Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Clay County Health And Rehabilitation during CMS and state inspections, most recent first.
Failure to designate a qualified Infection Preventionist: The facility’s IP position was vacant, and the DON and ADON were performing IP duties without SPICE training or other specialized infection prevention and control training. The Administrator stated the facility was attempting to hire an IP.
A resident with DM, heart disease, HF, and HTN had hospital discharge medication orders that were not accurately transcribed into the MAR. The ADON failed to enter routine insulin aspart 10 units with meals, and Coreg was scheduled once daily instead of BID, even though the discharge summary ordered BID dosing. The resident’s BGs were often in the 200s and 300s with multiple readings over 400, and BP and pulse were monitored daily while the incorrect Coreg schedule remained in place.
A resident with dementia and severe cognitive impairment experienced significant weight loss while on a nutrition care plan. The RD documented continued decline and recommended increasing health shakes from daily to three times daily, but no order was entered and the resident continued receiving only one shake daily. Staff and the DON reported the RD recommendation was missed because it was emailed to the wrong person and there was no process for reviewing RD notes.
A resident returned after hospitalization for COVID-19 pneumonia with a low TSH noted on the hospital discharge summary and a recommendation for repeat thyroid testing. The MD documented the suppressed TSH during the initial H&P visit, but the note had no plan to recheck thyroid labs or otherwise address the abnormal result, and the chart contained no evidence of follow-up thyroid testing or thyroid-related orders.
Consultant Pharmacist failed to identify missing lab monitoring for a resident with diabetes receiving Metformin. The resident’s chart showed an A1c history and a NP note calling for routine A1c monitoring after Accu-Cheks were discontinued, but no order for ongoing A1c testing was present. Monthly MRRs were completed without any lab recommendations, and the Consultant Pharmacist acknowledged he did not recommend an A1c test; the Consultant Pharmacist Supervisor and DON confirmed the omission.
Failure to Monitor Diabetes Medication Regimen: A resident with diabetes mellitus was receiving Metformin and had finger stick blood sugars discontinued after the NP noted stable CBGs and recommended routine A1c monitoring. However, no A1c lab monitoring was ordered, and the Physician, Consultant Pharmacist Supervisor, and DON all stated the resident should have had quarterly A1c testing; the Physician acknowledged he had not ordered it and staff had not recognized the missing monitoring.
Expired medications were found in the med room, including Pneumovax 23 syringes, acetaminophen suppositories, and cough medicine past their expiration dates. The UM, Pharmacist, and DON all stated expired meds should be removed, but the facility had no assigned person or checklist for checking the med room. In a separate event, a medication aide left the 300-hall med cart unattended and unlocked in the hallway while a resident was nearby.
A medication aide performed a resident’s CBG check without gloves, without hand hygiene before or after the procedure, and without disinfecting the resident-labeled glucometer afterward. The glucometer was returned to its storage bag and medication cart while disinfectant wipes were available, despite facility policy and the glucometer instructions requiring disinfection after each use. The DON and Administrator confirmed staff were expected to follow the facility’s hand hygiene, standard precautions, and glucometer disinfection policies.
Failure to document pneumococcal immunization education and status. A resident admitted with CHF and COPD had no record that education on the vaccine’s benefits and side effects was provided to the resident or RP, no documentation that the vaccine was offered, and no record showing it was received, refused, or withheld for a medical contraindication. The DON said the prior IP had left and she and the Assistant DON were covering IP duties, while the Administrator acknowledged resident immunizations were not up to date.
Failure to offer and document COVID-19 vaccination for a resident reviewed for immunizations. The EMR had no record that the vaccine was offered, no documentation of education to the resident or RP about benefits and risks, and no record of consent or refusal. The DON said she did not have a list of residents who had received the vaccine and could not provide the resident's status, and the Administrator stated resident immunizations were not up to date.
Missed Required Physician and NP Visits: The facility failed to ensure required face-to-face physician or NP visits occurred every 60 days for three residents. Records showed gaps in routine assessments for residents with dementia, CHF, CAD, HTN, and functional dependence, and the physician acknowledged that some visits slipped by while he tracked them with scheduler software and did not have an NP to assist.
The facility inaccurately coded MDS assessments, marking bed rails as restraints for several residents who used them for mobility. Additionally, active diagnoses were incorrectly documented, such as pneumonia and hypertension, due to misunderstandings by the MDS Coordinator. Interviews revealed a lack of adherence to proper coding procedures, despite expectations for accuracy from the Administrator and DON.
