Clayton Rehab: Hospice Pain Care Failure - NC
The infected pressure injury on the right hip of Resident 26 measured nearly two inches wide, almost two inches long, and nearly half an inch deep. It was draining a mixture of blood and serum. It had tunneled, meaning the damage extended through a narrow channel down into the tissue beneath the skin's surface. It had a pungent odor. And when the hospice nurse visited on October 20, 2025, to observe a dressing change, he concluded that acetaminophen was not enough.
He requested orders for morphine and Ativan.
He got a refusal instead.
The hospice nurse, whose name was not included in the inspection report, told federal inspectors during a phone interview on October 22 that he had watched Nurse 13 change the dressing on Resident 26's wound and formed a professional opinion: the resident needed something stronger than Tylenol to get through the procedure. Morphine and Ativan, he explained, are standard orders for hospice patients, used to address pain and the anxiety symptoms that often accompany end-of-life illness, including elevated heart rate, rapid breathing, and restlessness. He submitted the requests to the hospice provider on October 20.
Four days later, on October 24, the facility's nurse practitioner learned about the new orders.
She did not implement them. During a phone interview with inspectors on October 27, the nurse practitioner said she did not believe morphine or Ativan were appropriate because Resident 26 was not, in her assessment, showing signs of pain. She said she had observed a dressing change herself at some point but could not recall the date. She saw nothing that concerned her. She believed acetaminophen was sufficient.
The hospice nurse had scored Resident 26's pain at a 3 on a standard scale, placing it in the mild-to-moderate range. The nurse practitioner's position was that this score did not warrant stronger intervention. The hospice nurse's position was that a man on hospice with an infected, tunneling wound that smelled strongly enough to note in a clinical record needed more than over-the-counter pain relief to get through having that wound dressed.
Both cannot be right.
The inspection, completed October 30, 2025, flagged the situation as a deficiency causing minimal harm or potential for actual harm, affecting a small number of residents. That designation sits uneasily against the clinical picture: a wound deep enough to tunnel, infected enough to produce discharge and odor, on a patient already enrolled in end-of-life care.
When inspectors interviewed the facility's Regional Director of Operations, Administrator, and Regional Clinical Director together on the afternoon of October 27, the three said that if nursing staff could not reach hospice staff about concerns involving Resident 26, they should escalate to the nurse practitioner. The nurse practitioner, of course, was the person who had already reviewed and rejected the hospice nurse's clinical judgment.
The hospice nurse had asked for the orders on October 20. The nurse practitioner learned about them on October 24. The inspection was completed on October 30. The report does not say whether Resident 26 ever received morphine. It does not say whether he is still alive.
What it says is that a man with a deep, infected, foul-smelling wound on his hip was enrolled in hospice, that the nurse responsible for his comfort at the end of his life believed he needed stronger medication, and that the facility declined.
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.
Download the official CMS inspection PDF from Medicare.gov
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 20, 2026 · Our methodology
Clayton Rehabilitation and Healthcare Center in Clayton, NC was cited for violations during a health inspection on October 30, 2025.
The infected pressure injury on the right hip of Resident 26 measured nearly two inches wide, almost two inches long, and nearly half an inch deep.
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.