Below 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 Tazewell during CMS and state inspections, most recent first.
Facility staff did not properly assess or supervise residents who smoked, resulting in multiple residents smoking unsupervised, possessing lighters and cigarettes, and not using required safety equipment. One resident with a history of non-compliance and medical issues suffered burns after smoking with oxygen, and staff interviews confirmed that unsupervised smoking was a known issue. Smoking materials were not secured, and safety precautions were lacking, leading to a serious incident and the identification of an Immediate Jeopardy situation.
Staff failed to administer prescribed Bacitracin ointment for burns to one resident due to lack of awareness that the medication was available as house stock, resulting in a missed treatment. Additionally, another resident did not receive the full colonoscopy prep as ordered, including a clear liquid diet and Dulcolax tablets, leading to an incomplete procedure. These incidents were confirmed through record review, resident and staff interviews, and facility documentation.
A resident with a chronic arterial and later pressure ulcer did not consistently receive wound care as ordered, with multiple missed or undocumented treatments over several months. The resident reported difficulty obtaining dressing changes, and the DON confirmed both the wound's progression and gaps in care documentation, especially when the resident was out of the facility.
A resident with multiple complex medical conditions did not receive scheduled doses of Oxycontin on six occasions because the medication was not available onsite or sent by the pharmacy. Nursing documentation and interviews with the DON and Regional Nurse Consultant confirmed the medication was not accessible in the Pyxis system, and facility leadership could not explain the cause of the unavailability.
A resident's annual MDS assessment was not completed within the required timeframe due to a software change, resulting in the assessment being missed. The resident, with conditions including atrial fibrillation and diabetes, had their assessment delayed beyond the 12-month requirement. The issue was identified during a survey and discussed with facility leadership.
A resident's quarterly MDS assessment was not completed within the required timeframe due to a software change in the facility. The resident, with conditions such as diabetes and hypertension, had their last assessment on 10/13/23, and as of early March, no further assessments were done. The MDS coordinator acknowledged the oversight during an interview.
The facility staff failed to accurately document the completion dates of MDS assessments for two residents, leading to deficiencies. For one resident, the MDS assessment indicated severe cognitive impairment and required assistance with daily activities, but documentation showed completion dates after the ARD. Similarly, another resident's assessment indicated intact cognition, but again, documentation was completed after the ARD. Facility staff acknowledged the error, with no evidence of timely completion.
A resident with complex medical conditions, including heart failure and diabetes, was admitted to an LTC facility without dietary orders included in their baseline care plan. This omission was identified during a closed record review, highlighting a failure to adhere to the facility's policy requiring dietary instructions as part of the baseline care plan. The issue was discussed with the facility's leadership, but no further information was provided before the exit conference.
A nursing facility failed to complete necessary admission assessments and documentation for a resident with complex medical conditions, leading to medication errors post-discharge. Additionally, assessments for another resident were documented after their death, violating facility policies. The DON acknowledged the need for timely and accurate documentation.
The facility failed to administer medications as ordered for two residents and did not have care orders for a percutaneous cholecystectomy drain for another resident. One resident did not receive Gabapentin despite its availability, and another missed multiple medications without documented reasons. Additionally, a resident with a biliary drain lacked specific care orders upon admission.
A resident with severe cognitive impairment and multiple health conditions did not receive two doses of the prescribed antibiotic Augmentin. The facility's MAR showed the 9:00 AM dose was omitted without explanation, and the 9:00 PM dose was missed because the resident was sleeping. The facility's policy requires adherence to prescriber orders, but no further information was provided to the survey team.
The facility staff did not include the required resident census information in the daily nurse staffing postings for 11 out of 36 days reviewed. The surveyor found missing census documentation on specific days in February and March 2024. The issue was discussed with the Administrator, DON, and other regional staff, and the DON confirmed that the staff member did not document the census on those days.
