Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clayton Nursing And Rehab Center during CMS and state inspections, most recent first.
Surveyors found that the vaccine refrigerator temperature logs in the medication storage room were not completed on numerous dates across both day and night shifts, with large gaps in documentation over many months. An LPN acknowledged that the vaccine fridge temperature log was not being done routinely, despite nurses being responsible for all temperature logs. The DON confirmed that refrigerator temperatures were expected to be checked once per shift and recorded on the log, but this monitoring and documentation did not consistently occur.
Surveyors found that food service sanitation practices were deficient when a plate warmer used for clean dishes contained dried food particles, dried liquid splashes, and trash, and the stove and oven used for meal preparation were visibly soiled with dried food, liquid splashes, dirt, grease, and baked-on food stains. The DM acknowledged that the condition of the plate warmer, stove, and oven was dirty and did not meet his expectations, affecting food preparation and service for all residents.
Surveyors found that the facility failed to consistently implement its infection prevention and control program. A resident on Enhanced Barrier Precautions (EBP) received direct care from two CNAs who did not don required PPE despite EBP signage on the door. In a separate incident, a resident on EBP was transferred with a mechanical lift, and after completing care and removing PPE, CNAs moved the lift directly to another room without cleaning or disinfecting it. The CNAs later acknowledged they had not followed protocol, and the DON, serving as Infection Preventionist, stated that staff are expected to perform hand hygiene, follow infection control precautions, and clean and disinfect all medical equipment after each use.
Staff administered medications to several residents in the dining area during mealtimes, requiring residents to stop eating to take medication cups and receive eye drops from an LPN. Overhead paging announcements were made in the dining area on multiple mornings to reach an LPN, and kitchen serving-area ceiling vents were observed to be covered with dust and dirt, discoloring the vents and surrounding ceiling. These actions and conditions did not support a safe, clean, comfortable, and homelike environment for residents during meals.
Surveyors found that MDS assessments were not accurately completed for three residents. One resident receiving Nitrofurantoin for UTI prophylaxis did not have antibiotic use captured on the MDS, as confirmed by the MDS coordinator. Another resident with COPD and dementia, who had an order for PRN oxygen and an oxygen concentrator at the bedside, had no oxygen use documented on the MDS, which the DON acknowledged was inaccurate. A third resident with multiple comorbidities and a documented diagnosis of ankle edema was observed with red, swollen legs and ankles, yet the MDS did not reflect ankle edema, and the DON confirmed this omission.
Surveyors found that care plans for two residents were not updated to reflect current medical needs. One resident with COPD and other chronic conditions had a physician order for PRN oxygen at 2 L/min via nasal cannula, but this oxygen use was not included in the care plan, as confirmed by the DON. Another resident with multiple neurologic and urologic diagnoses, as well as wasting disease and sarcopenia, was observed with red, swollen ankles and legs; a physician note documented ankle edema, yet the care plan did not address this condition, which the DON acknowledged was missing.
A resident admitted with COPD, Alzheimer’s disease, dementia with agitation, major depressive disorder, and essential HTN had a physician order for PRN O2 at 2 L/min via nasal cannula for respiratory distress, but this treatment was not included on the baseline care plan completed at admission. Record review showed the baseline care plan lacked any indication that the resident used O2 as needed, and the DON confirmed that the resident does utilize PRN O2 and that this omission was incorrect.
A resident with chronic respiratory failure, COPD, OSA, emphysema, and MRSA carrier status had a physician order for supplemental O₂ at 2 L/min that did not specify the frequency of administration. The resident was observed in bed using a nasal cannula connected to an O₂ concentrator, and the DON acknowledged that the order lacked required frequency details. This omission in the oxygen order was identified during survey review as a failure to provide respiratory care in accordance with professional standards.
The facility failed to meet the nutritional needs and preferences of residents by not serving the menu items as planned and not providing alternate meal options. During a dinner observation, residents were served Jell-O instead of cheesecake, and the meatloaf lacked glaze due to missing ingredients. Staff interviews revealed that the kitchen did not have the necessary supplies, and residents were not informed of the menu changes. Additionally, no alternate meals were offered, contributing to the deficiency.
The facility failed to properly label and store food items in the Dietary Department, leading to potential cross-contamination risks. Observations revealed multiple unlabeled and undated food items, including containers with unidentified substances, open bags of food, and uncovered pans. The Healthcare Group Services Operationalist confirmed that staff are expected to label and date all items, which should be covered and not open to air. This deficiency could impact all 30 residents consuming food from the kitchen.
