Clayton Rehab: Diabetic Wound Care Missed for Days - NC
The resident, identified in inspection records only as Resident 1, had active diabetic ulcers on his right great toe and right ankle. A wound physician had written orders for diabetic wound care. On September 17 and September 18, the treatment administration record shows blanks where a nurse's initials should appear confirming the treatments were done.
Nobody had done them.
The staffing picture inspectors pieced together shows how the gap happened. A medication aide held the primary assignment on the day shifts for both days. Nurses were designated to cover that medication aide's responsibilities. On September 17, Nurse 18 covered the medication aide during the day. Nurse 5 signed for medications that evening, according to the medication administration record. On September 18, Nurse 9 covered the medication aide during the day, and Nurse 5 was assigned to the resident on the evening shift.
When inspectors interviewed Nurse 18 on October 16, she said she had never performed treatments for Resident 1. She had not been told it was her responsibility.
The nurse who had been covering insulin for the medication aide told inspectors she did not think it was realistic to carry her own patient assignment on another hall, cover insulin, and also complete treatments, even if she had been told to do so.
Nobody disputed that the treatments were missed. The blanks in the record are unambiguous.
The wound physician saw the resident again on September 19, the day after the second missed treatment. He documented that the right great toe diabetic ulcer measured 0.8 centimeters by 0.5 centimeters with no measurable depth. He noted the wound's progress was not at goal, attributing this to the resident's generalized decline. The right ankle wound, measuring 1 centimeter by 1 centimeter with no measurable depth, he described as at goal.
On September 25, the resident was transferred to another facility.
When inspectors spoke with the wound physician on October 17, he said that the last time he saw Resident 1, there had been no signs of infection. He considered the wounds stable. He also noted the resident carried multiple serious conditions, including diabetes, congestive heart failure, and chronic obstructive pulmonary disease, any of which could reduce oxygen delivery to wounds and slow healing.
The inspection, conducted as a complaint investigation and completed October 30, 2025, cited the facility under a deficiency tag associated with providing care and services to attain or maintain residents' highest practicable well-being. Inspectors rated the harm level as minimal or potential for actual harm.
What the record shows is a man with wounds that require consistent daily attention, a staffing structure that left the question of who was responsible unanswered across two shifts on two consecutive days, and a set of nurses who each, when asked, said the same thing: no one told me.
The wound physician said the wounds were stable when he last checked. He did not say what two days without treatment meant for a diabetic patient whose progress was already not at goal.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clayton Rehabilitation and Healthcare Center from 2025-10-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
Clayton Rehabilitation and Healthcare Center in Clayton, NC was cited for violations during a health inspection on October 30, 2025.
The resident, identified in inspection records only as Resident 1, had active diabetic ulcers on his right great toe and right ankle.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.