The facility failed to complete comprehensive Care Area Assessments (CAA) for two residents, leading to deficiencies in addressing triggered care areas. A resident with pressure ulcers and another on psychotropic medication did not have detailed analyses of their conditions. The MDS Coordinator admitted to initially not understanding CAA requirements, resulting in incomplete assessments.
The facility failed to conduct necessary bed rail assessments for three residents, leading to a deficiency in safety protocol compliance. A resident with a history of falls and another with moderate cognitive impairment had not been assessed since late 2023, despite using bed rails. Another resident with paraplegia also lacked a recent assessment. The DON cited staff changes as a reason for the oversight, while both the DON and Administrator expected assessments to be done quarterly or annually per policy.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist responsible for the Infection Prevention and Control Program. During the Entrance Conference, the Administrator stated that the Infection Preventionist position was vacant and that the ADON and DON were performing those duties, but neither had completed SPICE training or any other specialized infection prevention and control training. The DON later confirmed that the previous Infection Preventionist had left in early March 2026 and that she and the new ADON were currently performing Infection Preventionist functions without SPICE training or other specialized infection prevention and control training. The Administrator also stated that the facility was attempting to hire an Infection Preventionist.
Missed and Incorrectly Entered Admission Medication Orders
Penalty
Summary
The facility failed to transcribe and implement hospital discharge orders for a resident with type 2 diabetes, atherosclerotic heart disease, heart failure, and hypertension after re-admission. The resident’s hospital discharge medication list included insulin aspart 10 units three times daily with meals, insulin aspart sliding scale coverage before meals and at bedtime, and insulin glargine 15 units twice daily. The resident’s electronic record showed that the admission medications were entered by the ADON, but the routine insulin aspart 10 units with meals was not entered into the active orders. The resident’s blood glucose was monitored four times daily and was documented most often in the 200s and 300s, with readings greater than 400 on multiple occasions during the review period. The facility also failed to transcribe and implement the resident’s carvedilol order correctly. The hospital discharge summary listed carvedilol 12.5 mg by mouth twice daily, but the active order entered in the electronic record was for Coreg 12.5 mg by mouth twice daily while the MAR was scheduled for once daily in the morning. The MAR showed the resident received Coreg only once daily from the time of re-admission through the end of the reviewed period. During that same period, the resident’s blood pressure and pulse were monitored at least daily, with systolic blood pressures documented as high as 180, diastolic pressures as high as 108, and pulse rates as high as 112. Interviews identified that the ADON entered the admission orders but did not verify them with the physician because he was not aware he needed to do so. He acknowledged missing the routine insulin aspart order and entering the Coreg time code incorrectly. The UM stated she did not usually do admission orders and did not perform a second check. The DON stated admission orders were supposed to be checked against the discharge summary and that a second nurse check was expected, but she did not open each order in the electronic system to confirm the time codes. The Medical Director stated the facility should follow and verify discharge summary orders, and he said the resident should have received Coreg as ordered.
Failure to Implement RD Nutrition Recommendation for Resident With Weight Loss
Penalty
Summary
The facility failed to follow RD recommendations for a resident with significant weight loss and a nutritional problem identified in the care plan. The resident had dementia, severe cognitive impairment, and behaviors/rejection of care documented on the MDS. Her care plan called for RD evaluation, diet changes as needed, weight monitoring, and monitoring for symptoms of malnutrition, with a goal of maintaining weight within 5% of body weight and consuming at least 50% of meals daily. The resident’s weight declined from 120 pounds to 110 pounds, then to 109.6 pounds, 109 pounds, and later 101.8 pounds. An RD note documented significant weight loss and stated the resident was receiving a health shake daily and that the RD recommended increasing the health shakes to three times daily to support continued weight loss. However, there was no physician order for the increase in health shakes. Staff interviews showed the resident continued to receive the health shake only once daily. The RD stated the recommendation had been emailed to the DON, but the email was sent to the wrong person and was missed. The DON stated she had not received the recommendation, there was no process for reviewing RD notes, and she relied on the RD emailing recommendations so she could enter orders. The Administrator stated something happened in the process and the facility had not received the RD recommendations for the resident.
