Clayton Rehabilitation And Healthcare Center

F 0583

Keep residents' personal and medical records private and confidential.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, record review, and staff interviews the facility failed to ensure staff were knowledgeable that

they should protect the privacy of a resident's medical information by not texting over a nonsecure personal phone to the Nurse Practitioner a resident's name and medical information. This was for 1 of 1 sampled resident reviewed for privacy of health care information (Resident #1).The findings included:Record review revealed Resident # 1 was admitted to the facility on [DATE REDACTED] after being hospitalized from [DATE REDACTED] to 9/10/25. Resident # 1 also had a gastrostomy tube placed while hospitalized . Review of nursing notes revealed an entry documented by the Interim DON (Director of Nursing) on 9/10/25 at 6:30 PM noting at 6:30 PM Resident # 1 had arrived by stretcher to the facility. Interview with the interim DON on 10/16/25 at 10:40 AM revealed she was the Unit Manager at the time Resident # 1 was admitted on [DATE REDACTED]. According to the interim DON, there was a MA (medication aide) assigned to the hall to which Resident # 1 was admitted , and Nurse # 5 was working on the hall who covered the Medication Aide's hall for things the Medication Aide could not do. Nurse # 5 was then responsible for Resident # 1's care after he was admitted

on [DATE REDACTED] at 6:30 PM.Interview with Nurse # 5 on 10/15/25 at 4:40 PM revealed he had been working on

the hall adjacent to the hall where Resident # 1 was admitted and he had never been told he was responsible for the resident. Around 8:30 PM on 9/10/25 MA # 2 came to get him because Resident # 1 was bleeding from his gastrostomy tube site. He was able to apply a bandage to Resident # 1's gastrostomy site and get it to stop bleeding. He could find no medical history or orders in the electronic

record and tried to call the former DON without success. Somewhere between 11:00 and 11:50 PM, he was still present in the facility when the night shift nurse came to get him because the resident's gastrostomy tube site was bleeding again and the nurse was a newer nurse and wanted his help. He again helped stop

the bleeding. He was concerned about the resident, and he wanted to make sure the NP (Nurse Practitioner) knew to check the resident first thing in the morning given that there were no orders and he had bleeding to his gastrostomy tube site. He therefore sent a text to the NP. Nurse # 5 was interviewed regarding whether the facility used a secure and private messaging communication application to communicate with the NP and replied he had not been told about a way to communicate in a secure manner. He showed the surveyor a text he had sent to the NP on the night of 9/10/25 on his personal phone which had the resident's name (Resident #1) and information about the resident bleeding from his gastrostomy site. According to Nurse # 5 he had done this out of concern and because no one had trained him otherwise that he could not text medical information with resident's names and personal health information on a personal phone to the NP.The interim DON was interviewed on 10/16/25 at 10:40 AM and reported they did not have any type of secure health care messaging app that would be compliant with HIPPA (the Health Information and Health Insurance Portability and Accountability Act). Nurses were to call and verbally speak to the NP if there was a need to do so.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clayton Rehabilitation and Healthcare Center

204 Dairy Road Clayton, NC 27520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Resident #19 was documented as having received her carbidopa-levodopa at the following times 12:00am dose was administered at 12:55am, 4:00am dose was administered at 5:44am, 8:00am dose was administered at 11:14am, 12:00pm dose was administered at 11:22am, 4:00pm dose was administered at 6:23pm, and the resident was not documented as having been administered the 8:00pm dose.

An interview conducted with Resident #19 on 10/17/25 at 11:10am revealed on 10/11/25 she missed one (1) dose of carbidopa-levodopa. She experienced aggressive tremor and some confusion.

An interview conducted with the Director of Nursing (DON) on 10/17/25 at 2:30pm revealed she was unaware Resident #19 missed a dose of her carbidopa-levodopa medication.

