interventions for a resident at moderate risk for skin breakdown; failed to complete required monthly skin checks and weekly skin assessments; and failed to timely assess and measure a newly identified pressure ulcer for one of three residents (R1) reviewed for pressure ulcers. This failure resulted in R1 developing an unstageable, infected pressure ulcer to the right ischium.Findings Include:The facility's Policy and Procedure for the prevention and treatment of skin breakdown policy, not dated, documents, it is the policy to properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement… […]

• Actual harm, isolatedF689Mar 2, 2023

  Facility failures resulted in two deficient practices. A. Based on interview, observation, and record review, the facility failed to ensure fall prevention interventions were in place and new fall prevention interventions were implemented following a fall for one of one resident (R31) reviewed for falls in the sample of 26. As a result, on 09/13/22, R31 was witnessed ambulating barefoot, and subsequently slipping and falling. R31 was transported to a local hospital for evaluation where she was diagnosed with sustaining a left clavicle fracture and a fracture of the left distal radius during the fall. B. Based on interview, observation and record review, the facility failed to prevent a resident identified as an elopement risk from eloping the building unsupervised. […]

• No harm, potential for more than minimal, patternF880Apr 4, 2025

  Based on observation, record review, and interview, the facility failed to follow standard precautions and perform hand hygiene before or after administration of oral medications for eight residents (R2, R4, R6, R15, R21, R25, R29, and R33) and failed to not touch medications with bare hands (R21) out of nine residents reviewed for medication administration in a sample of 29. Findings include: The facility's Administering Oral Medications policy, dated 2010, under Steps in the Procedure documents the following steps: 1.) Wash your hands. […]

• No harm, potential for more than minimal, patternF758May 15, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents receiving antipsychotic medications had relevant clinical indication and diagnosis for the use of antipsychotic medication for five residents (R21, R28, R30, R42, and R43), and failed to include targeted behaviors for one (R42) of five residents reviewed for unnecessary medications in the sample of 23. Findings include: An Antipsychotic Medication Use policy, revised December 201,6 under a section titled Policy Interpretation and Implementation the following: 7. […]

• No harm, potential for more than minimal, patternF880Aug 5, 2021

  Based on observation, interview, and record review, the facility failed to separate COVID positive residents and residents who are quarantined for exposure for 6 residents (R6-R11) reviewed for COVID in a sample of fifteen. Findings Include: The CDC (Center for Disease Control) guidelines for COVID-19 in Long Term Care shows The location of the COVID-19 care unit should ideally be physically separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. […]