The facility failed to notify residents of the outcomes of their grievances, as grievance forms lacked documentation of investigation steps, findings, and corrective actions. Interviews revealed that the Resident Council was not always informed about grievance findings, and the Administrator acknowledged incomplete grievance forms.
A facility failed to conduct required quarterly care plan meetings for a resident, resulting in an outdated care plan. The resident, admitted earlier, had his last care plan meeting in April 2024. He reported not recalling recent meetings, and the MDSC confirmed the oversight, acknowledging the missed meetings.
The facility failed to provide prescribed Restorative Nursing Program (RNP) services to two residents, impacting their ability to perform activities of daily living (ADLs). One resident was supposed to receive RNP services for passive range of motion exercises to both arms, but these were provided only once in September and not at all in October. Another resident was to receive RNP services for upper and lower extremities, but the sole Restorative Aide was unable to deliver these services due to other duties. The Director of Nursing confirmed the lack of service delivery.
The facility did not implement enhanced barrier precautions for residents with wounds or urinary catheters, as PPE was not available outside their rooms and staff were observed providing care without PPE. This oversight was due to a lack of awareness of updated guidelines by the staff.
The facility failed to obtain current signed Influenza Vaccine Informed Consent Forms for residents who received the flu vaccine. Interviews and record reviews revealed that five residents did not have the necessary consent documentation in their medical records. The LVN stated that residents signed the ICF annually, leading to missing consents for the recent vaccinations.
A resident with decreased mobility due to a stroke was unable to reach their call light, which was placed on a chair behind their bed. This oversight left the resident anxious and unable to request assistance for basic needs. Staff interviews confirmed the call light should have been within reach.
A resident reported dissatisfaction with the food served, noting burnt macaroni salad and peach cobbler with salt instead of sugar. The Food Service Director acknowledged these issues, attributing them to new dietary staff requiring supervision. A grievance form confirmed the resident's complaints, highlighting problems with food preparation.
Failure to Routinely Monitor and Document Vaccine Refrigerator Temperatures
Penalty
Summary
Surveyors identified a deficiency related to the storage and monitoring of medications in the facility’s locked medication storage room, specifically the vaccine refrigerator. During an observation on 02/10/26 at 12:55 pm, the vaccine fridge temperature log for January 2025 through February 2026 was found to be incomplete. Numerous dates on the day shift log were left blank, including extended periods such as 01/01/25 through 01/18/25, 01/20/25 through 06/01/25, 06/03/25 through 07/23/25, 07/25/25 through 09/12/25, 09/15/25 through 09/31/25, and multiple additional gaps through 02/08/26. The night shift log also contained multiple missing entries on specific dates throughout 2025, indicating that temperatures were not consistently documented as required. In an interview on 02/10/26 at 12:56 pm, an LPN confirmed that the vaccine medication fridge temperature log was not being completed routinely and stated that nurses are responsible for completing all temperature logs. On 02/11/26 at 1:38 pm, the DON further confirmed there had been inconsistency with checking the vaccine fridge temperature log. The DON stated that the fridge temperature should be checked once per shift and documented on the appropriate log, and acknowledged that this did not occur as required.
Unsanitary Storage of Dishes and Unclean Cooking Equipment in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in food service sanitation when kitchen staff failed to properly store dishes and maintain clean cooking equipment. During a random kitchen observation, the plate warmer, which is intended to hold clean plates ready for meal service, was found to contain dried food particles, dried liquid splashes, and trash. The stove was observed with dirty, dried food particles and dried liquid splash marks on the front, and dirt and grease covering the back. The oven interior had baked-on food stains throughout. The Dietary Manager confirmed that the plate warmer, stove, and oven were dirty and did not meet his expectations. These conditions were present in an area used to prepare and serve food for all 36 residents listed on the census provided by the Administrator, indicating that food was not being prepared and served under sanitary conditions as required by professional standards.
Failure to Implement EBP PPE Use and Disinfection of Shared Equipment
Penalty
Summary
The deficiency involves the facility’s failure to implement an ongoing infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and proper use of personal protective equipment (PPE). On the 200 hall, a resident with an EBP sign posted on the door was observed receiving direct care from two CNAs who did not wear any PPE while in the room. One CNA was already in the room without PPE, and the second CNA entered the room, closed the door, and provided direct care without donning PPE. After approximately five minutes, both CNAs assisted the resident out of the room in a wheelchair. In a subsequent interview, one of the CNAs confirmed that both were providing direct care to the resident, acknowledged that neither wore PPE, and stated they should have done so. The deficiency also includes failure to clean and disinfect shared resident-care equipment between uses. A resident on EBP was transferred from a wheelchair to a bed using a mechanical lift, and staff providing direct care appropriately donned mask, gown, and gloves. After completing the brief change, the CNAs removed their PPE, performed hand hygiene, and immediately took the mechanical lift to another room without cleaning or sanitizing it. In an interview, both CNAs confirmed they did not follow protocol by failing to clean the mechanical lift after use and stated that all medical equipment is supposed to be wiped down with bleach after each use. The DON, who serves as the facility’s Infection Preventionist, stated that all nursing staff are to perform hand hygiene before and after patient care and follow all infection control precautions, and that all medical equipment is to be cleaned and disinfected after each use.