A phone interview conducted on 10/17/25 at 2:40pm with Nurse Aide (NA) #11 revealed she worked 7:00pm to 11:00pm on 10/11/25 and she recalled Resident #19 telling NA #11, she missed a dose of her carbidopa-levodopa medication. NA #11 stated she did not tell the hall nurse because the nurse was right next to her room with the medication cart and she assumed that she was going into Resident #19's room soon.

A phone interview conducted on 10/17/25 at 3:00pm with Nurse #19 revealed she recalled giving Resident #19 carbidopa-levodopa medication; however, the medication was administered late due to her being new to the hall and Resident # 19's room was at the end of the hall. The nurse further explained she had the medication on the cart however, she gave the medication late.

An interview with the Administrator on 10/17/25 revealed he was unaware Resident #19 missed a dose of medication.

A phone interview conducted on 10/20/25 at 3:38pm with Pharmacy Director revealed that if a resident missed a dose of carbidopa-levodopa medication it would not have immediate effect on the resident if a dose was missed, because the dosage of carbidopa-levodopa is not enough to affect a person if they missed one dose.

An interview conducted on 10/20/25 at 4:15pm with the Nurse Practitioner revealed there would not be any harm to Resident #19's health if a dose of carbidopa-levodopa medication was missed.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clayton Rehabilitation and Healthcare Center

204 Dairy Road Clayton, NC 27520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

chest compressions and that having a rigid surface underneath the resident didn't make that much difference. The Regional Clinical Director revealed that she was a former CPR instructor. The Administrator stated that not using the overhead intercom system to call a Code Blue was only a delay of seconds or minutes, not rising to the level of a delay in response for Resident #24.

A phone interview was conducted with the Physician on [DATE REDACTED] at 4:40 PM. The Physician stated that there was no way of knowing what the underlying event was that caused Resident #24 to stop breathing, making

the correlation of the potential success of CPR also unknown. The Physician further stated that a catastrophic event does not have a correlation with the success of CPR even if performed with expert procedures.

Observations were made of facility crash carts on [DATE REDACTED] at 9:41 AM, which revealed all necessary equipment was available, to include backboards on both carts.

A representative from the American Heart Association was interviewed on [DATE REDACTED] at 2:52 PM regarding the course material taught for basic life support. The representative identified herself as the person who is called by instructors when they have material and content questions. This representative reported the following information. Ideally individuals are to be moved to a hard surface which is typically the floor to do CPR. If that is not reasonable, then another hard surface can be used such as a table. The material content included the information that doing compressions on an individual on a soft surface would further push them into the soft surface whereas compressions on a hard surface help create adequate blood flow to the heart with compressions.

The facility Administrator was informed of Immediate Jeopardy on [DATE REDACTED] at 6:10 PM.

The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of

the noncompliance.

Resident #21 & Resident #24 suffered related to this deficient practice. Nurse #1, Nurse #2, Nurse #3, Nurse #4, NA #1, and NA #2 failed to ensure basic lifesaving support was provided effectively when CPR was administered to residents who lost signs of life and compressions were performed without the residents being on a rigid surface for both Resident #21 and Resident #24. Additionally, the facility staff failed to do the following for Resident #21: 1) ensure staff knew how to announce a Code Blue to obtain assistance when a resident was without signs of life; 2) ensure the resident's code status was in the facility's electronic record; and 3) ensure emergency equipment was in a place which would not delay resuscitation efforts. Resident #21 and Resident #24 expired.

All facility residents have the potential to be affected by failing to ensure the code status was in the medical record. An audit will be completed by the Social Service Director/Designee

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clayton Rehabilitation and Healthcare Center

204 Dairy Road Clayton, NC 27520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

treatments for the resident. She did not think it was realistic for her to have her own assignment on another hall, cover insulin coverage for the Medication Aide, and also do treatments even if she had been told.