Failure to Assess and Supervise Resident Smoking Leads to Injury and Immediate Jeopardy
Penalty
Summary
Facility staff failed to ensure that residents identified as smokers were properly assessed for their capability and safety needs regarding smoking. Several residents, including those with significant medical histories such as schizoaffective disorder, COPD, asthma, and muscle weakness, were not adequately evaluated for safe smoking practices. In one case, a resident with a history of non-compliance and moderate cognitive impairment was not given a complete safe smoking assessment upon admission, despite documentation indicating the facility was aware of his smoking behavior and non-compliance with safety protocols. Staff did not provide adequate monitoring and supervision of residents who smoked, allowing them to access lighters, cigarettes, and electronic cigarettes unsupervised. Multiple residents were observed smoking without staff supervision, not using required safety equipment such as smoking aprons or cigarette holders, and possessing smoking materials in their personal belongings. In one incident, a resident smoked while using oxygen, resulting in burns to his face and hand, and was later observed smoking unsupervised again after returning from the emergency department. Staff interviews confirmed that unsupervised smoking was a known and ongoing practice, and that residents often disregarded facility smoking policies. Facility documentation and staff interviews revealed that smoking paraphernalia was not consistently secured, and safety precautions such as fire blankets were not available in designated smoking areas. Residents and staff reported that the enforcement of smoking policies had become lax, with residents allowed to keep their own lighters and cigarettes and smoke at will. The lack of supervision and failure to implement and enforce safety measures led to multiple instances of unsupervised smoking, non-compliance with safety protocols, and a serious injury to a resident.
Failure to Follow Provider Orders for Medication and Procedure Preparation
Penalty
Summary
Facility staff failed to provide treatment and care according to medical provider orders for two residents. For one resident with multiple diagnoses including schizoaffective disorder and COPD, staff did not administer Bacitracin ointment to burns on the face, nares, and right hand as ordered after the resident returned from the emergency department. The medication was not given on a specified day shift, and documentation indicated the nurse was waiting for the ointment from the pharmacy, despite it being available as house stock. The nurse was unaware of this, resulting in the omission of the ordered treatment. For another resident with intact cognition, staff did not follow physician orders for colonoscopy preparation. The resident reported that the facility failed to provide a clear liquid diet and did not administer the prescribed Dulcolax tablets as directed, leading to an incomplete colonoscopy due to inadequate bowel prep. Review of records confirmed that only one dose of Dulcolax was given, and a consult note documented that the facility failed to administer the proper prep according to the patient. The facility's documentation and staff interviews confirmed these failures to follow provider orders.
Failure to Consistently Provide and Document Wound Care as Ordered
Penalty
Summary
Facility staff failed to provide wound care as ordered for one resident with a chronic arterial ulcer that later became a pressure ulcer. Review of the treatment administration records (TAR) over several months revealed multiple missed or undocumented wound care treatments, including specific dates in June 2024, March 2025, and May 2025 where wound care orders were not signed off or completed as scheduled. The resident reported having to seek out staff to have dressings changed and described a history of the wound extending from the heel up the leg, though it had since improved. The resident also stated that a former wound nurse refused to provide care, and the Director of Nursing (DON) confirmed the wound's progression and noted the resident's tendency to leave the facility, which sometimes interfered with scheduled care. The DON acknowledged that on some days when wound care was missed, the resident was out of the facility, but also agreed that care should have been documented as provided on a PRN basis or in the notes if completed at a different time. The lack of documentation and missed treatments were not explained by any further information prior to the survey exit conference. The deficiency centers on the failure to consistently provide and document wound care as ordered for a resident with a significant wound history.
Failure to Ensure Availability of Ordered Pain Medication
Penalty
Summary
Facility staff failed to ensure that a medical provider-ordered narcotic pain medication, Oxycontin, was available for administration to a resident on six separate occasions. The resident, who was cognitively intact and had multiple diagnoses including hemiplegia, muscle weakness, chronic kidney disease, and seizure disorder, reported to the surveyor that staff had previously allowed their scheduled pain medication to run out. Review of the clinical record confirmed that Oxycontin was not administered at the scheduled times due to the medication being unavailable, as documented in nursing progress notes and verified by the Director of Nursing and Regional Nurse Consultant. The medication was not present in the facility’s onsite medication supply system (Pyxis) and was not sent by the pharmacy as required. The facility’s policy on administering medications states that medications are to be administered in accordance with prescriber orders. Despite this, the resident’s Oxycontin was not available for administration on multiple occasions, and facility leadership could not provide an explanation for why the medication was not sent by the pharmacy or available onsite. No additional information regarding the unavailability of the medication was provided to the survey team prior to the exit conference.