Medication Administration and Environmental Issues in Dining and Kitchen Areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when staff administered medications in the dining area during mealtimes, used an overhead paging system in the dining area, and did not maintain clean kitchen vents. During a lunch meal observation, one resident was seated and eating when an LPN approached, handed the resident a medication cup, and then administered eye drops before the resident resumed eating. Two other residents who were seated and eating at their respective tables were also approached by the same LPN, given medication cups, and stopped eating their meals to take their medications. In an interview, the LPN stated that she usually administers medications in common areas and during mealtimes because that is where all the residents are. Additional observations showed that the overhead paging system was used in the dining area on two separate mornings to call an LPN to contact another staff member. A separate observation of the kitchen serving area revealed that the ceiling vents were covered with dust and dirt, causing portions of the vents and surrounding ceiling to appear brownish-black instead of their intended white color. These conditions were identified as contributing to the failure to maintain a sanitary and homelike environment for residents who eat their meals in the dining area.
Inaccurate MDS Assessments for Antibiotic Use, Oxygen Therapy, and Edema
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, resulting in omissions of current clinical conditions and treatments. For one resident with type 2 diabetes mellitus, traumatic brain injury, quadriplegia, obstructive and reflux uropathy, and a need for assistance with personal care, the record showed a physician’s order for Nitrofurantoin 100 mg for UTI prophylaxis. However, review of this resident’s MDS dated [DATE] showed that antibiotic use was not checked, and the MDS Coordinator confirmed during interview that the resident was currently taking an antibiotic and that she failed to capture this on the assessment. Another resident with COPD, Alzheimer’s disease, dementia with agitation, major depressive disorder, and hypertension was observed with an oxygen concentrator at the bedside, and physician orders documented oxygen at 2 L/min via nasal cannula as needed for respiratory distress. The resident’s MDS dated [DATE] contained no indication of oxygen use, and the DON confirmed the resident does utilize oxygen as needed and that the MDS was not accurate. A third resident with Parkinsonism, severe dementia, obstructive and reflux uropathy, wasting disease, and sarcopenia was observed asleep in a wheelchair with red, swollen legs and ankles. A physician progress note documented a diagnosis of ankle edema, but the MDS dated [DATE] did not indicate ankle edema. The DON confirmed that this resident does have ankle edema and that the MDS assessment was not accurate.
Failure to Accurately Reflect Oxygen Use and Ankle Edema in Resident Care Plans
Penalty
Summary
Surveyors identified a failure to develop and implement accurate, comprehensive care plans for two residents. One resident with COPD, Alzheimer's disease, dementia with agitation, major depressive disorder, and essential HTN had a physician order dated 08/05/25 for oxygen at 2 L/min via nasal cannula as needed for respiratory distress. However, review of this resident's care plan dated 08/04/25 showed no indication that the resident utilized oxygen as needed. During an interview on 02/13/26 at 9:20 am, the DON confirmed that the resident does use oxygen as needed and acknowledged that the care plan does not indicate this and that it should. For another resident with diagnoses including Parkinsonism, severe dementia, obstructive and reflux uropathy, wasting disease, and sarcopenia, surveyors observed the resident asleep in a wheelchair in the dining area on 02/10/26 at 10:30 am, with legs and ankles appearing red and swollen. Record review showed a physician progress note dated 08/21/24 documenting a diagnosis of ankle edema. However, the resident's care plan revised on 07/31/25 contained no indication of ankle edema. In an interview on 02/13/26 at 9:30 am, the DON confirmed that the resident does have ankle edema and stated that the resident's care plan did not meet her expectations because it should include the ankle edema and does not.