Continued review of Resident # 1's September 2025 TAR revealed blanks by the orders for the diabetic wound care on 9/17/25 and 9/18/25. Review of staffing sheets revealed Medication Aide # 1 was assigned

on the dayshift of 9/17/25 and the evening shift did not have a designated staff member. According to Resident # 1's MAR (Medication Administration Record), Nurse # 5 signed for medications on the evening of 9/17/25. According to the assignment sheet Nurse # 18 covered MA # 1 on 9/17/25 during the day shift.

Review of staffing sheets revealed MA # 1 was assigned on the day shift of 9/18/25. Nurse # 9 was the nurse assigned to cover MA # 1 on 9/18/25. Nurse # 5 was assigned to Resident # 1 on the evening shift of 9/18/25. Interview with Nurse # 18 on 10/16/25 at 4:07 PM revealed she had never done treatments for Resident # 1. She had not been told it was her responsibility. On 9/19/25 the Wound Physician noted he saw the resident again and documented the following information. The resident's right great toe diabetic ulcer measured 0.8 cm X 0.5 cm X and no measurable depth. The wound progress was not at goal due to generalized decline of patient. The right ankle diabetic wound was measured to be 1 cm X 1 cm with no measurable depth. This wound was documented to be at goal. On 9/25/25 the resident was transferred to another care facility. The facility Wound Physician was interviewed on 10/17/25 at 2:30 PM and reported the following information. The last time that he saw Resident # 1 there had been no signs of infection with his wounds. He felt his wounds were stable. He had multiple medical conditions such as diabetes, congestive heart failure, chronic obstructive pulmonary disease, and diabetes which could contribute to oxygen problems to the wounds and/ or healing problems.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clayton Rehabilitation and Healthcare Center

204 Dairy Road Clayton, NC 27520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Few

The facility Wound Physician was interviewed on [DATE REDACTED] at 2:30 PM and reported the following information.

The last time that he saw Resident # 1 there had been no signs of infection. He felt his pressure sores were stable and there had been no harm if he had missed dressing changes. He had multiple medical conditions such as diabetes, congestive heart failure, chronic obstructive pulmonary disease, and diabetes which could contribute to oxygen problems to the wounds and/ or healing problems.

1. 3. Record review revealed Resident # 18 was admitted to the facility on [DATE REDACTED]. The resident had diagnoses

which included Parkinson's disease, dementia, diabetes, anemia, osteoarthritis, and chronic obstructive pulmonary disease.

Resident # 18's admission MDS (Minimum Data Set Assessment), dated [DATE REDACTED] coded the resident as severely cognitively impaired and as dependent on staff for turning in the bed. The resident was coded as having one unstageable pressure sore.

On [DATE REDACTED] (Monday) PA (Physician Assistant) #1 documented the following information in a progress note.

The resident had been more confused, lethargic and with decreased oral intake over the weekend. The resident had new unstageable pressure sores to his left thigh and his right heel. The left thigh appeared bruised with significant redness and was questionable for infection. She would start the resident on an antibiotic and consult wound to follow.

Interview with PA # 1 on [DATE REDACTED] at 3:57 PM revealed the following information. When she saw the resident

on [DATE REDACTED] he was altered mentally, and she was suspicious of some sort of infection. The area of skin breakdown was on the left hip. The left hip looked bruised as well as having the sore on the hip. She had verbally spoken to the primary nurse. She did not recall which nurse this was. She told the nurse to keep

the resident off the left hip, keep the area covered, and consult the facility wound nurse.

According to staffing records, Nurse # 10 was assigned to care for Resident # 18 from 7:00 AM to 11:00 PM on [DATE REDACTED] and on [DATE REDACTED] from 7:00 AM to 3:00 PM. Nurse # 10 was interviewed on [DATE REDACTED] at 12:35 PM and again on [DATE REDACTED] at 12:00 PM and reported she did not recall the PA instructing her to keep the left hip wound covered or to keep the resident off his left side. She knew the resident did not have skin breakdown

on [DATE REDACTED] when she last worked with him prior to the date of [DATE REDACTED]. The first she was aware of the area was on [DATE REDACTED]. At that time the area on his left hip was covered but she did not know who had put the covering on the hip or when it had been done According to staffing records, NA (Nurse Aide) # 6 was assigned to care for Resident # 18 on [DATE REDACTED] from 7:00 AM to 3:00 PM. NA # 6 was interviewed on [DATE REDACTED] at 12:15 PM and reported she did not recall any area of skin breakdown on the resident while she cared for him on [DATE REDACTED].