Physician Visit Lacked Plan for Abnormal Thyroid Lab
Penalty
Summary
The facility failed to ensure the physician visit included a plan to address an abnormal low thyroid lab result noted in the hospital discharge summary for one resident. The discharge summary documented that the resident had been hospitalized for COVID-19 pneumonia and that her TSH was low at 0.36, with a recommendation to follow up with the primary care provider for repeat thyroid function tests. After readmission to the facility, the resident’s record did not contain a diagnosis of thyroid disease, an order for thyroid medication, or any documentation that the facility obtained repeat thyroid labs. A physician visit note by the Medical Director documented that the resident was being seen for an initial assessment and history and physical after hospitalization and stated that TSH was suppressed, but the note did not include a plan to recheck thyroid function or otherwise address the abnormal thyroid lab. The resident had severe cognitive impairment on the admission MDS. During interview, the Medical Director stated he had mentioned the suppressed TSH in the note but had missed ordering a recheck, and he agreed there should have been a plan to recheck it. The Administrator stated he expected staff to review the discharge summary and follow and implement the orders from the discharge summary.
Consultant Pharmacist Failed to Identify Missing A1c Monitoring for Resident on Metformin
Penalty
Summary
The Consultant Pharmacist failed to identify irregularities related to laboratory monitoring for a resident with diabetes who was receiving Metformin. The resident was admitted with diagnoses including diabetes mellitus, and the medical record showed an A1c of 7.9% dated 7/02/25, which was the last documented A1c in the chart. A Nurse Practitioner progress note dated 10/30/25 stated the resident’s CBGs were stable, recommended discontinuing Accu-Cheks, and directed continued routine A1c monitoring while continuing Metformin, but there was no order in the record for routine A1c monitoring. The Consultant Pharmacist completed monthly medication regimen reviews on 11/12/25, 12/22/25, 1/15/26, 2/11/26, 3/13/26, and 4/12/26, and none included recommendations for laboratory monitoring. During interview, the Consultant Pharmacist stated he had not recommended an A1c lab test for Metformin monitoring and said he sometimes looked for lab results and sent recommendations to the Physician, but did not catch everything. The Consultant Pharmacist Supervisor stated that for a resident taking diabetic medication such as Metformin, the Consultant Pharmacist should have reviewed lab results for medication monitoring and recommended blood sugar monitoring such as an A1c. The DON also stated the Consultant Pharmacist did not make a recommendation for A1c laboratory tests for the resident.
Failure to Monitor Diabetes Medication Regimen
Penalty
Summary
The facility failed to ensure monitoring for medication management was completed as recommended by the medical provider for a resident with diabetes mellitus who was receiving Metformin 500 mg by mouth every day. The resident was admitted with diagnoses including diabetes mellitus, and a Nurse Practitioner progress note stated that the capillary blood glucose levels were stable, recommended discontinuing Accu-Chek finger sticks, and continuing routine A1c monitoring along with Metformin. The Nurse Practitioner discontinued the finger stick blood sugars, but the resident's physician orders did not include any diagnostic lab tests for diabetes monitoring after that change. During interviews, the Physician stated the resident should have had an A1c test quarterly to monitor blood sugar levels and acknowledged he had missed that the testing needed to be done and had not ordered it. The Consultant Pharmacist Supervisor stated that a resident taking diabetic medication such as Metformin should have been monitored with an A1c laboratory test. The DON stated the resident should have had an A1c test scheduled quarterly, that the physician did not order additional monitoring, and that facility staff had not recognized the need for it even though the resident's progress notes were reviewed and discussed at morning meetings.
Expired Medications Stored and Medication Cart Left Unlocked
Penalty
Summary
Expired medications were found stored in the medication room during observation with the Unit Manager. Three prefilled Pneumovax 23 0.5 mL single-dose syringes were in the refrigerator with an expiration date of 1/24/26, two acetaminophen 650 mg suppositories had an expiration date of 3/2026, and four unopened 118 mL bottles of dextromethorphan HBR guaifenesin had an expiration date of 2/2026. The Unit Manager stated expired medications should be removed and discarded but was not sure who was responsible for checking the medication room for expired medications. The Pharmacist stated expired medications should be removed and discarded from the medication room and reported that pharmacy only performed spot checks rather than an all-inclusive review of all medications stored there. He stated the facility was responsible for checking for expired medications outside of the monthly pharmacy spot checks. The DON stated the medication room was supposed to be checked weekly but was not assigned to a specific individual and there was no checklist or documentation of the checks, describing it as an honor system. In a separate observation, the 300-hall medication cart was left unattended in the hallway and unlocked while a resident was nearby, and the Medication Aide acknowledged she should have locked the cart before walking away.
