Clayton Nursing and Rehab Center

Inspectors wroteBased on observation, and interviews, the facility failed to properly store medications located in the facility medication storage room when the staff failed to ensure medication fridge temperature log is being monitored routinely. This deficient practice is likely to result in medications being used in resident care at risk of not receiving the full benefits of medication.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions when staff failed to:1. Properly store dishes in sanitary conditions.2. Keep the stove and oven clean. These deficient practices are likely to affect all 36 residents listed on the resident census list provided by the Administrator on 02/09/26 and are likely to lead to foodborne illnesses in residents if safe food handling practices are not adhered to and food stored properly.

Inspectors wroteBased on observation and interviews, the facility failed to implement an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) by1. Not ensuring Personal Protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) was used for residents with required Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities).2. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure a safe, clean, and homelike environment for 3 (R #9, R #13, and R #15) of 9 (R #3, R #4, R #5, R #9, R #13, R #15, R #16, R #33, and R #39) residents reviewed for dining when staff: -Administered medications in the dining area during mealtimes.-Used an overhead paging system to call facility staff.-Maintain the vents in the kitchen to ensure they are free from dirt and dust build up. These deficient practices could likely affect all 30 residents that eat their meals in the dining area, as identified by the list identified by the Dietary Manager on 02/09/26 by creating an uncomfortable and sanitary living environment.

Inspectors wroteBased on record review, observation, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 3 (R #4, R #8, and R #9) of 5 (R #4, R #6, R #8, R #9, and R #11) residents reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 2 (R #8 and R #9) of 4 (R #4, R #8, R #9, and R #28) residents reviewed for care plans. This deficient practice could likely result in residents not getting the needed care and services.

Inspectors wroteBased on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 1 (R #8) of 1 (R #4, R #8, and R #28) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #1) of 3 (R #1, R #3, and R #8) residents reviewed for respiratory care when the facility failed to ensure medical orders indicated the frequency of when to administer R #1 oxygen. These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of their conditions.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the nutritional needs and preferences were met for all 30 residents listed on the facility census provided by the Administrator on 10/28/24 when staff failed to: 1. Serve the food items listed on the menu. 2. Provide residents with an alternate meal menu. If the facility is not providing meal as listed on the menu, an alternative meal or offering an alternate meal menu to residents, then residents are likely to experience weight loss, frustration, and depression.

Inspectors wroteBased on observation and interview the facility failed to store food in a manner that prevented cross contamination when staff failed to label and date open food items. These failures have the potential to result in cross contamination, the growth of food borne pathogens, and food borne illness (foods that are contaminated with harmful pathogens such as bacteria, viruses, and fungi). This failure had the potential to affect all 30 residents who ate food from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to notify 4 (R #3, 21, 24 and 25) residents reviewed of the outcomes/resolutions of their grievances. This deficient practice could likely result in the facility not considering the needs of the residents or adequately resolving their grievances and lead to a decrease in resident quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure the care plan was revised for 1 (R #3) out of 1 (R #3) residents reviewed when staff failed to conduct a quarterly care plan meetings as required. These deficient practices are likely to result in staff not being aware of residents' care needs and preferences, and residents not receiving the needed care.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's ability to perform activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) was maintained for 2 (R #6 and R #25) of 2 (R #6 and R #25) residents reviewed for restorative therapy (RT; therapy in which a resident trains on abilities they already have to perfect them and help maintain the physical abilities to perform ADLs.) If the facility does not ensure that residents receive restorative services, then the residents are likely to experience a decrease in their ability to walk, transfer (move from one place to another), and do other activities of daily living.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were put into place for 6 (R #3, #15, #28, #29, #8 and #7) of 6 (R #3, #15, #28, #29, #8 and #7) residents who had an open wound or a urinary catheter (a thin, flexible tube that is inserted into the bladder through the urethra which is used to drain urine from the bladder when a person is unable to urinate on their own). If EBP are not put in place for residents with sources of multi-drug resistant organisms (MDRO; germs that are resistant to many antibiotics and can cause serious infections.) then the chance of spreading those organisms to all residents in the facility increases. [...]

Inspectors wroteBased on observation, record reviewtyg, and interview, the facility failed to provide reasonable accommodations of resident needs and preferences for 1 (R #6) of 1 (R #6) residents reviewed when staff did not ensure R #6 had access to his call light. These deficient practice is likely to result in residents being unable to request assistance in times such as needing help with transferring, after falling, or other acute distress.

Inspectors wroteBased on interview, the facility failed to ensure foods were palatable (pleasant to taste) and to the resident's satisfaction for 1 (R #21) of 1 (R #21) residents. This deficient practice is likely to affect residents' ability to eat and enjoy meals, and is likely to cause unplanned weight loss. A. On 10/28/24 at 2:47 PM, during an interview with R #21, R #21 stated that on 10/27/24 during dinner the previous night the macaroni salad was extreme. The resident stated the macaroni salad smelled burnt. R #21 stated the peach cobbler had salt instead of sugar. B. On 10/30/24 at 9:05 am during interview, [NAME] #1 stated they came to work on 10/29/24, and there was burnt pasta in the refrigerator from the dinner the night before (10/28/24). C. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that medications were stored safely and securely. This deficient practice is likely to affect all 31 residents identified on the alphabetical census list provided by the Director of Nursing on 10/2/23. This deficient practice is likely to put residents at risk of overdosing/taking medication that is not prescribed to them if residents have access to unsecured medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the nutritional needs and preferences were met for all 31 residents listed on the facility census provided by the Director of Nursing (DON) on 10/02/23 by not following Dietitian approved menu's, and not communicating with Dietitian when there is a meal substitution. These deficient practices are likely to result in resident weight loss, frustration, and not meeting their nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to treat and communicate resident's pain levels with their physician for 1 (R #22) of 1 (R #22) resident reviewed for pain management. If facility fails to communicate pain levels to physicians, then residents are likely to experience exacerbated (make worse) pain.

Inspectors wroteBased on record review, interviews, and observations the facility failed to honor resident meal preferences for 2 (R #'s 1 and 22) of 2 (R #'s 1 and 22) residents by not providing the meal selected by the residents on their meal tickets. This deficient practice is likely to result in weight loss due to the resident not eating and/or an allergic reaction to the food being served to the resident.

Inspectors wroteBased on record review and interview, the facility failed to ensure that medical records were complete and accurate for 1 (R #22) of 1 (R #22) resident reviewed. This deficient practice is likely to result in staff not knowing resident's pertinent discharge information and communication preference.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately establish, maintain, and implement an infection prevention and control program for all residents by failing to: 1. Ensure clean laundry area and dirty laundry areas were kept separate from each other. 2. Ensure that if no door exists between the soiled and clean areas that there was a negative pressure system in place. 3. Ensure that R #8's Foley catheter bag (FCB) was not on the floor. 4. Ensure that R #27's nasal cannula tubing [oxygen (O2) tubing used to deliver O2 to the face of the person wearing it] was not on the floor. Failure to plan and implement an infection control program is likely to cause the spread of infections and illness to residents and staff within the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that medications were administered as ordered for 1 (R #29) of 1 (R #29) residents reviewed for medications not administered as ordered by the physician. This deficient practice can likely result in a resident failing to obtain maximum wellness and/or suffering prolonged illness.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents have a safe and functional environment for 2 (R #4 and #20) of 2 (R #4 and 20) residents reviewed. This deficient practice could likely result in residents living in an environment in poor repair.