According to staffing records NA # 10 was assigned to care for Resident # 18 on the 3:00 PM to 11:00 PM shift on [DATE REDACTED]. NA # 10 was interviewed on [DATE REDACTED] at 4:20 PM and reported she did not reca

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clayton Rehabilitation and Healthcare Center

204 Dairy Road Clayton, NC 27520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

not see orders or the hospital discharge summary either when she looked on her shift for Resident # 1. It seemed to her as if orders might not have been confirmed in the electronic system. Nurse #6 indicated it did show up on the MAR for her to flush the resident's gastrostomy tube and she had done that. She did not give an enteral feeding to the resident.Review of the Resident # 1's orders revealed on 9/11/25 (the day following admission) an order was entered at 3:37 PM for the same enteral feeding and flush (Osmolite 1.5 cal Oral Liquid 300 ml via PEG with a bolus flush of 90 ml of water before and after each bolus feeding with one change. The enteral feeding was to be given every six hours. Resident # 1's MAR reflected the scheduled times were changed to 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM.Review of the MAR revealed Medication Aide # 1 signed twice on 9/11/25 that the enteral formula was administered. The first time was by the first order which had the enteral feeding scheduled at 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM. By this order MA # 1 initialed by the 10:00 AM enteral feeding. The MAR was blank for the 2:00 PM scheduled time. On the new 9/11/25 order (which had the enteral feeding scheduled at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM) there was an X by the 12:00 AM, 6:00 AM, and 12:00 PM times and MA # 1 documented the 6:00 PM enteral feeding was administered. Therefore, the two enteral feedings which were documented as given on 9/11/25 were at 10:00 AM and 6:00 PM.MA # 1 was interviewed on 10/17/25 at 10:15 AM and reported the following information. She had worked a double shift on 9/11/25 and she would go get the nurse when the enteral feeding was showing due on the MAR. She only called the nurse who covered her to administer the enteral feeding twice that day. When she looked at Resident # 1's MAR, she just recalled it flagging enteral feedings to be done twice that day. The MA validated the tube feeding had only been given twice that day. Review of Resident #1's medical record revealed no documented hypoglycemic episodes on 9/10/25 or 9/11/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clayton Rehabilitation and Healthcare Center

204 Dairy Road Clayton, NC 27520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

of nursing skills, there was a column which was to be completed if a nurse required additional training. The SDC Nurse further reported the following information. How to manage medical emergencies was covered with newly hired nurses. They were taught where the crash carts were located and regarding equipment and how to check for a resident's code status. Newly hired nurses were taught that when a resident was found unresponsive the staff member is to yell out first for someone to page overhead on the intercom to get more help. Nurses are taught how to access the treatment cart, that there is a supply room with a lock

on it and how to access supplies through the lock. They are taught to call a provider if clarification or information needs to be shared with the provider. She (the SDC Nurse) was not able to locate any licensed nurse competency checklist that had been completed for Nurse # 5 and Nurse # 6. These two nurses had a medication administration evaluation, which was a separate form, completed but no further competency evaluation. She (the SDC Nurse) was not aware of problems Nurse # 6 might have experienced in caring for residents. She thought there might have been some issues with Nurse # 5 regarding medication competency, but she thought the former DON (Director of Nursing) was responsible for following up with him about any validations. She was not sure what the issue had been. She did not know if the competency issue had been resolved. Part of the current year, she (the SDC nurse) worked full time and part of the year

