Clayton Rehab: Hospice Pain Care Failures - NC
Federal inspectors cited Clayton Rehabilitation and Healthcare Center, located at 204 Dairy Road, following a complaint inspection completed October 30, 2025. The deficiency involved the pain management of a resident identified in inspection records as Resident #26, a hospice patient in end-of-life care.
The wound on Resident #26's right hip measured 5 centimeters wide, 4.5 centimeters long, and 1 centimeter deep. It had tunneling, meaning a narrow channel extending from the skin's surface down into the underlying tissue. It had serosanguineous drainage, a mixture of blood and serum. Inspectors noted a pungent odor.
The hospice nurse visited on October 20, 2025, and watched Nurse #13 perform a dressing change. In a phone interview with inspectors on October 22, he said it was his opinion that Resident #26 needed something stronger than acetaminophen to manage pain during those dressing changes, given the wound infection. He requested orders for morphine and Ativan from the hospice provider that same day. He explained that Ativan addresses anxiety symptoms that appear at end of life, including increased heart rate, rapid breathing, and restlessness, and that both medications are standard orders for hospice patients.
The hospice nurse had scored Resident #26's pain at a 3 on a standard scale, placing him in the mild-to-moderate range.
The nurse practitioner told inspectors she learned about the new morphine and Ativan orders on October 24, four days after the hospice nurse had requested them. She said she did not feel those medications were appropriate. Her reason: Resident #26 was not exhibiting signs or symptoms of pain. She said she believed acetaminophen was strong enough to address any pain or discomfort from the wound infection and the dressing changes.
She told inspectors she had observed a dressing change herself, though she could not recall the date.
The hospice nurse and the nurse practitioner reached opposite conclusions watching the same patient undergo the same procedure on a wound that was infected, tunneling, and producing foul-smelling drainage. One of them had the authority to block the stronger medication. That was the nurse practitioner.
On October 27, inspectors interviewed the facility's Regional Director of Operations, Administrator, and Regional Clinical Director together. They said that if nursing staff could not reach hospice staff about concerns involving Resident #26, the staff should alert the nurse practitioner. The nurse practitioner was the same clinician who had already reviewed the situation and decided morphine was unnecessary.
The inspection report does not state whether Resident #26 received morphine before the survey closed, or whether he was still alive at the time inspectors completed their review on October 30. It does not record what the resident said about his own pain, or whether he was able to say anything at all.
What it records is the wound: five centimeters wide, tunneling inward, infected, and being dressed with acetaminophen as the only pharmaceutical option for pain, while a hospice nurse's request for something stronger sat unresolved for days.
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.
Federal inspectors cited Clayton Rehabilitation and Healthcare Center, located at 204 Dairy Road, following a complaint inspection completed October 30, 2025.
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.