Missed Annual MDS Assessment Due to Software Change
Penalty
Summary
The facility staff failed to complete an annual Minimum Data Set (MDS) assessment for Resident #51 within the required 12 months or 366 days of the previous assessment. Resident #51, who has diagnoses including atrial fibrillation, diabetes, and malignant neoplasm of the bladder, had an annual MDS assessment with an Assessment Reference Date (ARD) of 01/31/23. The subsequent annual assessment was not completed until 02/28/24, exceeding the mandated timeframe. During an interview, the MDS coordinator revealed that the oversight occurred due to a change in the software system in October, which resulted in the resident's MDS assessment being missed. This issue was discussed with the facility's administration and clinical leadership, but no further information was provided to the survey team before the exit conference.
Missed Quarterly MDS Assessment Due to Software Change
Penalty
Summary
The facility staff failed to complete a quarterly Minimum Data Set (MDS) assessment for Resident #18 within the required timeframe of 3 months or 92 days from the previous assessment. Resident #18, who has diagnoses including diabetes, anxiety, and hypertension, had their last quarterly MDS assessment completed on 10/13/23. As of 03/06/24, no further MDS assessments had been completed. During an interview, the MDS coordinator revealed that a change in the software system in October led to the oversight of this resident's MDS assessment. The issue was discussed with the facility's administration and clinical leadership, but no additional information was provided to the survey team before the exit conference.
Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility staff failed to accurately document the completion dates of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the assessment process. For Resident #120, the MDS assessment with an Assessment Reference Date (ARD) of February 8, 2024, was signed as completed on February 13, 2024. The assessment indicated severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 5 out of 15, and the resident required assistance with oral hygiene, toileting hygiene, bathing, and dressing. However, the documentation showed that multiple parts of the MDS were completed after the ARD, with the Social Worker, LPN, and RN signing their sections on dates later than the ARD. Similarly, for Resident #132, the MDS assessment with an ARD of January 25, 2024, was signed as completed on January 29, 2024. The resident was assessed as having intact cognition with a BIMS score of 15 out of 15 and required assistance with bathing and dressing. Again, the documentation indicated that multiple parts of the MDS were completed after the ARD, with the Social Worker and RN signing their sections on dates later than the ARD. The facility's staff, including the Regional Director of Clinical Services and the Director of Nursing, acknowledged that MDS interviews should not be completed after the ARD date, and no documentation was found to indicate that the interviews were completed on or before the ARD date.
Failure to Include Dietary Orders in Baseline Care Plan
Penalty
Summary
The facility staff failed to ensure that the baseline care plan for a resident included dietary orders, which is a requirement for providing effective, person-centered care. The resident in question had a complex medical history, including diagnoses such as Metabolic Encephalopathy, Pneumonia, Non-ST Elevation Myocardial Infarction, Persistent Atrial Fibrillation, Heart Failure, Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Adult Failure to Thrive. Despite these significant health issues, the baseline care plan and its summary, both dated 12/22/23, did not contain any dietary orders or instructions, nor did the medical provider orders associated with these documents. The deficiency was identified during a closed record review, where it was noted that the facility's policy on baseline care plans mandates the inclusion of dietary orders as part of the minimum healthcare information necessary for resident care. The survey team discussed this concern with the facility's administration and clinical leadership, including the Administrator, Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and the Regional Director of Clinical Services. However, no additional information or corrective measures regarding this oversight were provided to the survey team before the exit conference.
Deficiencies in Admission Assessments and Documentation
Penalty
Summary
The facility staff failed to complete necessary nursing assessments and documentation for Resident #152 upon admission. The resident, who had multiple complex medical conditions including Metabolic Encephalopathy, Pneumonia, and Heart Failure, was admitted from an acute care hospital. However, there was no admission progress note documenting the resident's arrival time or condition, nor was there a nursing assessment conducted at any point during their stay. Additionally, the resident's weight and code status were not documented. After the resident was discharged to the hospital, medications were erroneously documented as administered on 19 occasions. For Resident #154, the facility staff documented assessments after the resident had died. The Minimum Data Set (MDS) assessment was signed as completed after the resident's death, and a skin assessment and depression screen were documented as completed 40 and 87 hours post-mortem, respectively. The staff involved stated that these assessments might have been completed earlier but documented later, which is against the facility's policy that requires prompt documentation. The survey team discussed these deficiencies with the facility's administration, including the Director of Nursing (DON) and other regional clinical leaders. The DON acknowledged that the assessments should have been documented at the time they were completed and that any late documentation should be marked as such. The facility's policies on medication administration and documentation were reviewed, highlighting the need for accurate and timely record-keeping to ensure effective communication and care delivery.