she had worked part time. When she worked part time, it was her understanding that the Unit Managers and the former DON helped to validate competencies, but she did not know who specifically was doing the competencies. She knew she had only been working part time when Nurse # 6 was hired. She currently was only working part time at the present time. She did have a Licensed Nurse Competency form for Nurse # 2 which was signed by her and Nurse # 2 on [DATE REDACTED]. Under the category of Medical Emergencies Nurse # 2 had given herself a self-evaluation score of 4 indicating she was confident and the SDC Nurse had signed off her competency was validated.During an interview with the former DON on [DATE REDACTED] at 8:34 AM

the former DON reported the following. She was aware of only an isolated incident with Nurse # 5 which was he did not stay with a resident when the resident took medications to make sure the resident swallowed them. She did not know of follow up about that. She thought the SDC Nurse would have that.Interview with the interim DON on [DATE REDACTED] at 10:40 AM revealed she was the Unit Manager at the time Resident # 1 was admitted on [DATE REDACTED]. The other Unit Manager and the former DON had helped put orders

in the electronic record for Resident # 1 on [DATE REDACTED] and Nurse # 5 had been told that Resident # 1 had arrived and he was responsible for the resident. He should have been able to see and follow orders in the resident's electronic medical record system. He should have known not to text the NP. If there was a need to communicate with the NP, he should have known that he should call her.On [DATE REDACTED] at 5:30 PM the Administrator, Regional Clinical Director, and the Regional Director of Operations were interviewed and reported they could not find a completed licensed nurse competency checklist for Nurse # 5 and Nurse # 6.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clayton Rehabilitation and Healthcare Center

204 Dairy Road Clayton, NC 27520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

medication can be returned to the pharmacy. The consultant pharmacist indicated that the controlled medications should be sent back to the pharmacy at the next delivery/pick up time that day or the next day.

The consultant pharmacist confirmed that the nurses should be counting the number of medication cards and the number of narcotics on each card at the change of each shift to reconcile narcotic usage. The Consultant Pharmacist also indicated that shift change substance inventory count sheet should be signed by the oncoming nurse and off going nurse with the total number of medication cards, number of new medication cards, and number of medication cards removed.An interview was conducted with the Regional Clinical Director on [DATE REDACTED] at 2:30 PM. The Regional Clinical Director stated that the discharged residents with controlled medications should have their controlled medications returned to the pharmacy. The Regional Clinical Director revealed that the process was for the Director of Nursing to reconcile the controlled medications with the nurse assigned to the medication cart and put them under double lock until

they can be returned to the pharmacy. It was also the expectation of the Regional Clinical Director that the Shift Change Controlled Substance Inventory Count Sheets for each medication cart be completely filled out and verified by two nurses.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clayton Rehabilitation and Healthcare Center

204 Dairy Road Clayton, NC 27520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

in the antibiotic medication package if it had been administered correctly. In a phone interview with the facility Wound Physician on 10/24/25 at 2:23 pm he stated he saw Resident #26 on 10/17/25 for wound care. The facility Wound Physician indicated the pressure wound on Resident #26's right hip was completely infected and therefore ordered the antibiotic Amoxicillin-Potassium Clavulanate 875 mg to be administered twice a day on 10/17/25 with Resident #26's first dose to begin that same evening. It was his expectation that Resident #26 received his Amoxicillin-Potassium Clavulanate 875 mg as ordered to prevent further worsening of the bacterial infection in the pressure wound. During an interview on 10/24/25 at 2:30 pm the Regional Clinical Director was interviewed regarding the inability to reconcile the number of antibiotics on hand versus the doses documented as administered. According to the Regional Clinical Director the facility had not been able to identify any other source the nurses would have been able to obtain the antibiotic in order to administer it except for the facility's back up medication supply and the resident's own supply which was delivered on 10/17/25. There were no other residents receiving the antibiotic Amoxicillin-Potassium Clavulanate 875 mg during the time Resident # 26 was prescribed this antibiotic. It was the Regional Clinical Director's expectation that the number of tablets documented as administered should be reconcilable with the number removed from the resident's supply.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clayton Rehabilitation and Healthcare Center

