Inspection Reports for
Clayton Nursing and Rehab Center
419 HARDING STREET, CLAYTON, NM, 88415
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than New Mexico average
New Mexico average: 7.1 deficiencies/year
Deficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 8
Date: Oct 31, 2024
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations, including resident care, grievance handling, restorative therapy, nutrition services, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs such as call light accessibility, failure to notify residents of grievance outcomes, incomplete care plan meetings, inadequate restorative therapy services, failure to serve meals as posted and provide alternate menus, poor food palatability, improper food storage and labeling, and failure to implement enhanced barrier precautions for residents with wounds or urinary catheters.
Deficiencies (8)
Failed to provide reasonable accommodations of resident needs and preferences for call light accessibility for resident #6.
Failed to notify residents of the outcomes/resolutions of their grievances for residents #3, 21, 24, and 25.
Failed to conduct quarterly care plan meetings for resident #3 as required.
Failed to ensure residents #6 and #25 received restorative nursing program services as ordered.
Failed to serve food items as listed on the menu and did not provide alternate meal menus for all 30 residents.
Failed to ensure food was palatable and to resident satisfaction for resident #21.
Failed to properly label and date open food items in the dietary department, risking cross contamination and foodborne illness.
Failed to implement enhanced barrier precautions for 6 residents with wounds or urinary catheters, including lack of PPE outside rooms and failure of staff to use PPE during care.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 30
Residents affected: 1
Residents affected: 30
Residents affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #1 | Confirmed call light was out of reach for resident #6 | |
| Director of Nursing | Director of Nursing | Confirmed call light should be near resident #6; stated restorative nursing program services should be provided to residents #6 and #25; stated PPE was available and staff were being in-serviced on enhanced barrier precautions |
| Minimum Data Set Coordinator | MDS Coordinator | Responsible for scheduling and conducting resident care plan meetings; stated resident #3 missed last two quarterly care plan meetings |
| Restorative Certified Nursing Assistant | RCNA | Stated he provided restorative nursing program services but was prevented from providing services to residents #6 and #25 due to other duties |
| Registered Nurse #1 | RN | Stated restorative nursing program services gave resident #6 a sense of purpose and should be provided |
| Dietary Manager | Dietary Manager | Stated facility did not have supplies for cheesecake or glaze for meatloaf; stated alternate meals were not made or offered due to low census |
| Registered Dietitian | RD | Stated residents should be served meals as posted or be informed of changes; stated posted menus should include alternate menu choices |
| Food Service Director | Food Service Director | Acknowledged new dietary staff needed supervision and was aware of burnt pasta and peach cobbler mistakes |
| Healthcare Group Services Operationalist | HCGS Operationalist | Stated staff are expected to label and date all food items and cover them to prevent contamination |
| Skin Care Team Lead Nurse | SHTL Nurse | Stated updated guidelines for enhanced barrier precautions were recently brought to her attention |
| Director of Nursing/Infection Preventionist | DON/IP | Stated PPE was available and staff were being in-serviced on enhanced barrier precautions |
| Administrator | Administrator | Stated staff did not complete grievance forms fully and residents should know grievance resolutions |
Inspection Report
Census: 31
Deficiencies: 8
Date: Oct 5, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, infection control, nutrition, and facility safety at Clayton Nursing and Rehab Center.
Findings
The facility was found deficient in multiple areas including pain management communication, medication administration errors, unsecured medication storage, failure to follow dietitian-approved menus, inaccurate medical records documentation, infection prevention and control program deficiencies, and environmental safety issues such as unrepaired resident room damage.
Deficiencies (8)
Failed to treat and communicate resident's pain levels with their physician for 1 resident reviewed for pain management.
Failed to ensure medications were administered as ordered; chewable aspirin given instead of delayed release.
Medication cart left unlocked and unattended, risking resident access to medications.
Failed to follow dietitian-approved menus and did not communicate meal substitutions to dietitian.
Failed to honor resident meal preferences by not providing meals selected on meal tickets.
Failed to maintain complete and accurate medical records for 1 resident, including discharge communication.
Failed to implement infection prevention and control program adequately, including improper storage of Foley catheter bag and oxygen tubing, and lack of separation between clean and soiled laundry areas.
Failed to maintain a safe and functional environment; resident rooms had unrepaired damage including missing toilet tank lid and hole in drywall.
Report Facts
Medication administration count: 55
Medication administration count: 50
Medication administration count: 5
Residents affected: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Administered chewable aspirin instead of delayed release aspirin; confirmed medication cart was left unlocked |
| Director of Nursing | Director of Nursing | Provided expectations regarding breakthrough pain medication and medication cart security; confirmed Foley catheter bag and oxygen tubing should not be on floor |
| Facility Medical Director | Facility Medical Director | Interviewed regarding pain medication orders for resident #22 |
| Dietary District Manager | Dietary District Manager | Interviewed about meal substitution log and communication with dietitian |
| Registered Dietitian | Registered Dietitian | Interviewed about meal substitutions and resident meal preferences |
| Restorative Aide | Restorative Aide | Confirmed staff served incorrect vegetable to resident #22 |
| Registered Nurse #1 | Registered Nurse | Interviewed about resident #22 discharge planning and reintegration |
| Administrator | Administrator | Interviewed about discharge planning documentation and environmental safety issues |
| Maintenance Director | Maintenance Director | Interviewed about room damage and repair work orders |
| Housekeeping/Laundry Supervisor | Housekeeping/Laundry Supervisor | Interviewed about laundry area layout and lack of negative pressure system |
| Infection Preventionist | Infection Preventionist | Interviewed about laundry area separation and infection control practices |
| Registered Nurse #4 | Registered Nurse | Confirmed oxygen tubing placement for resident #27 |
Inspection Report
Deficiencies: 1
Date: Jul 13, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with care standards related to maintaining or improving range of motion for residents, specifically addressing treatment for a resident with decreased range of motion and contractures.
Findings
The facility failed to ensure that one resident with decreased range of motion and contractures of the left hand received appropriate treatment and services to prevent further decline. Observations and interviews confirmed the resident's left hand was clenched in a fist without the required rolled-up washcloth to relieve tension, contrary to the care plan and family instructions.
Deficiencies (1)
Failure to provide appropriate care to maintain or improve range of motion for a resident with contractures of the left hand, including not placing a rolled-up washcloth in the resident's hand as required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed that the resident was to have a rolled up cloth in his left hand at all times to relieve tension. | |
| CNA #1 | Observed the resident's left hand clinched without the cloth and confirmed the cloth was to be checked daily. |
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