Clayton Rehab: Dietary System Failed Nonverbal Resident - NC
The woman, identified in federal inspection records only as Resident 4, has highly impaired hearing and is nonverbal. She can communicate through sign language, writing, and a communication board. According to her responsible party, some staff simply do not try.
Inspectors from the Centers for Medicare and Medicaid Services visited Clayton Rehabilitation and Healthcare Center on October 15 and 16, 2025, and observed both meals firsthand.
On October 15, at 1:15 in the afternoon, the resident sat in the dining room with a peanut butter and jelly sandwich, carrots, potatoes, and a cookie. The posted menu that day listed hamburger steak as the main entree, chicken fried steak as an alternative, and thyme chicken as an additional option. A corporate regional manager confirmed the thyme chicken was available. Inspectors watched the entire meal. No staff member approached the resident to offer her any of the meat entrees.
The next day was the same. At 12:55 PM on October 16, the resident received another peanut butter and jelly sandwich, this time with potato salad, salad, and fruit cocktail. Other residents were served lasagna. An egg salad sandwich was listed as an alternate entree on the dining room board.
When inspectors asked the facility's corporate regional dietary manager to look at the resident's tray that second afternoon, the manager's explanation was simple: the resident must not have liked the steak the day before, or the lasagna that day.
The resident's family member told inspectors a different story entirely.
The responsible party said the peanut butter and jelly sandwich was supposed to be a supplement added alongside a main entree, not a replacement for one. The resident liked chicken. She would have eaten the thyme chicken on October 15 if anyone had offered it to her. The responsible party used sign language with the resident directly and confirmed she also would have eaten the egg salad sandwich on October 16 if someone had tried to communicate with her.
Food had been a recurring problem, the responsible party told inspectors. She had raised the issue with facility staff before. Staff would tell her the resident did not like beef or pasta, which they said limited what they could offer on certain days. The responsible party pushed back on that characterization. The resident did like some kinds of beef. Certain cuts were harder for her to swallow, but that was not the same as a blanket dislike. She liked lasagna. Her difficulty was with macaroni noodles specifically, not pasta across the board.
The real explanation, it turned out, was in the software.
The dietary manager and the corporate regional dietary manager, interviewed together on the evening of October 16, described a computer system the facility uses to track resident food preferences, likes, and dislikes. Resident 4 had accumulated a long list of beef-related dislikes in the system. When the system detected that beef was the main entree, it automatically flagged the peanut butter and jelly sandwich as her alternative entree. It did not flag the thyme chicken on October 15. It did not flag the egg salad sandwich on October 16. It did not prompt staff to offer her anything else.
The peanut butter and jelly sandwich, the managers acknowledged, was designed to be a side supplement to accompany a main entree. The system had not been recognizing it that way.
The resident is diagnosed with both dementia and protein calorie malnutrition. Her quarterly assessment from September 2025 rated her as moderately cognitively impaired. She weighs whatever the kitchen's algorithm decides she should eat that day.
Her responsible party had been raising concerns about communication failures at the facility before inspectors ever arrived. Staff, she said, did not always try. A communication board sat available. The resident could write. She knew sign language. On two consecutive days, while hot food moved from the kitchen to every other table in the dining room, none of those tools were used.
The deficiency was cited at the level of minimal harm or potential for actual harm. The facility's plan of correction was not included in the inspection record reviewed for this report.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
Clayton Rehabilitation and Healthcare Center in Clayton, NC was cited for violations during a health inspection on October 30, 2025.
The woman, identified in federal inspection records only as Resident 4, has highly impaired hearing and is nonverbal.
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.