Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Heritage Hall Clintwood during CMS and state inspections, most recent first.
The facility staff failed to administer medications as ordered for three residents, including Gabapentin and Prednisone, despite these being available in the backup supply. This deficiency affected residents with conditions such as cerebral palsy, neuropathy, diabetes, and COPD. The facility's emergency pharmaceutical service policy was not properly utilized, leading to lapses in medication administration.
Facility staff failed to maintain effective infection control during medication administration and tray line service. LPNs did not perform hand hygiene before donning gloves or after removing them, contrary to facility policy. Additionally, staff did not adhere to appropriate transmission-based precautions, with policies lacking definitions for necessary measures. The administrator and DON were informed of these issues.
A resident with memory issues was transferred to a hospital for hyperglycemia and later admitted for hypernatremia. The facility staff failed to provide written notification of the transfer to the resident's responsible party, despite verbal acknowledgment. The process involved placing information in a folder sent with the resident, but documentation of the contents was lacking, and no written notification to the responsible party was evident.
A resident's care plan was not updated to reflect their behavior of placing an uncovered nebulizer in a recliner and covering it with personal items. Despite staff awareness of the behavior, the care plan lacked documentation, leading to multiple observations of improper storage. Interviews with staff confirmed the nebulizer should have been covered, but the resident's actions were not documented in their care plan.
Facility staff failed to document the amounts of enteral feeding residuals for a resident, despite orders to check and record them every eight hours. The resident, with intact cognition and dependent on others for daily activities, had an order since November 2023 for residual checks. The facility's procedure requires documentation of residual amounts to assess feeding tolerance and minimize aspiration risk, but this was not done, as confirmed by the Regional Director of Clinical Services.
A resident with chronic obstructive pulmonary disease and obstructive sleep apnea did not receive oxygen as ordered by the provider. The resident's oxygen was observed to be set at higher levels than the prescribed 2 liters per minute on multiple occasions. The resident stated that the nursing staff set the oxygen, and they did not adjust it themselves. The issue was discussed with the facility's administration and clinical leadership.
The facility failed to monitor two residents for side effects of psychotropic medications, as evidenced by the absence of documentation in their clinical records. One resident was prescribed fluoxetine, trazodone, and bupropion, while another was on quetiapine. Both residents' care plans included goals to prevent adverse effects, but there was no evidence of monitoring for potential side effects. The Regional Director of Clinical Services confirmed the lack of documentation, which should have been recorded in the Medication Administration Records.
Two residents had incomplete Durable Do Not Resuscitate (DDNR) forms, with sections left unanswered regarding their capability to make informed medical decisions. One resident's form lacked certification of decision-making capability, while the other resident's form did not specify their cognitive status despite a full BIMS score. These deficiencies were identified during a survey and discussed with the facility's leadership.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility staff failed to administer medications according to provider orders for three residents, leading to deficiencies in medication management. For Resident #10, who has cerebral palsy and neuropathy, the nursing staff did not administer Gabapentin as ordered due to a reported lack of availability from the pharmacy. However, a review indicated that the medication was available in the backup supply, suggesting a failure in accessing or utilizing the emergency pharmaceutical services as per the facility's policy. Similarly, Resident #44, diagnosed with diabetes, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea, did not receive Prednisone as prescribed for an acute COPD exacerbation. The medication was reportedly pending from the pharmacy, yet it was available in the backup supply. This indicates a lapse in following the facility's protocol for emergency medication access, which should have ensured timely administration. For Resident #292, who suffers from chronic obstructive pulmonary disease, chronic pancreatitis, and post-traumatic stress disorder, the staff again failed to administer Gabapentin as ordered. The medication was not given due to the absence of a medication card, despite being available in the backup supply. The Director of Nursing confirmed that staff could access the backup supply using a PIN, but this procedure was not followed, leading to the deficiency.
Infection Control Deficiencies in Hand Hygiene and Precautionary Measures
Penalty
Summary
Facility staff failed to maintain an effective infection control and prevention program, as observed during medication administration for three residents. Licensed Practical Nurses (LPNs) did not perform hand hygiene before donning gloves or after removing them during medication pass. Specifically, one LPN was observed not performing hand hygiene before donning gloves while assembling medications for a resident, although hand hygiene was performed after glove removal. Another LPN used wipes instead of proper hand hygiene between residents and failed to perform hand hygiene after glove removal. The facility's hand hygiene policy, which requires hand hygiene before and after glove use, was not adhered to. Additionally, during tray line service, staff members failed to adhere to appropriate transmission-based precautions. A staff member entered a room with neutropenic precautions without following the required protective measures, and another staff member was unable to identify the correct precautions for residents under contact and enhanced barrier precautions. The facility's policies did not adequately define the necessary measures for these precautions, and staff were reportedly following outdated CDC guidelines that did not address all required precautions. The administrator and director of nursing were informed of these concerns.
