Inspection Reports for Clayton House

Facility failed to maintain an environment free from chronic unpleasant odors, specifically a strong urine smell throughout the 200 hall and room 204.

Facility failed to ensure all 26 residents were offered activities designed to promote active involvement with each other and the community.

Medication error: Metoprolol Succinate extended release 25mg tablet was crushed and administered, contrary to manufacturer instructions.

Facility failed to have all components and procedures to comply and properly operate doors equipped with Special Locking, affecting occupant evacuation.

Exit doors are not maintained to be operable by a single hand motion from the inside at all times without keys; thumb turn locks were found on exit doors.

Outside premises not maintained in a clean and safe condition, including missing bricks on front porch patio causing tripping hazard, deteriorated paint on soffits, and a cracked window pane needing replacement.

Failed to provide supervision for a facility licensed as a Special Care Unit during a time when the front door was malfunctioning, resulting in a resident with dementia eloping without staff knowledge.

Failed to provide supervision for 2 of 5 sampled residents with a history of falls and elopement episodes, resulting in injuries and safety risks.

Failed to assure sufficient staff were available to provide feeding assistance for 2 of 6 sampled residents, resulting in delayed feeding assistance.

Failed to ensure residents were free from mental and physical abuse, neglect, and exploitation related to personal care and supervision.

Failed to ensure required staffing hours for the Special Care Unit with a census of 44 were met for 6 of 12 shifts sampled from 07/02/21 to 07/05/21.

Failed to provide personal care for residents requiring assistance with toileting.

Failed to provide supervision for residents including those who eloped and had falls with injuries.

Failed to ensure residents' laundry was completed on each shift.

Failed to clarify medication orders for a controlled substance resulting in doses administered too close together.

Failed to administer medications as ordered including crushing enteric coated aspirin and incomplete antibiotic administration.

Failed to observe residents actually taking medications and found medications on the floor.

Failed to implement infection control measures during medication administration including failure to wash or sanitize hands and punching medications into bare hands.

Failed to ensure physical restraints were used according to physician's orders including assessment, consent, and monitoring.

Failed to treat residents with respect, dignity, consideration, and right to privacy related to residents wandering into other residents' rooms uninvited and sleeping in their beds.

Facility failed to ensure CDC and NC DHHS guidance for COVID-19 infection prevention related to PPE use and social distancing was implemented and maintained in a memory care unit.

Facility failed to provide services necessary to maintain residents' health related to resident rights during COVID-19 pandemic, including failure to ensure PPE use and social distancing.

Facility does not meet Building Code requirements for the installed magnetic locking system; missing wiring diagram and components map at fire alarm panel.

Outside premises not maintained in a clean and safe condition; rotting fascia trim, missing soffit vents, flaking paint, damaged soffits, cracked and uneven concrete walks, and unsafe debris piles.

Failure to maintain fire safety equipment; gaps between resident room doors and door frame stops allowing passage of smoke.

Facility does not meet Building Code requirements for the installed magnetic locking system; missing wiring diagram and components map at fire alarm panel.

Outside premises not maintained in a clean and safe condition with exterior damages such as rotting fascia trim, missing soffit vents, peeling paint, holes in siding, and unsafe walkways.

Old pavilion and fountain debris left outside fenced enclosure creating unsafe rubble pile.

Failure to maintain fire safety equipment; gaps around door and door frame stops in resident room 205.

Facility does not meet Building Code requirements for the installed magnetic locking system; no wiring diagram and components map at fire alarm panel.

Outside premises not maintained in a clean and safe condition; rotting fascia trim and damaged soffits at multiple locations, cracked and uneven concrete walk.

Failure to maintain fire safety equipment in safe condition; exit sign and emergency lighting at left-hand front exit not energized.

Resident room doors have gaps between door and door frame stops, compromising smoke resistance (specifically Room 205).

Facility does not meet Building Code requirements for installed magnetic locking system; no wiring diagram or components map at fire alarm panel.

Facility lacks emergency lighting in exit lobby and exit door not marked with exit sign/light.