Medication Administration and Care Deficiencies
Penalty
Summary
The facility nursing staff failed to administer Gabapentin to a resident as per the provider's order. The resident, who had diagnoses including diabetes and chronic pain, had a provider order for Gabapentin 800 mg four times a day for neuropathy. On a specific date, the medication was not administered because the nurse documented that it was on order and waiting for pharmacy delivery, despite the medication being available onsite in the backup supply. The Director of Nursing was informed of the failure to administer the medication, and it was noted that the responsible nurse worked on an as-needed basis. Another resident with a percutaneous cholecystectomy drain did not have provider orders for the care and monitoring of the drain upon admission. The resident had multiple diagnoses, including chronic respiratory failure and acute cholecystitis. The care plan noted the presence of a biliary drain, but no specific orders were found in the medical records. The facility staff later sought instructions from the hospital regarding the care of the drain, which included flushing the drain only if clogged and changing the dressing weekly or as needed. Additionally, the facility staff failed to administer several medications to another resident as ordered by the provider. The resident had multiple diagnoses, including metabolic encephalopathy and heart failure, and was severely impaired in cognitive skills. On a specific date, several medications, including Atorvastatin, Ferrous Sulfate, and others, were not administered at the scheduled times, with no documentation explaining the omissions. The facility policy stated that medications should be administered according to prescriber orders, but this was not adhered to in this case.
Medication Administration Error for a Resident
Penalty
Summary
The facility staff failed to ensure that a resident was free from significant medication errors, as evidenced by the omission of two doses of the antibiotic Augmentin. The resident, who had a complex medical history including Metabolic Encephalopathy, Pneumonia, and other serious conditions, was prescribed Augmentin to be administered every 12 hours for five days. However, on one occasion, the 9:00 AM dose was not administered, and there was no documentation explaining the omission. Additionally, the 9:00 PM dose was not given because the resident was sleeping, as noted in the Medication Administration Record (MAR). The resident was assessed as severely impaired in cognitive skills, with both short-term and long-term memory problems, which underscores the importance of adhering to prescribed medication schedules. The facility's policy on administering medications requires adherence to prescriber orders, including any specified time frames. Despite this policy, the survey team found that the facility did not provide further information or justification for the missed doses during their meeting with the facility's administrative and clinical leadership.
Failure to Document Resident Census in Nurse Staffing Postings
Penalty
Summary
The facility staff failed to ensure that the daily nurse staffing postings included the required resident census information for 11 out of 36 days reviewed. The surveyor reviewed the daily nurse staffing sheets from February 1, 2024, through March 7, 2024, and found that the daily resident census was not documented on specific days, including February 3, 4, 10, 11, 17, 18, 24, 25, and March 1, 2, and 3, 2024. On March 7, 2024, the survey team discussed this concern with the Administrator, Director of Nursing (DON), Regional Nurse Consultant, and the Regional Director of Clinical Services. The following day, the DON confirmed that the staff member responsible did not write the census on the form for those days. No further information was provided to the survey team before the exit conference on March 8, 2024.
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Illustrative
What surveyors actually found near you
We read the 40 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tazewell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westwood Center | 15.8 mi | ★★★★★ | 0 | 0 |
| Mercer Healthcare Center | 16.4 mi | ★★★★★ | 0 | 0 |
| Mcdowell Healthcare Center | 16.5 mi | ★★★★★ | 4 | 0 |
| Bluestone Health And Rehabilitation | 17.5 mi | ★★★★★ | 15 | 1 |
| Clinch Valley Medical Center | 17.6 mi | ★★★★★ | 0 | 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.