Failure to Provide Written Notification of Resident Transfer
Penalty
Summary
The facility staff failed to provide written notification to the responsible party (RP) of a resident's transfer to an emergency department. The resident, who was rarely/never understood and had issues with short-term and long-term memory, was transferred to a local hospital for evaluation of hyperglycemia and was later admitted to a different hospital with hypernatremia. Although the unit manager, an LPN, documented that the RP was aware of the transfer, there was no evidence of written notification being provided to the RP. The unit manager described a process where written information, including bed hold information, was placed in a green folder sent with the resident to the hospital. However, the LPN did not document what information was included in the folder, and there was no awareness of written transfer notification being sent to the RP. The resident's admission record indicated that the RP was their adult child and grandchild. Despite the nurse consultant providing evidence of ombudsman notification, no evidence of written notification to the RP was found. The issue was discussed with the DON, RDCS, and nurse consultant, but no further information was provided before the exit conference.
Failure to Update Care Plan for Nebulizer Storage
Penalty
Summary
The facility staff failed to review and revise the comprehensive care plan (CCP) for Resident #44, who was observed to have their nebulizer machine uncovered and partially covered with clothing in their room. Despite the resident's cognitive assessment indicating full mental capacity, the care plan did not reflect the resident's behavior of placing the nebulizer in the recliner and covering it with personal items. This oversight was noted during multiple observations by the surveyor, who found the nebulizer inappropriately stored on different occasions. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Infection Preventionist (IP), revealed that the nebulizer should have been covered after use. However, it was reported that the resident would place the nebulizer in the recliner and cover it with clothing and other items. The surveyor's review of the resident's records did not find any documentation of this behavior, indicating a failure to update the CCP to address the resident's actions and preferences. The issue was discussed with the Director of Nursing and other clinical leaders, but no additional information was provided to the survey team before the exit conference.
Failure to Document Enteral Feeding Residuals
Penalty
Summary
The facility staff failed to adhere to medical provider orders regarding the monitoring of enteral feeding residuals for a resident. The resident, who was assessed with intact cognition and dependent on others for various activities of daily living, had an order in place since November 2023 to have enteral feeding residuals checked and documented every eight hours. However, a review of the resident's June 2024 Medication Administration Record revealed that while the checks were documented as occurring, the actual amounts of the residuals were not recorded. The facility's procedure for checking gastric residual volume, revised in November 2018, requires that the amount of gastric residual be documented to assess the resident's tolerance of enteral feeding and minimize the risk of aspiration. Despite this requirement, the facility staff did not document the residual amounts, a fact confirmed by the Regional Director of Clinical Services. This oversight was discussed with the facility's Director of Nursing, Regional Director of Clinical Services, and Nurse Consultant by the survey team.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility staff failed to administer oxygen according to the provider's orders for a resident diagnosed with chronic obstructive pulmonary disease and obstructive sleep apnea. The resident's clinical record included a provider order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath, with the order documented on 05/30/24. However, observations revealed that the resident's oxygen was set at 3 and 3 1/2 liters per minute on different occasions, contrary to the prescribed 2 liters per minute. The resident, who had a BIMS score of 15, indicated that the nursing staff set the oxygen, and they did not adjust it themselves. The issue was reviewed with the facility's administration and clinical leadership, but no further information was provided to the survey team before the exit conference.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility staff failed to monitor two residents for side effects of psychotropic medications, as evidenced by the absence of documentation in their clinical records. Resident #23 was prescribed fluoxetine, trazodone, and bupropion, and their care plan included a focus on preventing negative effects from these medications. However, there was no evidence of monitoring for potential side effects such as anticholinergic, cardiovascular, metabolic, neurologic, or psychosocial effects. The Regional Director of Clinical Services confirmed the lack of documentation, which should have been recorded in the Medication Administration Records. Similarly, Resident #24, who was prescribed quetiapine, an antipsychotic medication, also lacked documentation of monitoring for side effects. The resident's care plan aimed to prevent adverse effects, but there was no evidence of monitoring for general, cardiovascular, metabolic, or neurologic side effects. The Regional Director of Clinical Services confirmed the absence of documentation, and the survey team discussed these findings with the facility's Director of Nursing and other staff members.
Incomplete DDNR Forms for Two Residents
Penalty
Summary
The facility staff failed to maintain complete and accurate clinical records for two residents, leading to deficiencies in their Durable Do Not Resuscitate (DDNR) forms. For Resident #87, the DDNR form dated 6/7/24 was incomplete, as it lacked certification regarding the resident's capability to make informed decisions about medical treatment. Additionally, the section that should be completed if the resident is determined incapable of making such decisions was also left unanswered. This oversight was identified during a meeting with the facility's Director of Nursing, Regional Director of Clinical Services, and Nurse Consultant. Similarly, Resident #292's DDNR form was incomplete, with sections 1 and 2 left blank. Despite having a BIMS score of 15, indicating full cognitive capacity, the form did not specify whether the resident was capable or incapable of making informed decisions. The form also lacked completion of the subsequent section that should be filled if the resident is deemed incapable. This issue was brought to the attention of the facility's administrative and clinical leadership, but no further information was provided to the survey team before the exit conference.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 9 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clintwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elkhorn Health & Rehabilitation | 11.3 mi | ★★★★★ | 0 | 0 |
| Heritage Hall Wise | 13.8 mi | ★★★★★ | 0 | 0 |
| Norton Community Hospital Snf Unit | 18.4 mi | ★★★★★ | 6 | 0 |
| Letcher Manor | 19.5 mi | ★★★★★ | 1 | 0 |
| Pikeville Nursing And Rehab Center | 22.4 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Heritage Hall Clintwood.
100% money-back within 48 hours.
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.