Facility did not provide closets or wardrobes for each resident; example room 206 had only one closet for two residents.

Outside premises not maintained in a clean and safe condition; rotting fascia trim, damaged soffit and trim, leaking A/C unit, cracked and uneven concrete walkways.

Facility not maintained free of chronic unpleasant odors; strong urine smell in main entry and certain rooms.

Ceilings, floors, and walls not kept in good repair; patched ceilings unfinished, stained floors, missing transition strips, holes and gaps in walls.

Facility not maintained free of hazards; trip hazards, unsafe door latches, rusted door frames, obstructed exits, improperly stored oxygen bottles.

Fire safety rehearsals not conducted quarterly on each shift; records incomplete and lacking descriptions.

Building equipment including fire safety, electrical, mechanical, and plumbing not maintained in safe operating condition; exit doors difficult to open, plumbing issues, fire door gaps, unapproved door hold opens, and fire doors not latching properly.

Facility did not provide working exhaust ventilation in all designated areas including medication room, soiled linen, and women's guest bathroom.

Walls and doors throughout the facility had black horizontal scrape marks, smudges, missing paint, and damaged baseboards.

The Nurses' Station desk had missing and peeling paint, and the molding was discolored and damaged.

The outlet cover plate next to the closet in Resident Room #304 was bent and loose.

Walls, ceilings, and floors were not kept clean and in good repair, with peeling paint, scraped areas, stains, and holes observed in multiple locations including residents' rooms, hallways, dining room, and bathrooms.

Furniture in residents' living areas including chairs, nightstands, and chests were worn, chipped, peeling, or broken.

Failure to assure referral and follow-up to meet the health care needs of Resident #2 related to skin breakdown, including failure to notify the primary care provider resulting in delayed wound care referral.

Failure to assure every resident's right to receive care and services which are adequate, appropriate, and in compliance with relevant laws and regulations, related to the above health care deficiency.

Door at the end of A Hall of the special care unit was not equipped with a sounding device and was unlocked due to mag lock malfunction.

Walls and floors were not kept clean and in good repair for residents' bedrooms and restrooms on B and C Halls.

Furniture in residents' living areas was not in good repair including chairs, sofas, and television stand.

Resident's room (309), shower room and handicapped bathroom on C Hall, and television room on A Hall were not maintained in an uncluttered, clean and orderly manner, free of obstructions and hazards.

Residents were not treated with respect, consideration, and dignity including staff failing to assist a resident when asked, inappropriate staff comments, and staff interactions with exit-seeking resident and resident labeled a hoarder.

Medication administration errors observed including failure to administer Hydralazine with meals and failure to apply Zinc Oxide ointment as ordered.

Minimum number of staff were not present at all times to meet the needs of residents in the Special Care Unit for 31 of 63 shifts sampled in March and April 2017.

Mandatory annual state approved infection prevention training was not provided for 2 of 3 medication aides employed more than one year.

One of 3 staff sampled hired after 10/01/13 did not have examination and screening for controlled substances performed.

Facility failed to maintain the grounds free of hazards; structurally unsound and abandoned out building remains on the grounds.

Walls not maintained clean and in good repair; water infiltration and mildew damage around through wall mounted AC unit.

Failed to install a required fire alarm manual pull station at a Dining Room exit door.

Wood ramp used for egress is not maintained; wood decking rotten, handrail split and splintered with protruding nails, and ramp surfaces lack anti-slip material.

Personal Care Aides and Medication Aides performed laundry duties between 7am and 9pm, contrary to regulations limiting housekeeping duties during these hours.

Failed to assure adequate supervision of residents with wandering and aggressive behaviors, resulting in injuries including a hip fracture requiring surgical intervention.

Failed to notify primary care providers regarding behavioral incidents for two residents.

Failed to maintain minimum staffing levels in the Special Care Unit for 24 of 42 shifts from 12/25/16 to 01/07/17.

Failed to assure all residents received care and services which were adequate, appropriate, and in compliance with relevant laws related to personal care and supervision.

Outside grounds not free from hazards including abandoned station wagon and structurally damaged outbuilding.

