Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive and swallowing impairments, who required full feeding assistance and a modified diet, was left unsupervised with a meal that did not meet prescribed texture requirements. The resident choked on improperly prepared food, leading to aspiration, emergency intervention, and hospitalization for aspiration pneumonia.
Surveyors observed multiple infection control deficiencies, including staff failing to perform hand hygiene and change gloves after providing care to residents on enhanced barrier precautions, PPE storage bins placed directly on the floor, and several wheelchairs with cracked surfaces that could not be properly sanitized. These lapses were acknowledged by staff and management during interviews.
A resident was diagnosed with Major Depressive Disorder and had a care plan developed for this condition, but the facility did not update the PASARR to reflect the new diagnosis. This lapse was identified during the annual survey and confirmed by the Director of Social Services.
A resident was prescribed Duloxetine for depression without a documented diagnosis of depression in the medical record. The medication was administered and referenced in the care plan, and a pharmacy review indicated the physician did not want to reduce the dose since the medication was recently started. This resulted in a deficiency due to the absence of a supporting diagnosis for the antidepressant order.
The facility did not provide documentation showing that physicians reviewed and responded to pharmacist-identified irregularities in monthly drug regimen reviews for two residents. Required consult reports and physician responses were missing, as confirmed by staff interviews.
Surveyors found employee personal items, such as a purse, keys, and a jacket, stored on a chair in the kitchen pantry room, which was confirmed by a manager as a common staff practice. This storage method did not meet professional standards for food service safety and had the potential to affect multiple residents.
Garbage and refuse were not properly contained, as a trash receptacle lid in the dish room was blocked by a box, hindering staff from drying hands without contamination, and a dumpster lid was left open while not in use. These issues were acknowledged by management staff.
Surveyors identified that two residents had inconsistencies in their medical records, including a mismatch between a bed safety evaluation and care plan regarding a floor mat intervention, and conflicting gender information between a POST form and MDS admission screening.
A resident was unable to access the call button while in bed, as it was found on the floor under the bed and out of reach. A CNA confirmed the call button was not accessible and noted that such incidents occur when residents knock them off the bed. The call button was returned to the bed but not secured, and the DON was informed of the situation.
Failure to Provide Required Feeding Assistance and Diet Consistency Resulting in Resident Aspiration
Penalty
Summary
A resident with significant cognitive and physical impairments, including neurocognitive disorder, aphasia, dysphagia, and Parkinson's disease, was dependent on staff for full feeding assistance and required a modified diet with ground meat and specific supervision during meals. Despite these documented needs, the resident was left unsupervised in the dining room with a meal that did not meet the prescribed texture requirements. The nurse aide responsible for delivering the tray cut the turkey into smaller pieces but did not remain to feed the resident, as she was assigned to assist another resident at the same time. The aide also reported confusion regarding the resident's feeding requirements and did not recall receiving full feed training prior to the incident. During the meal, the resident began to choke on a piece of turkey, was found drooling, cyanotic, and not breathing by an activities leader, who then called for help. Multiple staff members attempted the Heimlich maneuver and finger sweeps without success, and emergency services were called. The resident was subsequently transferred to the emergency department, where he was diagnosed with aspiration pneumonia and a thoracic aortic aneurysm. The resident's family declined further aggressive interventions, and he was returned to the facility on antibiotics and hospice care. Interviews and record reviews revealed that the resident's care plan and speech therapy recommendations clearly indicated the need for full feeding assistance and close supervision during meals, as well as specific diet modifications. However, staff failed to ensure that the resident received the required level of assistance and the correct meal consistency. The system failure in meal service and staff supervision directly resulted in the resident's aspiration event and subsequent harm.
Infection Control Lapses and Unsanitary Equipment Identified
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple observed lapses in hand hygiene, improper use of personal protective equipment (PPE), and the presence of unsanitary equipment. During Foley catheter care for a resident on enhanced barrier precautions (EBP), two nurse aides removed their gloves but did not perform hand hygiene or re-glove before continuing care tasks such as adjusting clothing and linens. Both staff members acknowledged this was not their usual practice and attributed the lapse to nervousness. Additionally, ten PPE storage bins were found placed directly on the hallway floor outside rooms of residents on EBP, contrary to facility expectations as confirmed by the Regional Operations Coordinator Registered Nurse. Further observations revealed that three wheelchairs, including those used by two residents and an extra chair in the hallway, had cracks or holes exposing inner padding, making them impossible to sanitize. In one instance, the Assistant Director of Nursing (ADON) assisted with feeding a resident without performing hand hygiene or changing gloves after adjusting the resident's bed and bedside table. The ADON acknowledged this lapse during an interview. The presence of unsanitary wheelchairs and improper hand hygiene practices were confirmed by both the ADON and the Regional Operations Coordinator.
