Heritage Hall Clintwood

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF684Jun 27, 2024

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to administer medications per the provider orders for 3 of 18 current residents, Resident #10, #44, and #292. The findings included: 1. For Resident #10, the facility nursing staff failed to administer the medication Gabapentin per the provider orders. Gabapentin is a controlled drug in the state of Virginia. Resident #10's diagnoses included, but were not limited to, cerebral palsy and neuropathy. […]

• No harm, potential for more than minimal, patternF880Jun 27, 2024

  Based on observations, staff interviews, clinical record review, and facility document review facility staff failed to maintain an effective infection control and prevention program for three of four residents observed during medication pass and on two of two units (Resident #8, Resident #10, Resident #65). The findings were: 1. For Resident #8, Resident #10 and Resident #65, facility staff failed to perform hand hygiene prior to donning gloves or after removing gloves during medication administration observations. Surveyor observed licensed practical nurse (LPN #1) don gloves prior to assembling Resident #8's medications on 06/25/24 at 8:25 a.m. The nurse did not perform hand hygiene prior to donning gloves. LPN #1 performed hand hygiene with soap and water after removing the gloves. […]

• No harm, potential for more than minimal, patternF880Jan 15, 2021

  Based on observations, interviews, and the review of documents, it was determined the facility staff failed to properly implement COVID-19 prevention and/or control measures. The findings include: Observations of the facility on 1/5/21 revealed two (2) staff members using N95 masks with exhalation valves. On 1/5/21 at 10:25 a.m., a facility administrative staff member (ASM #1) was observed to be wearing a N95 mask with an exhalation valve. On 1/5/21 at 11:03 a.m., a facility staff member (SM #1) was observed to be wearing a N95 mask with an exhalation valve. On 1/5/21, ASM #1 provided the surveyor with the container/packaging of the aforementioned N95 masks. The N95 packaging stated the N95 mask had an Exhalation Valve. […]

• No harm, potential for more than minimal, isolatedF623Jun 27, 2024

  Based on interviews and clinical record review the facility staff failed to provide a resident's responsible party with written information related to a discharge/transfer for one (1) of 22 sampled residents (Resident #34). The findings were: For Resident #34, facility staff failed to provide the responsible party (RP) with written notice of the resident's transfer to an emergency department. Resident #34's minimum data set with an assessment reference date of 01/16/24 assessed the resident as being rarely/never understood. The resident was assessed as having problems with short-term memory and long-term memory. The resident was assessed at continuously having behaviors of inattention and disorganized thinking. […]

• No harm, potential for more than minimal, isolatedF657Jun 27, 2024

  Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to review and revise a comprehensive care plan (CCP) for 1 of 22 sampled residents, Resident #44. The findings included: The facility staff failed to review and revise Resident #44's CCP to indicate they would cover their nebulizer machine with clothing and other items. Resident #44's diagnoses included, but were not limited to, diabetes, chronic obstructive pulmonary disease, and obstructive sleep apnea. Section C (cognitive patterns) of Resident #44's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/05/24 included a brief interview for mental status (BIMS) score of 15 out of a possible 15 points. […]