Ceiling construction not maintained; privacy curtain track loose in Women's Bath.

No preventative measures to prevent water migration from AC unit in Staff Break Room.

Failure to maintain active fire protection devices; missing fire extinguisher in cabinet at front left-hand side hall.

Emergency lighting not functioning in corridor at rear exit HC wood ramp.

Missing manual pull station on required exit door in Dining Room.

Unsafe outbuildings on site posing hazard to residents and staff; outbuilding with 4'x4' hole in roof about to collapse.

Smoke-barrier door hardware not maintained; cross-corridor doors adjacent to Room 103 do not latch.

Wood ramp construction at rear of facility not maintained; rotten wood decking, spitting handrails, exposed nails, and non-anti-slip surfaces.

Improper storage of oxygen cylinders; oxygen bottles not stored in approved racks in Med Room.

Mechanical exhaust fans not exhausting interior air in Women's Bath/200 Hall.

Corridor handrails are unfastened to the corridor walls at multiple locations.

Outside grounds are not free from hazards including abandoned vehicles, debris, and structurally damaged outbuilding.

Ceiling construction is not maintained; ceiling unfastened and damaged due to water leak.

Plumbing fixtures not maintained; toilet out of order in Women's Bathroom.

Corridor walls need sheet-rock repair and finishing.

AC unit at exterior wall lacks preventative measures to prevent water migration.

Interior door hardware damaged preventing doors from latching (e.g., Room 107).

Fire extinguisher missing in cabinet at front left-hand side hall.

Emergency lighting failed to illuminate in emergency mode at multiple corridor locations.

Required exit door in Dining Room lacks manual pull station for fire alarm.

Outbuilding at rear yard has large hole in roof and is about to collapse.

Smoke-barrier door hardware not maintained; cross-corridor doors adjacent to Room 103 do not latch.

Wood ramp at rear of facility has rotted decking, damaged handrails, and non-anti-slip surfaces.

Oxygen cylinders improperly stored not in approved racks in Med Room.

Mechanical exhaust fans not exhausting interior air in Spa/100 Hall and Women's Bath/200 Hall.

Facility failed to assure the walls, floors and ceilings in resident rooms, shared bathrooms, hallways, dining room, kitchen, and the kitchen's pantry were kept in good repair including peeling, detached, missing, and dangling ceiling covering, detached baseboards, missing or peeling paint, scuffed areas, cracks, open holes and creviced areas that could possibly serve as an entry point and harbor for pests.

Facility failed to maintain an environment free of hazards and obstructions as evidenced by failing to repair an uncovered electrical outlet beside a resident's bed who was oxygen dependent, resulting in the oxygen machine being plugged in to an electrical outlet in the common 200 hallway, creating a trip/fall hazard; failing to enclose an electrical outlet and light switch left in an unoccupied empty resident room (#209); failing to enclose electrical wiring approximately 6 feet high on the wall next to the entrance door in the activity room; and storing 4 unused televisions on the floor in the television room on the 300 hall.

Facility failed to maintain a clean, orderly, and contamination-free kitchen, dining and food storage areas as evidenced by an infestation of live and dead roaches in the kitchen and dining room.

Facility failed to assure all residents were free of physical harm and neglect, including failure to protect Resident #4 from physical harm by Resident #3 who pushed Resident #4 resulting in a hip fracture; failure to investigate family concerns of Resident #4's injuries; and failure to follow bed bug protocol for Residents #8 and #11.

Facility failed to assure minimum staffing requirements were maintained to meet the needs of residents in the special care unit for 32 of 42 shifts sampled.

Facility failed to assure special care unit staff received required orientation and training including 6 hours of training within one week of employment and 20 hours within six months for 2 of 6 staff sampled.

Facility failed to assure complete screening and examination for controlled substances was performed for 1 of 6 staff sampled (Staff A) hired after 10/01/13.

Facility failed to provide an environment free of hazards due to the presence of bed bugs in multiple locations.

Failed to provide table service that included a non-disposable butter knife and a non-disposable bowl to all residents.