Heritage Hall Big Stone Gap

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

32.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 82 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 65.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 41 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 180 beds and averages 165.5 residents a day — about 92% occupied, or roughly 14 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.11 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.41 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.56 hrs/resident/day on weekends vs 3.33 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.48 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 27% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 3 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

41 citations, most serious first. The 16 most serious are shown; the remaining 25 are one tap away and print in full.

• Actual harm · G2024-11-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. Resident #2's diagnosis list indicated diagnoses that included, but were not limited to, Depression, Chronic Kidney Disease-Stage 3 (three), Anxiety Disorder, Type 2 (two) Diabetes Mellitus, Dementia, Mood Affective Disorder, Transient Ischemic Attack (TIA), and Cerebral Infarction. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 10/16/24,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. Resident #2's diagnosis list indicated diagnoses that included, but were not limited to, Depression, Chronic Kidney Disease-Stage 3 (three), Anxiety Disorder, Type 2 (two) Diabetes Mellitus, Dementia, Mood Affective Disorder, Transient Ischemic Attack (TIA), and Cerebral Infarction. The most recent minimum data set (MDS) with an assessment reference date…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-19 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. On 10/21/24, Resident #1 ingested eight (8) separate medications including six (6) psychotropics that were ordered for another resident resulting in transfer to the emergency department where they were subjected to invasive medical procedures including intravenous fluids and blood work. According to The Centers for Medicare and Medicaid (CMS), a psychotropic drug is defined in the regulations at §483.45(c)(3), as any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. This is harm. The findings included: Resident #3, was found in the floor of the Alzheimer's unit with head wounds, and was transferred to a local hospital. Resident #3 was placed on comfort care due to their injuries, and subsequently expired. Resident #2 reportedly hit Resident #3, resulting in a head wound. Resident #3's diagnoses included, but were not limited to, diabetes,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2021-05-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Two incidents resulted in transfer to a higher level of care following incidents occurring on 2/04/21 and 4/11/21. In the 5/1/21 attempt, the resident was found in room laying in bed with eyes closed with call light tied tightly around neck. The resident was turning blue and when released and untied call light cord, resident stated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2021-05-12 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interview, and clinical record review, the facility staff failed to coordinate necessary behavioral health care services to attain the highest practicable physical, mental, and psychological well-being for 1 of 27 residents, Resident #121. The finding included: For Resident #121, facility staff failed coordinate behavioral health care services between the resident's guardian, facility staff, physician, and behavioral health care services following suicidal ideations resulting in three separate suicide attempts. In one of the attempts, The resident was found in room laying in bed with eyes closed with call light tied tightly around neck. The resident was turning blue and when released and untied call light cord, resident stated (he/she) wished to die. This is harm. Resident #121's diagnosis list indicated diagnoses, which included, but not limited to Mood Disorder due to Known Physiological Condition, Schizoaffective Disorder Unspecified, Major Depressive Disorder Recurrent…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-11-19 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, staff interview, and facility document review, the facility staff failed to maintain an infection prevention and control program to provide a safe, sanitary, environment and help prevent the development and transmission of communicable disease and infection on 1 of 4 facility units (North Hall). The findings included: During a medication pass and pour observation, Licensed Practical Nurse (LPN) #4 failed to perform hand hygiene between residents. On 11/19/24 at 8:55 AM, during a medication pass and pour observation, surveyor observed LPN #4 administer medications to Resident #6. LPN #4 returned to the medication cart and began preparing medications for another resident, Resident #5, without performing hand hygiene. At 9:02 AM, LPN #4 donned gloves, entered Resident #5's room, administered oral and inhaled medications, removed gloves and returned to the medication cart without performing hand hygiene. In the presence of the surveyor, LPN #4 then proceeded to another nursing unit and obtained a medication from the in-house pharmacy supply system and then to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-02-01 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview and clinical record review the facility staff failed to develop a comprehensive care plan for 1 of 31 residents, Resident #43. The findings included: For Resident #43, the facility staff failed to develop a care plan for hospice services. Resident #43's face sheet listed diagnoses which included but not limited to mood disorder, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and chronic kidney disease. The most recent minimum data set with an assessment reference date of 11/09/22 coded the resident as having both long- and short-term memory problems with severely impaired cognitive skills for daily decision making, in section C, cognitive patterns. Section O, special treatment, procedures and programs, coded the resident as receiving hospice care while a resident at the facility. This is a significant change assessment. Resident #43's comprehensive care plan was reviewed. Surveyor could not locate a hospice care plan. Resident #43's clinical record was reviewed and contained a physician's order summary for January 2023, which