Failure to Disinfect Glucometer and Follow Standard Precautions During CBG Check
Penalty
Summary
The facility failed to implement its infection prevention and control policies during a capillary blood glucose (CBG) check for a resident assigned a glucometer for individual use. During a continuous observation, Medication Aide #1 removed the resident-labeled glucometer from the medication cart, carried it to the resident’s room with supplies, and performed the finger stick and blood glucose test. After obtaining the result, she exited the room with the lancet and glucometer, placed the glucometer back into its zippered storage bag, and returned it to the medication cart without disinfecting it, even though disinfectant wipes were available on the cart. The facility’s glucometer disinfection policy stated that glucometers are to be cleaned and disinfected after each use, regardless of whether they are intended for single-resident or multiple-resident use. The glucometer instruction manual also directed staff to put on gloves, inspect the meter, clean it, and disinfect all external surfaces after use. During interview, Medication Aide #1 stated she knew glucometers were supposed to be disinfected after each use and said she had planned to disinfect all three glucometers after completing all CBG checks on her hall, but then said she had forgotten to disinfect the resident’s glucometer. The facility also failed to follow its standard precautions and hand hygiene policies during the same CBG check. Medication Aide #1 did not perform hand hygiene before entering the room, did not wear gloves while touching the resident’s finger and blood during the finger stick, and did not perform hand hygiene after the procedure before leaving the room. She later sanitized her hands at the medication cart. In interview, she first said she did not wear gloves because she did not know she was supposed to, then said she typically wore gloves but had gotten nervous and forgotten. The DON and Administrator both stated that gloves, hand hygiene, and glucometer disinfection were required and that staff should follow facility policy.
Failure to Document Pneumococcal Immunization Education and Status
Penalty
Summary
The facility failed to document that a resident or Responsible Party was educated about the benefits and potential side effects of the pneumococcal immunization, and failed to document whether the resident received the immunization, refused it, or did not receive it because of a medical contraindication. The deficiency involved 1 of 5 residents reviewed for immunizations, Resident #6, who was admitted with diagnoses including congestive heart failure and chronic obstructive pulmonary disease. Review of the electronic medical record showed no documentation that education was provided, that the pneumococcal immunization was offered, or that it was received or refused. The facility policy stated that each resident is to be assessed for pneumococcal immunization upon admission and offered the vaccine unless medically contraindicated or already immunized under physician-approved standing orders. The DON stated the previous Infection Preventionist left in early March 2026 and that she and the new Assistant DON were performing IP functions, but she could not provide documentation for Resident #6. The Administrator stated the facility was attempting to hire an IP and was aware that resident immunizations were not up to date.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to assess a resident for eligibility and ensure the resident was offered the COVID-19 vaccine for 1 of 5 residents reviewed for immunizations (Resident #6). The facility policy stated that COVID-19 vaccinations would be offered to residents according to CDC guidelines unless medically contraindicated, the individual had already been immunized, or the individual refused the vaccine. Review of Resident #6's electronic medical record showed no documentation that the COVID-19 vaccine was offered, and there was no documentation that the resident or responsible party was educated about the benefits and potential risks of the vaccine or that the resident consented to or refused it. The DON stated that the previous IP left in early March 2026 and that she and the new Assistant DON were performing the IP's functions, but she did not have a list of residents who had received the COVID-19 vaccine and could not provide information about Resident #6's vaccination status. The Administrator stated the facility was attempting to hire an IP and was aware that resident immunizations were not up to date.
Missed Required Physician and NP Visits
Penalty
Summary
The facility failed to ensure physician or nurse practitioner face-to-face visits occurred at least once every 60 days for 3 of 3 residents reviewed for physician visits. Resident #62 had diagnoses including congestive heart failure, dementia, and diabetes, and was documented as severely cognitively impaired and dependent on staff for most activities of daily living. Her record showed a nurse practitioner progress note on 12/18/25 and a physician annual wellness visit on 3/31/26, with no documentation of any physician or NP assessment between those dates. The physician stated he used scheduler software to track required visit dates, but acknowledged he currently did not have an NP and had let some visits slip by. Resident #44 had dementia and was seen by an NP on 1/29/26 for a 90-day follow-up visit, then by the physician on 4/20/26 for a federally mandated visit and acute visit. Her record contained no documentation of a physician or NP visit from 1/30/26 through 4/19/26, an 80-day gap. Resident #9 had diagnoses including coronary artery disease and hypertension, with moderately impaired cognition and moderate staff assistance needed for most activities of daily living. Her record showed an NP note on 12/11/25 and a physician federally mandated visit on 2/10/26, with no further documentation of assessment afterward; the physician confirmed the resident should have been seen on 4/16/26 but was not because he was not at the facility. The DON and administrator stated the physician was responsible for seeing residents as required by regulation.