Failure to Update PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to update the Pre-admission Screening and Resident Review (PASARR) for a resident who was diagnosed with Major Depressive Disorder. Record review showed that the resident received this diagnosis on 01/28/25, and a care plan was developed on the same date to address the new diagnosis. However, the PASARR was not updated to reflect this change in the resident's mental health status. This deficiency was confirmed during the annual survey process through both record review and staff interview, with the Director of Social Services acknowledging that the PASARR should have been updated.
Antidepressant Prescribed Without Documented Diagnosis
Penalty
Summary
A deficiency was identified when a resident was prescribed Duloxetine 60 mg for depression without a documented diagnosis of depression in the medical record. The medication order was active for ten days before being discontinued, and the care plan referenced the use of an antidepressant for depression. Additionally, a pharmacy review noted that the physician declined a gradual dose reduction because the antidepressant had been recently initiated. The lack of a documented diagnosis for depression in the resident's record, despite the presence of an active antidepressant order and related care plan entry, led to the deficiency finding.
Lack of Physician Response to Pharmacist Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to provide evidence that the attending physician reviewed and responded to irregularities identified by the pharmacist during monthly drug regimen reviews for two of five residents reviewed under the Unnecessary Medications pathway. For one resident, pharmacist reviews were located, but the facility could not produce the pharmacist consult reports or the physician's responses to recommendations made on two separate occasions. Similarly, for another resident, the facility was unable to provide the pharmacist consult report or the physician's response to the pharmacist's recommendations. Staff interviews confirmed that the required documentation of physician review and response to pharmacist recommendations was not available for the specified dates.
Personal Items Improperly Stored in Kitchen Pantry
Penalty
Summary
During a kitchen inspection, surveyors observed employee personal items, including a purse, keys, and a jacket, stored on a chair in the kitchen pantry room. This storage practice was confirmed by the Corporate District Manager, who acknowledged that staff had been using this area for their personal belongings. The presence of these items in the pantry room was not in accordance with professional standards for food service safety, as required for proper food storage and handling. The deficiency was identified through direct observation and staff interviews, with the potential to affect multiple residents given the facility's census of 53. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Improper Containment of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal and containment of garbage and refuse in the kitchen pantry and dumpsters. During observation, a trash receptacle lid at the dish room hand washing station was blocked by a box, preventing staff from drying their hands without risk of contamination. Additionally, the dumpster lid outside was observed to be left open while not in use. These deficiencies were confirmed through staff interviews, where both the Corporate District Manager and the Assistant Director of Nursing acknowledged the improper conditions.
Inaccurate Medical Records and Documentation Discrepancies
Penalty
Summary
The facility failed to maintain accurate and consistent medical records for two residents. For one resident, a bed safety evaluation did not indicate the use of a floor mat, while both the care plan and physician orders documented a floor mat on the right side of the bed, and visual observation confirmed its presence. The floor mat intervention had been implemented following a post-fall event. For another resident, there was a discrepancy in gender identification between the West Virginia POST form, which listed the resident as female, and the MDS admission screening, which recorded the resident as male. These inconsistencies were identified during record review and staff interviews.
Call System Not Accessible to Resident in Bed
Penalty
Summary
During an observation in a resident's room, a resident was found sitting on the side of her bed and requested assistance to locate her call button in order to get help for her roommate. The call button was discovered on the floor under the bed, out of the resident's reach. In an interview, a CNA acknowledged that the call button was not accessible and stated that residents sometimes knock them off the bed. The CNA placed the call button back on the bed but did not secure it. The DON was also made aware that the call light was not within the resident's reach. These findings indicate that the facility failed to ensure the call system was accessible to residents while in bed or other sleeping accommodations within the resident's room.
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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 Ivydale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Miletree Center | 22.2 mi | ★★★★★ | 10 | 0 |
| Minnie Hamilton Health Care | 22.2 mi | ★★★★★ | 23 | 0 |
| Braxton Healthcare Center | 22.3 mi | ★★★★★ | 0 | 0 |
| Roane General Hospital | 22.4 mi | ★★★★★ | 14 | 0 |
| Summersville Healthcare Center | 24.1 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.