Clayton House

The facility failed to maintain an environment free from chronic unpleasant odors. Observations revealed a strong smell of urine at the facility entrance, throughout the 200 hall, and in/around resident room 204.

The facility failed to ensure all 26 residents were offered activities designed to promote active involvement with each other and the community. Evidence showed a lack of consistent activity implementation for the resident population.

The facility failed to maintain an environment free from chronic unpleasant odors. Multiple observations revealed a strong smell of urine upon entrance and throughout the 200 hall, specifically including room 204. Interviews indicated the odor had persisted for months and that housekeeping and maintenance schedules were insufficient to address the issue.

The facility failed to provide adequate supervision for residents in a Special Care Unit, resulting in four out of five sampled residents eloping from the facility without staff knowledge. This occurred because the front door and other exit doors were malfunctioning, with sounding devices that were not properly controlled or connected to a fire panel.

The facility failed to provide adequate supervision for residents in a Special Care Unit, resulting in four out of five sampled residents with dementia and wandering behaviors eloping from the building without staff knowledge. This occurred because the front door was malfunctioning, and the staff's door alarm system did not require deactivation, allowing exits to occur unnoticed. The facility's maintenance was unable to resolve the keypad issue, leaving doors vulnerable to being pushed open.

The facility failed to provide adequate supervision for two residents with a history of falls and wandering. Specifically, one resident experienced two unwitnessed falls resulting in a head laceration, and another resident experienced two episodes of elopement within one month.

The facility failed to ensure required staffing hours for the Special Care Unit (SCU) were met. Based on record reviews, there were staffing shortages on 6 of 12 sampled shifts between 07/02/21 and 07/05/21, specifically failing to meet the required staff hours for the resident census on various shifts.

The facility failed to provide necessary personal care for 2 of 5 sampled residents who required assistance with toileting. Specifically, a resident with incontinence was found with urine-soaked clothing and briefs, as staff had not provided incontinence care since approximately 12:00pm or 12:30pm.