Clayton Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Oct 30, 2025

  Based on observation, record review, and interviews with staff, Physician, Paramedics, and Fire Department First Responders, the facility failed to ensure basic lifesaving support was provided effectively when residents lost signs of life on weekends. The facility failed to ensure emergency equipment was in a place which would not delay resuscitation efforts for Resident # 21. One facility nurse (Nurse # 1) reported a delay in finding an AMBU bag (Artificial Manual Breathing Unit) to ventilate Resident # 21 and another facility nurse (Nurse # 2) along with emergency medical responders reported an AMBU bag was never used by facility staff to ventilate Resident # 21. […]

• Immediate jeopardy, isolatedF684Jul 21, 2021

  Based on record review and staff and physician interviews the facility failed to reconcile and transcribe the hospital physician discharge orders on readmission to the facility and failed to provide glucose monitoring and sliding scale insulin coverage as recommended by the hospital discharging physician for 1 of 3 resident (Resident #168) reviewed for diabetic management. This resulted in Resident #168 being admitted to the hospital on 07/06/2019 for diabetic ketoacidosis (DKA) which required the administration of intravenous insulin. DKA is the formation of a toxic chemical in the blood caused by prolonged high blood glucose which can be life threatening. […]

• Actual harm, isolatedF686Oct 30, 2025

  Based on observation, record review, and interviews with resident, staff, responsible party (RP), Physician, Physician Assistant, Nurse Practitioner, and Hospice Nurse the facility failed to, 1) ensure the Wound Physician's unclear plan of pressure sore treatment for a resident (Resident # 17) was clarified 2) ensure a dressing was changed when a resident's (Resident # 17's) dressing saturated through to the pillowcase and the resident voiced pain from the pressure sore 3) ensure treatment orders were obtained and initiated when residents (Resident # 1 and Resident # 18) were identified with pressure sores (4) ensure nurses knew they were responsible for pressure sore care for residents (Resident # 1 and Resident # 26) and that care was completed and 4) ensure a nurse could access the… […]

• No harm, potential for more than minimal, widespreadF755Oct 30, 2025

  Based on record review, staff interviews, and a pharmacy consultant interview, the facility failed to have effective systems in place for the return of controlled medications to the pharmacy for 4 of 4 medication carts (100-hall, 200-hall, 300-hall, 400-hall). Findings included:Documentation of instructions on the Shift Change Controlled Substance Inventory Count sheets revealed every controlled substance medication and count sheet added or removed from the medication cart must be documented on the form.Documentation on the Shift Change Controlled Substance Inventory Count sheet, dated as initiated on [DATE] for the 100-hall medication cart, revealed the following information. […]

• No harm, potential for more than minimal, patternF812Feb 13, 2026

  Based on observations and staff interviews, the facility failed to clean 1 of 1 walk-in refrigerator in the main kitchen, failed to label and date opened non-perishable food items stored in the dry goods pantry in the main kitchen, and failed to label juice stored for use in 1 of 2 nourishment refrigerators (Nourishment room [ROOM NUMBER]). This practice had the potential to affect the food served to residents. The findings included: a. During the initial tour of the main kitchen on 2/9/26 at 10:25 AM with Dietary Manager #1 an observation of the walk-in refrigerator revealed a puddle of milk from two busted 8-ounce cartons of milk on the floor under the storage racks on back wall of refrigerator. […]