204 Dairy Road Clayton, NC 27520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation and interview with resident and staff the facility failed to provide palatable food to a resident when a burnt, blackened piece of toast was served to a resident. This was for 1 of 5 residents reviewed for dietary services provided to residents (Resident # 27). The findings included.Resident # 27 was admitted to

the facility on [DATE REDACTED] and had a current diet order for a regular diet. Resident # 27's quarterly Minimum Data Set Assessment, dated 9/12/25, coded the resident as moderately cognitively impaired.On 10/18/25 at 8:45 AM Resident # 27 was observed eating her breakfast meal and had completed a portion of it. She was observed with a piece of toast on her plate which she had not yet eaten. She picked up the toast and both sides were observed black from being burnt. The entire piece of toast was approximately 75 % black.

Resident # 27 reported she was going to try to eat it. Resident # 27's roommate spoke up and reported the resident did not need to eat the toast. On 10/18/25 at 8:57 AM the Administrator was asked to view the resident's toast with the surveyor and informed the resident that the dietary department could get her a piece of toast that was not burnt.During an interview with the Facility Dietary Manager (DM) and a Regional Corporate Dietary Manager on 10/16/25 at 5:00 PM the DM reported that the dietary department had some new staff, and they were also experiencing problems with having enough oven space to cook because one of the ovens was broken. They tried to get trays to residents on a time schedule while dealing with these issues. According to an interview with the Administrator on 10/18/25 at 4:45 PM, the burnt toast should not have left the dietary department and been served to the resident.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clayton Rehabilitation and Healthcare Center

204 Dairy Road Clayton, NC 27520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm

information that the resident should be offered chicken on 10/15/25 or an egg salad sandwich on 10/16/25.

The peanut butter and jelly sandwich was intended to be a side supplement to a main entree, but the system had not been recognizing this.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clayton Rehabilitation and Healthcare Center

204 Dairy Road Clayton, NC 27520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Based on record review, observation and interviews with residents and staff, the facility failed to deliver meal trays at regular consistent, scheduled times while experiencing a problem with a broken oven. This issue affected 2 of 3 halls two halls reviewed for mealtime deliveries (200 hall and 400 hall). This deficient practice had the potential to affect multiple residents for meal delivery.The findings included:Review of facility meal delivery times revealed the hall scheduled to receive the latest carts was the 400 Hall. Delivery to this hall was scheduled for the following times:Breakfast 8:10 AMLunch 1:10 PMDinner 6:10 PM Review of Resident # 8's annual Minimum Data Set assessment, dated 9/6/25, revealed Resident # 8 was cognitively intact. During an interview with Resident #8, who resided on the 400 Hall, the resident reported that meals were late. Specifically, at times he received his evening meal after 7:00 PM. On 10/15/25 the surveyor arrived at the 400 Hall at 1:20 PM. Interview with NA #5 revealed the lunch trays had just arrived one minute ago at 1:19 PM and they were going to start handing the trays to residents. On 10/16/25 at 8:37 AM it was observed that the breakfast trays arrived at the 400 Hall. Resident #8 was observed served breakfast at 8:42 AM. On 10/16/25 at 1:25 PM it was observed the lunch trays arrived at the 400 Hall.