Baseline Care Plan Omitted PRN Oxygen Order for Newly Admitted Resident
Penalty
Summary
The facility failed to create an accurate baseline care plan for a newly admitted resident by omitting an essential treatment order. Record review showed the resident was admitted with COPD, Alzheimer’s disease, dementia with agitation, major depressive disorder, and essential HTN. Physician orders dated 08/05/25 directed that the resident receive oxygen at 2 L/min via nasal cannula as needed for respiratory distress. However, review of the resident’s baseline care plan dated 08/04/25 revealed no indication that the resident utilized oxygen as needed, despite this active order. In an interview, the DON confirmed that the resident does use oxygen PRN and acknowledged that the baseline care plan did not reflect this need and that it should have been included. This discrepancy between the physician’s oxygen order and the baseline care plan content constituted the identified deficiency in accurately capturing the minimum healthcare information necessary to properly care for the resident immediately upon admission.
Incomplete Oxygen Order for Resident with Chronic Respiratory Failure
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care in accordance with professional standards by not ensuring that a physician’s order for supplemental oxygen included the frequency of administration. A resident admitted with chronic respiratory failure with hypoxia, COPD, obstructive sleep apnea, emphysema, and MRSA carrier status had a physician order dated 09/14/25 for supplemental oxygen at 2 L/min, but the order did not specify how often or under what circumstances the oxygen should be administered. During observation on 02/10/26, the resident was seen in bed wearing a nasal cannula connected to an oxygen concentrator at the bedside. In an interview on 02/13/26, the DON confirmed that the oxygen order should indicate the frequency of administration and acknowledged that it did not, resulting in incomplete respiratory care orders for this resident. The survey findings state that this failure to specify oxygen frequency in the medical order was identified for 1 of 3 residents reviewed for respiratory care and was likely to result in residents receiving too much or not enough oxygen, which could lead to worsening of their conditions.
Failure to Meet Nutritional Needs and Menu Adherence
Penalty
Summary
The facility failed to meet the nutritional needs and preferences of all 30 residents as listed on the facility census. During a dinner observation, it was noted that the staff did not serve the food items as listed on the menu. Specifically, residents were served Jell-O with whipped topping instead of the French orange cheesecake that was on the menu, and the meatloaf served did not have the glaze as indicated. Interviews with staff, including an LPN and the Dietary Manager, revealed that the kitchen did not have the necessary ingredients for the cheesecake or the glaze for the meatloaf due to a delay in the food order. Residents expressed their dissatisfaction with the substitutions and confirmed they were not informed of the menu changes. Additionally, the facility did not provide an alternate meal menu to the residents. The Dietary Manager admitted that no alternate meals were made or offered, citing low census and minimal alternate requests as reasons. The Registered Dietitian confirmed that the posted menu should include alternate menu choices and that the meals served should match the posted menus. The lack of alternate meal options and failure to serve the menu items as planned contributed to the deficiency in meeting the residents' nutritional needs and preferences.
Failure to Properly Label and Store Food
Penalty
Summary
The facility failed to store food in a manner that prevents cross-contamination, as observed in the Dietary Department's refrigerators and freezers. Several food items were found unlabeled and undated, including a four-quart plastic container with an unidentified substance, two five-pound bags of slightly black colored stalks, a two-inch pan of red liquid, a six-quart plastic container of unidentified food, and a tray of 6 oz. glasses of yellow liquid. Additionally, a ten-pound bag of frozen diced chicken, two one-pound bags of beef patties, two one-pound bags of boiled eggs, two ten-pound rolls of Provolone cheese, and a fifty-pound bag of bread crumbs were open to air and not dated. A four-inch soiled steel pan with a two-ounce scoop containing crusted, crumbly food was also found open to air and not labeled or dated. During an interview, the Healthcare Group Services Operationalist stated that it was expected for staff to label and date all items, and they should be covered and not open to air. These failures have the potential to result in cross-contamination, the growth of foodborne pathogens, and foodborne illness, affecting all 30 residents who consume food from the kitchen.
Failure to Notify Residents of Grievance Resolutions
Penalty
Summary
The facility failed to notify four residents of the outcomes or resolutions of their grievances, as revealed through record review and interviews. The grievance log showed that grievances filed by residents regarding issues such as clothing not being changed, snacks being thrown out, cold air from the air conditioner during meal times, a missing candy dish, and a CNA talking on the phone during a shower were marked as resolved. However, the grievance forms lacked documentation of the steps taken to investigate, summaries of findings, confirmation of the grievances, corrective actions, or the issuance date of the written decision. Interviews with the Resident Council and the Administrator further highlighted the deficiency. The Resident Council stated that they were not always informed about the facility's findings regarding their grievances. The Administrator admitted that staff did not complete the grievance forms properly, which resulted in residents not being informed of the resolutions of their grievances.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to revise the care plan for a resident due to the absence of quarterly care plan meetings as required. The resident was admitted to the facility on an unspecified date, and the last care plan meeting was documented on April 30, 2024. During an interview on October 28, 2024, the resident expressed that he did not recall having a care plan meeting recently. Furthermore, the Minimum Data Set Coordinator (MDSC) acknowledged on October 30, 2024, that she was responsible for scheduling and conducting these meetings and confirmed that the resident had missed his last two quarterly care plan meetings.