Inaccurate MDS Coding for Bed Rails and Diagnoses
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for several residents, leading to incorrect documentation of bed rails as physical restraints. For multiple residents, including those with conditions such as muscle weakness, respiratory issues, and paraplegia, the MDS assessments incorrectly indicated the use of bed rails as restraints. Observations and interviews revealed that these bed rails were actually used for independent bed mobility and repositioning, not as restraints. The MDS Coordinator admitted to misunderstanding the MDS questions regarding bed rail use, resulting in incorrect coding. In addition to the bed rail coding errors, the facility also failed to accurately document active diagnoses for some residents. For instance, a resident with a history of pneumonia was incorrectly coded as having an active diagnosis of pneumonia on the MDS, despite no supporting documentation or physician orders indicating such a condition at the time of assessment. Similarly, another resident was not coded for hypertension as an active diagnosis, even though they were on medications for hypertension, which was confirmed by the MDS Coordinator and the Director of Nursing (DON). Interviews with the MDS Coordinator, DON, and Administrator highlighted a lack of understanding and adherence to proper MDS coding procedures. The Administrator and DON both expressed expectations for accurate MDS assessments, yet the repeated errors in coding suggest a systemic issue in the facility's assessment process. These inaccuracies in MDS coding could potentially impact the care and treatment plans for the residents involved.
Incomplete Care Area Assessments for Two Residents
Penalty
Summary
The facility failed to complete Care Area Assessments (CAA) comprehensively for two residents, leading to deficiencies in addressing the underlying causes and contributing factors of triggered care areas. Resident #46, who was admitted with diagnoses including diabetes, stroke, and end-stage renal disease, had a care area for pressure ulcers triggered. However, the MDS Coordinator did not provide a comprehensive analysis of findings, such as the nature of the problem, possible causes, contributing factors, and risk factors. It was merely noted that pressure ulcers would be addressed in the care plan due to the resident's admission with wounds. Similarly, Resident #51, admitted with debility, respiratory failure, and asthma with acute exacerbation, had a care area for psychotropic medication use triggered. Again, the MDS Coordinator failed to provide a detailed analysis of findings for this care area. During interviews, the MDS Coordinator admitted to not understanding the requirements for CAAs when she first started the position but acknowledged the deficiency in the assessments for these residents. The Administrator confirmed that it was expected for CAAs to be completed with a comprehensive analysis of findings for triggered care areas.
Failure to Complete Bed Rail Assessments for Residents
Penalty
Summary
The facility failed to complete necessary bed rail assessments for three residents, leading to a deficiency in compliance with safety protocols. Resident #1, who had a history of falling and required substantial assistance with bed mobility, had not had a bed rail assessment since November 2023, despite using bed rails for repositioning and sitting up. Similarly, Resident #51, with moderate cognitive impairment and requiring partial assistance, had not had a bed rail assessment since October 2023. Both residents were observed using bed rails without recent assessments to determine their safety and necessity. Resident #13, diagnosed with paraplegia and requiring maximum assistance with bed mobility, also lacked a recent bed rail assessment, with the last one completed in December 2023. The Director of Nursing acknowledged the lapse in completing these assessments, attributing it to changes in administrative nursing staff. Both the DON and the Administrator expressed expectations that bed rail assessments should be conducted quarterly or at least annually, in accordance with facility policy, but these expectations were not met, resulting in the deficiency.
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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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Nursing homes near Hayesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chatuge Regional Nursing Home | 7.4 mi | ★★★★★ | 9 | 0 |
| Valley View Care And Rehabilitation | 10.7 mi | ★★★★★ | 7 | 0 |
| Union County Nursing Home | 13.9 mi | ★★★★★ | 3 | 0 |
| Murphy Rehabilitation & Nursing | 18 mi | ★★★★★ | 2 | 0 |
| Graham Healthcare And Rehabilitation Center | 18.6 mi | ★★★★★ | 6 | 0 |
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