Resident #8 was served his meal at 1:28 PM. Dietary Aide #1, who was observed delivering the lunch trays, was interviewed on 10/16/25 at 1:25 PM about time the meal carts were arriving to the hall and reported the kitchen was experiencing a problem. They had two ovens. Each oven had three racks and one of the ovens was broken. They were cooking all the meals on three racks, and this ran them late getting the meals out by the delivery times. Review of facility meal delivery times revealed the 200 Hall received their meals at the following times.Breakfast Cart #1- 7:40 AM and Cart #2-7:50 AMLunch Cart #1-12:40 PM and Lunch Cart #2 12:50 PMDinner Cart #1-5:40 PM and Dinner Cart #2-5:50 PM Record review revealed Resident #3 was cognitively intact according to a quarterly Minimum Data Set assessment completed on 9/29/25 and resided on the 200 Hall. Interview with Resident #3 on 10/16/25 at 8:50 AM revealed the delivery of meals depended on the dietary department. At times they seemed to be on time and at other times she received the dinner meal at 7:00 PM. The Facility Dietary Manager and a Regional Corporate Dietary Manager were interviewed on 10/16/25 at 5:00 PM and reported the following information. There was only one working oven in the kitchen. According to the Facility Dietary Manager the problem with the oven started around 9/8/25 or 9/9/25 and had been problematic for over a month. Their goal was to have meals out within five minutes of the delivery times to the hall, but not having enough space to cook the meals was a problem. That evening (10/16/25) for the dinner meal both entrees were to be cooked in the oven along with numerous other items. This included rolls, chicken, brownies, oven browned potatoes, cookies, and pork chops. They were trying to accomplish cooking all those items in one oven and still getting the trays out to all the halls at a regularly scheduled time. When the menu called for most items to be baked or warmed in the oven then this affected their ability to stay on schedule. The Dietary Manager replied she was aware there had been some complaints about late trays on the 400 Hall, which was the last hall to receive trays.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clayton Rehabilitation and Healthcare Center

204 Dairy Road Clayton, NC 27520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

basal cell carcinoma to his back. Resident # 8 underwent [NAME] surgery for these areas on 9/17/25 and closure on 9/18/25 during a second visit. During a follow up visit on 10/3/25 the surgical site was stapled and wound care directions continued.

Review of Resident # 8's October 2025 TAR (Treatment Administration Record) revealed an order to cleanse Resident # 8's surgical wound site with Dakin's Solution daily and apply a hydrocellular foam dressing. The date of 10/10/25 was blank indicating the dressing was not performed.

Interview with Nurse # 20 on 10/27/25 at 2:30 PM revealed the TAR was incomplete. The nurse reported that she had done the dressing change to the resident's back wound but did not document the dressing. 3.A physician's order for Resident #26 dated 10/19/25 included cleanse right ischium (a paired bone forming the lower and back part of the hip bone) with normal saline solution, pack with kerlix soaked in Dakins solution (a diluted, buffered bleached-base antiseptic used to clean and disinfect wounds to prevent infection), cover with dry border gauze dressing change every day and evening shift for Stage 3 pressure wound to ischium and as needed for soiled or dislodged dressing.

A review of Resident #26's October 2025 Treatment Administration Record (TAR) recorded Resident #26's right ischium wound dressing was changed on 10/19/25 on the day shift (7:00 am until 3:00 pm) and was documented as completed by Nurse #3.

During a phone interview with Nurse #3 on 10/23/25 at 2:10 pm, she stated she did not change Resident #26's wound dressing because his room was not on her assignment. Nurse #3 further stated the treatment nurse (Nurse #13) was at the facility and she changed the wound dressing for Resident #26. When asked by this surveyor why her initials were on the TAR for Resident #26's day shift wound dressing change, she replied, I do not know why my initials were on the TAR because I did not change the dressing.

A review of Resident #26's October 2025 TAR recorded Resident #26's right ischium wound dressing was changed on 10/19/25 on the evening shift (3:00 pm until 11:00 pm) and was documented as completed by Nurse #1.

During a phone interview with Nurse #1 on 10/23/25 at 2:32 pm, she stated she did not change Resident #26's wound dressing because the treatment nurse (Nurse #13) was at the facility and she changed the wound dressing for Resident #26. When asked by this surveyor why her initials were on the TAR for Resident #26's evening shift wound dressing change, she replied, I do not know why my initials were on the TAR because I did not change the dressing.

