Clay Healthcare Center

Inspectors wroteBased 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.

Inspectors wroteBased 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. Facility census: 53.

Inspectors wroteBased upon record review and staff interview, the facility failed to update the Pre admission Screening and Resident Review (PASARR) when the resident was diagnosed with Major Depressive disorder. This was found to be true for one (1) resident of the four (4) reviewed during the annual survey process. Resident identifier #53. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to have a diagnosis of depression for the order of an antidepressant medication. This was true for one (1) of seventeen (17) residents reviewed during this annual survey process. Resident identifier # 258. Facility census:

Inspectors wroteBased on record review and staff interview, the facility was unable to provide evidence that the attending physician reviewed any irregularities identified by the pharmacist and either accepted or rejected the recommendations. This was true for two (2) of five (5) residents reviewed under the Unnecessary Medications pathway in the Long-Term Care Survey Process. Resident identifiers: #30 and #52. Facility census:

Inspectors wroteBased on observation and staff interviews, the facility failed to store food in accordance with professional standards for food service safety. This was a random opportunity for discovery with the ability to affect a multiple number of residents. Facility census: 53.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure disposal of garbage and refuse was properly contained in the kitchen pantry and in dumpsters with lids closed or covered. This was a random opportunity for discovery with the possibility of affecting multiple residents. Facility census: 53.

Inspectors wroteBased upon record review, staff interview and resident interviews, the facility failed to maintain an accurate medical record. This was found to be true for two (2) of seventeen (17) records reviewed during the annual survey process. Resident identifiers: #50 and #51. Facility census:

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the call system was accessible to residents while in their bed or other sleeping accommodations within the resident's room. This was a random opportunity for discovery. Resident identifier: #19. Facility census: 53.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure call lights were within reach for residents who had the ability to utilize them to request help. This was true for one (1) of two (2) residents reviewed under the environment pathway. Resident identifier: #16. Facility census: 55.

Inspectors wroteBased on observation and staff interview, the facility failed to respect residents' right to personal privacy and confidentiality of the medical record. This was a random opportunity for discovery. The failed practice was true for three (3) of 18 sample residents. Resident identifiers: #254, #38, and #34. Facility census: 55.

Inspectors wroteBased on observation and staff interview, the facility failed to honor the resident's right to a safe, clean, comfortable, and homelike environment. The facility failed to ensure a wall in a resident room was in good repair. Room identifier: 117. Resident identifier: #255. Facility census: 55.

Inspectors wroteBased on policy review, record review, and staff interview, the facility failed to ensure that all alleged violations involving abuse were reported. This was true for one (1) of (2) residents reviewed under the abuse pathway. Resident identifier: #19 . Facility census: 55.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a new PASARR (Pre-admission Screening) with a new diagnosis. This is true for one )1) of one (1) reviewed for PASARR. Resident identifier: #36. Facility census: 55.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure each resident had a person-centered comprehensive care plan, developed and implemented, with specific interventions of care to address the resident's medical, physical, mental, and psychosocial needs for three (3) of 18 sample residents reviewed. Resident #28's and Resident #104's care plan failed to address specific non-pharmacological approaches to anxiety. Resident #34's care plan failed to have specific Hospice approaches addressed. Resident identifiers: Resident #34, #104 and #28. Facility census: 55.

Inspectors wroteBased on record review and staff interview, the facility failed to revise a resident's comprehensive care plan based on an identified change in the residents care that was no longer applicable to the plan of care for one (1) of 18 sampled residents reviewed. Resident #28 no longer was receiving oxygen therapy, however, the focus problem with goals and approaches were continued to be included on the the current care plan. Resident identifier: Resident #28. Census: 55.

Inspectors wroteBased on observations, record review, and staff interview, the facility failed to provide an activity program that meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was found true for two (2) of (18) residents reviewed during the long-term care survey process. Resident identifiers: #8 and #19. Facility census: 55.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. A resident was given an antibiotic without adequate indications for its use. This was true for one (1) of two (2) residents reviewed under the antibiotic pathway. Resident identifier: #9. Facility census: 55.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure an order for a psychotropic medication included an indication for use. This is true for one (1) of five (5) residents reviewed for medications. Resident identifier: #36. Facility census: 55.

Inspectors wroteBased on contract review, record review and staff interview, the facility failed to ensure radiology services were available to meet a resident's needs. This is true for one (1) of three (3) residents reviewed for falls. Resident identifier: #2. Facility census: 55.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records. Physician Orders for Scope of Treatment (POST) forms were incomplete and/or inaccurate for one (1) of 18 records reviewed for accurate POST forms. Additionally, two (2) nurses signed off the administration of a medication which was not available in the facility. This was true for two (2) of five (5) scheduled medication times. Resident identifiers: #47 and #43. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident's antibiotic was the appropriate one for the infection it was being used to treat. A resident was given an antibiotic without adequate indications for its use. This was true for one (1) of two (2) residents reviewed under the antibiotic pathway. Resident identifier: #9. Facility census: 55.

Inspectors wroteBased 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.

Inspectors wroteBased on anonymous resident and family interviews, anonymous staff interviews, feedback in the Resident Council meeting, review of staffing sheets, review of the facility assessment, and staff interview, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights and physical, mental, and psychosocial well-being. Facility census:

Inspectors wroteBased on review of facility documentation, and staff interview , the facility failed to have the required members attend the Quality Assessment and Assurance (QAA) meetings at least quarterly. The facility failed to ensure the Medical Director or designee attended the QAA meetings at least on a quarterly basis. This practice had the potential to affect more than a limited number of residents. Facility census: 52.

Inspectors wroteBased on observation, staff and resident interview, the facility failed to provide care that promoted dignity for Resident #16. During a random opportunity for discovery, a sign was observed above a resident's bed noting the resident had an incontinent appliance. Resident identifier: Resident #16. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to have a Preadmission Screening and Resident Review (PASARR) Level II evaluation completed on a resident living in the facility. Resident identifier: #43. Facility census: 52. Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings. Regulations governing PASARR are found at 42 CFR 483.100-483.138. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to initiate a care plan for recent treatment with psychologist. This was a random opportunity for discovery. Resident identifier: #19. Facility census 52.

Inspectors wroteBased on record review and staff interview, the facility failed to revise a care plan in a timely manner. This was true for one (1) of 20 sample residents. Resident identifier: #19. Facility census 52.

Inspectors wroteBased on review of medical records and staff interview, the facility failed to provide necessary treatment services, consistent with professional standards of clinical practice by not administering an antibiotic medication as ordered by a physician. This was true for one (1) of 20 residents reviewed in the annual long-term care survey process. Resident identifier: #28. Facility census: 52.

Inspectors wroteBased on record review and staff interview, the facility failed to obtain accurate weights and verify weights as needed. This was true for one (1) of 20 residents sampled during the annual long-term care survey process. Resident identifier: #49. Facility census: 52.

Inspectors wroteBased on record review and staff interview, the facility failed to provide treatment / to intervene and seek psychologist consult in a timely fashion. This is true for one (1) of 20 residents reviewed in sample. Resident identifier: #19. Facility Census 52.