Heritage Hall Big Stone Gap

In the surveyor’s words

From the most serious findings on record at Heritage Hall Big Stone Gap, in the surveyor’s own words.

• Actual harm, isolatedF600Nov 19, 2024

  Based on staff interviews, clinical record review, and facility document review, the facility staff failed to assess, monitor, and treat bilateral hand contractures resulting in skin breakdown with maggot infestation for (1) one of (7) seven sampled residents, Resident #2. The findings include: For Resident #2, the facility staff failed to follow the medical provider orders for a wound consult on 9/12/24 and failed to follow the comprehensive care plan to monitor and notify therapy of a decline in bilateral hand contractures resulting in increased pain, skin breakdown to both hands, maggot infestation in the right hand, and transfer to an acute care hospital for further treatment. This was a closed record review. […]

• Actual harm, isolatedF684Nov 19, 2024

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents receive treatment and care in accordance with the comprehensive care plan and medical provider orders for (2) two of (7) seven sampled residents, Resident #2 and Resident #7. The findings include: 1. For Resident #2, the facility staff failed to provide treatment and care in accordance with the comprehensive care plan to monitor and treat bilateral hand contractures and failed to follow the medical provider orders for a wound consult resulting in skin breakdown in both hands, maggot infestation of the right hand, and transfer to an acute care hospital for further treatment. This was a closed record review. […]

• Actual harm, isolatedF760Nov 19, 2024

  Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure residents were free of significant medication errors for 1 of 7 sampled residents (Resident #1). Resident #1 received eight (8) separate medications in error placing the resident's health and safety in jeopardy resulting in transfer to a higher level of care. The findings included: For Resident #1, the facility staff failed to administer medications as ordered by the medical provider. […]

• Actual harm, isolatedF689Aug 15, 2023

  Based on staff interview, resident interview, clinical record review, and facility document review, the facility staff failed to provide adequate supervision to prevent accidents for 4 of 7 Residents (Resident #3, Resident #6, Resident #4, Resident #5). Resident #3 was found in the floor of the Alzheimer's unit with head wounds. Resident #3 was transferred to a local hospital. A CT (Cat Scan) was performed and showed a right occipitoparietal calvarial fracture, subdural hematoma, hemorrhagic parenchymal contusion in the right cerebellar hemisphere, and multifocal subarachnoid hemorrhage. Resident #3 was placed on comfort care and expired. […]

• Actual harm, isolatedF689May 12, 2021

  Based on resident interview, staff interview, clinical record review, and during the course of a complaint investigation, facility staff failed to ensure the resident environment remained as free of accident hazards related to call light cord availability for 1 of 27 residents, Resident #121 and failed to include investigation of an elopement with identifying how the resident was able to exit the building for one (1) of 27 sampled current residents (Resident #64). The findings included: 1. For Resident #121, the facility staff failed to remove the resident's call light cord following three separate incidents in which the resident had the call light cord wrapped around their neck. […]