Failure to Provide Restorative Nursing Program Services
Penalty
Summary
The facility failed to maintain the ability of two residents to perform activities of daily living (ADLs) due to inadequate provision of Restorative Nursing Program (RNP) services. Resident #6 was admitted to the facility and had physician orders for RNP services two to three times a week for passive range of motion exercises to both arms. However, documentation revealed that these services were provided only once in September and not at all in October. Interviews with the resident, a Restorative Certified Nursing Assistant (RCNA), a Certified Nursing Assistant (CNA), a Registered Nurse (RN), and the Director of Nursing (DON) confirmed that the resident did not receive the prescribed RNP services, which were intended to give him a sense of purpose and enjoyment. Similarly, Resident #25 was admitted with physician orders for RNP services three times a week for passive range of motion exercises to the upper and lower extremities. The RCNA, who was the only Restorative Aide in the facility, stated that he was often occupied with other duties, such as working on the floor and transporting residents, which prevented him from providing the necessary RNP services to Resident #25. The DON confirmed that Resident #25 did not receive the prescribed RNP services. This lack of service delivery was attributed to the RCNA's additional responsibilities, which hindered the consistent provision of restorative therapy to the residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for six residents who had either an open wound or a urinary catheter, increasing the risk of spreading multidrug-resistant organisms (MDROs). Observations revealed that personal protective equipment (PPE) was not available outside the rooms of residents with urinary catheters, and there were no signs indicating the need for PPE use during direct care. Specifically, residents with indwelling or suprapubic catheters did not have accessible PPE, and staff were observed providing care without using PPE. Additionally, residents with wounds also lacked PPE stations outside their rooms, and staff were observed providing care without PPE. Interviews with the Skin Care team lead nurse and the Director of Nursing/Infection Preventionist indicated a lack of awareness and implementation of updated EBP guidelines. The facility's procedure for EBP required PPE to be accessible and located outside patient rooms, but this was not adhered to, leading to the deficiency.
Lack of Signed Consent Forms for Flu Vaccinations
Penalty
Summary
The facility failed to ensure that a current Influenza Vaccine Informed Consent Form (ICF) was signed by residents prior to receiving the flu vaccine. This deficiency was identified during interviews and record reviews, which revealed that five residents who received the flu vaccine did not have a signed ICF in their medical records. The Director of Nursing confirmed that consents should be part of the medical record, but the Licensed Vocational Nurse (LVN) stated that residents only signed the ICF once, as the form indicated it was an annual requirement. This practice led to the absence of current consent forms for the residents who received the flu vaccine. The record reviews for the five residents showed that they received the flu vaccine on various dates, but their electronic medical records did not contain the necessary ICFs. The LVN mentioned that if a resident refused the vaccination, they would sign a declination form, and a new ICF would be required for future vaccinations. However, this process was not followed for the residents who received the vaccine, resulting in a lack of documentation to confirm whether the vaccine was given or refused, and whether the residents were educated about the vaccine's benefits and risks.
Failure to Ensure Resident Access to Call Light
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs and preferences, specifically regarding access to a call light. The resident, who had decreased mobility due to a history of a stroke, left and right-sided weakness, and impaired balance, required the call light to be within reach at all times. During an observation, the call light was found on a chair behind the resident's bed, out of reach, causing the resident to appear anxious and unable to request assistance for water and a shower. Interviews with a nurse aide and the Director of Nursing confirmed that the call light should have been placed within the resident's reach.
Food Palatability and Preparation Issues
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and met their satisfaction, as evidenced by the experience of one resident. On the evening of 10/27/24, a resident reported that the macaroni salad served during dinner smelled burnt, and the peach cobbler contained salt instead of sugar. Further interviews revealed that on 10/29/24, burnt pasta was found in the refrigerator, indicating issues with food preparation. The Food Service Director acknowledged the problems, attributing them to the new dietary staff who required significant supervision. A grievance form dated 10/28/24 corroborated the resident's complaint, noting that the pasta for the minestrone soup was scorched, coleslaw was served without dressing, and the peach cobbler was improperly prepared.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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