Clayton Rehab: Hospice Pain Care Failure for Dying Resident - NC
That dispute is at the center of a complaint inspection completed October 30, 2025, at Clayton Rehabilitation and Healthcare Center, a nursing home on Dairy Road in Clayton, North Carolina.
The resident, identified in inspection records only as Resident #26, had a pressure wound on his right hip that inspectors described in clinical detail. The wound measured 5 centimeters wide, 4.5 centimeters long, and 1 centimeter deep. It had serosanguineous drainage, a mixture of blood and serum. It had tunneling, a narrow channel burrowing from the skin's surface down into the tissue beneath. And it had what the inspection report called a pungent odor, meaning strong, sharp, and unpleasant.
The hospice nurse visited on October 20, 2025, and watched Nurse #13 change the dressing. In a phone interview with inspectors on October 22, he said the wound was infected and, in his opinion, Resident #26 needed pain medication stronger than acetaminophen for those dressing changes. He requested orders for Morphine and Ativan from the hospice provider that same day. He explained that Morphine would address pain and that Ativan was used for anxiety symptoms common in end-of-life patients, including increased heart rate, rapid breathing, and restlessness. He described both as standard physician's orders for hospice residents.
The nurse practitioner assigned to Resident #26 said she learned about those new orders on October 24, four days after the hospice nurse had requested them. She told inspectors she did not feel the medications were appropriate. Her reasoning: Resident #26 was not showing any signs or symptoms of pain. She said acetaminophen would be sufficient for any discomfort related to the wound infection and the dressing changes.
She also told inspectors she had personally observed a dressing change for Resident #26. She did not recall the date.
She did not observe any signs of pain or discomfort during that dressing change, she said.
The hospice nurse's pain assessment, documented in his progress notes, scored Resident #26 at a 3 on a standard pain scale, placing him in the mild-to-moderate range. The nurse practitioner's position was that this score, and her own observation, meant stronger medication was unnecessary. The hospice nurse's position was that a man with a tunneling, infected, foul-smelling wound being treated with Tylenol needed more.
On October 27, the facility's Regional Director of Operations, Administrator, and Regional Clinical Director were interviewed together. Their guidance was procedural: if nursing staff couldn't reach hospice staff about concerns, they should alert the nurse practitioner.
The nurse practitioner who had already declined the hospice nurse's request.
The inspection tagged the deficiency at a level of minimal harm or potential for actual harm, with few residents affected. That classification reflects the regulatory framework inspectors apply, not necessarily a clinical judgment about what Resident #26 experienced during his dressing changes in the days the medication dispute went unresolved.
The hospice nurse requested the morphine order on October 20. The nurse practitioner said she wasn't informed until October 24. The inspection was completed October 30. The records do not say whether Resident #26 ever received stronger pain medication, or what his dressing changes were like in the time between.
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 23, 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 #26, had a pressure wound on his right hip that inspectors described in clinical detail.
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.