In a phone interview with Nurse #13 on 10/21/25 at 2:53 pm, she stated Resident #26's right ischium wound dressing had not been changed since 10/18/25. Nurse #13 explained when she changed Resident #26's right ischium wound on 10/20/25 the dressing she removed from Resident #26's right ischium wound had her initials and was dated 10/18/25.

On 10/27/25 at 5:10 PM, the Administrator reported that nursing staff should not be signing for nursing care that they did not complete.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clayton Rehabilitation and Healthcare Center

204 Dairy Road Clayton, NC 27520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to treat moderate to severe pain) and Ativan (antianxiety medication that provides a calming and sedative effect) as needed. During a phone interview with Nurse #13 on 10/21/25 at 2:53 pm, Nurse #13 indicated

the Hospice Nurse came to the facility on [DATE REDACTED] for Resident #26. Nurse #13 further indicated the Hospice Nurse ordered Morphine and Ativan as needed for Resident #26 on 10/20/25. Review of the hospice progress note dated 10/20/25 documented by the Hospice Nurse documented a pain assessment using the PAINAD scale (pain assessment used for residents with advanced dementia which assesses pain in patients who may have difficulty communicating their pain). The PAINAD scale used a score of 0-3 for mild to moderate pain, 4-6 for moderate pain and 7-10 for severe pain. The Hospice nurse scored Resident #26's pain a 3 indicated mild to moderate pain. The hospice progress note also addressed the wound located on the resident's right hip and documented the wound with measurements of 5 centimeters (cm) in width x 4.5 centimeters (cm) in length x 1 centimeter (cm) in depth with serosanguineous (a term for bodily fluid that is a mixture of blood and serum) drainage and tunneling ( a narrow deep channel or passageway that extends from the skin's surface into the underlying tissues) and a pungent (a strong sharp unpleasant odor) odor. During a phone interview with the Hospice Nurse on 10/22/25 at 11:37 am, he stated he visited Resident #26 on 10/20/25 and observed the right hip pressure wound dressing change with Nurse #13. The Hospice Nurse reported that in his opinion, Resident #26 needed a pain medication stronger than acetaminophen for his dressing changes due to the wound infection. The Hospice Nurse indicated Morphine and Ativan are standard physician's orders for hospice residents that address common symptoms and needs in the end-of-life care and he requested the orders from the hospice provider for Resident #26 on 10/20/25. He explained that Ativan was used to help relieve anxiety symptoms (increased heart rate, rapid breathing and restlessness) in hospice residents. During a phone interview with the Nurse Practitioner (NP) on 10/27/25 at 1:21 pm, she stated she was informed by the Hospice Nurse on 10/24/25 of the new PRN orders for Morphine and Ativan. She indicated that she did not feel those medications were appropriate as Resident #26 was not exhibiting any signs/symptoms of pain. The NP indicated in her opinion the acetaminophen would have been strong enough to help with any pain or discomfort related to

the wound infection and dressing changes. The NP further indicated she had observed a dressing change for Resident #26 but did not recall the specific date and did not observe any signs/symptoms of pain or discomfort during the dressing change. On 10/27/25 at 5:10 pm the Regional Director of Operations, Administrator, and Regional Clinical Director were interviewed, and they indicated if the nursing staff was unable to reach and/or communicate with the hospice staff in regard to concerns about Resident #26, the nursing staff should alert the NP.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clayton Rehabilitation and Healthcare Center

204 Dairy Road Clayton, NC 27520

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

had learned from the Vendor's visit that the cost of repair outweighed the option to purchase a new oven.

The Regional Director of Operations along with the Administrator and the Regional Clinical Director were interviewed again on 10/24/25 at 2:30 PM. The Regional Director of Operations reported the following. She felt that the facility DM was not remembering the date that the oven quit working correctly and that the first

record of malfunction was on 9/19/25. After 9/19/25 they did work on trying to resolve the problem by working as the timeline of events given to the surveyor showed. This included working on it themselves and contacting more than one Vendor.

Event ID:

Facility ID:

If continuation sheet