read in part…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-02-01 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview and clinical record review the facility staff failed to review and revise a care plan for 1 of 31 residents, Resident #79. The findings included: For Resident #79 the facility staff failed to review and revise the care plan to include a pressure ulcer. Resident #79's face sheet listed diagnoses which included but not limited to chronic obstructive pulmonary disease, peripheral vascular disease and atherosclerotic heart disease. The most recent minimum data set with an assessment reference date of 01/23/23 assigned the resident a brief interview for mental status score of 13 out of 15 in section C, cognitive patterns. Section M, skin conditions, coded the resident as a stage 4 pressure ulcer. Section M of the minimum data set with an assessment reference date of 10/24/22 coded the resident as having a stage 4 pressure ulcer. Resident #79's comprehensive care plan was reviewed and contained a care plan for Skin Condition This care plan has a goal of will have not skin breakdown noted thru the next 90 days and has a start date of 10/05/22. The care plan did not…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-02-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview, clinical record review and facility document review the facility staff failed to provide care and services to meet the needs of the residents for 1 of 31 residents, Resident #43. The findings included: For Resident #43, the facility staff failed to follow physician's orders for the administration of the pain medication hydrocodone. Resident #43's face sheet listed diagnoses which included but not limited to osteoarthritis, intervertebral disc degeneration, low back pain, and right hip pain. The most recent minimum data set with an assessment reference date of 11/09/22 coded the resident as having both long- and short-term memory problems with severely impaired cognitive skills for daily decision making, in section C, cognitive patterns. Resident #43's comprehensive care plan was reviewed and contained a care plan for . is at risk for alteration in comfort r/t (related to) dx (diagnosis): Chronic pain, low back pain, DDD (degenerative disc disease), osteoarthritis, diabetic neuropathy Resident #43's clinical record was reviewed and contained a physician's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-02-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review and facility document review the facility staff failed to to obtain a diet order targeted to address the clinical condition of the resident for 1 of 31 current residents in the survey sample (Resident #32). Resident #32 was admitted to the facility with diagnoses including hepatorenal syndrome, type 2 diabetes mellitus with diabetic neuropathy, morbid obesity, spinal stenosis without neurogenic caudication, chronic obstructive pulmonary disease. The resident received hemodialysis three times per week. The resident had orders for insulin per sliding scale before meals and at hour of sleep. The surveyor was unable to interview the resident who was out of the facility for hemodialysis three days per week and attended group activities, scheduled smoking opportunities, and a leave of absence. On 1/30/23 the surveyor reviewed the clinical record. Monthly weights documented in the electronic record indicated weights were stable: 10/26/22=250; 11/4/22=250; 12/5/22= 248;…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-02-01 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview, clinical record review and facility document review the facility staff failed to provide ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility for 1 of 31 current residents in the survey sample (resident 32). Resident #32 was admitted to the facility with diagnoses including hepatorenal syndrome, type 2 diabetes mellitus wit diabetic neuropathy, morbid obesity, spinal stenosis without neurogenic caudication, chronic obstructive pulmonary disease. The surveyor was unable to interview the resident who was out of the facility for hemodialysis three days per week and attended group activities, scheduled smoking opportunities, and a leave of absence. On 1/26/23 the surveyor reviewed the clinical record. Found no evidence in the electronic clinical record or paper record of communication with the hemodialysis center. Nursing notes document the resident leaving and returning from dialysis. There were no notes about condition on leaving and returning. Vital…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2021-05-12 · tag F0607 — failed to have anti-abuse policies — pattern
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, employee record review and facility documentation review, the facility staff failed to obtain verification of licensure from the Department of Health Professions prior to hire for 1 (Employee # 8) of 8 Registered Nurses, for 1(Employee # 20) of 6 Certified Nursing Assistants and failed to re-verify licensure after expired dates on three (Employees # 6, # 17 and # 19) of 8 Registered Nurses and failed to re-verify the expired license of one (Employee # 24) of 6 Licensed Practical Nurses. And the facility staff failed to obtain a Criminal Background Check for one (Employee # 22) of 4 Unlicensed Nurses Aide and one (Employee # 24) of 6 Licensed Practical Nurses to obtain a Criminal Background Check prior to hire. The Findings included: 1. For Employee # 8, the facility staff failed to obtain licensure verification prior to hire. On [DATE]- [DATE], a review was conducted of employee records. Review of the personnel file for Employee # 8 was conducted and revealed Employee # 8 was hired on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2021-05-12 · tag F0842 — failed to keep accurate, complete medical records — pattern
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews and the review of documents, it was determined the facility staff failed to ensure complete and/or accurate clinical documentation for six (6) out of 27 sampled current residents (Resident #13, Resident #90, Resident #101, Resident #121, Resident #124, and Resident #138). The findings include: 1. The facility staff failed to insure Resident #13's clinical record included information about an episode of vomiting the resident experienced. Resident #13's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 4/26/21, was signed as completed on 4/27/21. Resident #13 was assessed as being able to make self understood and as being able to understand others. Resident #13's brief interview for mental status (BIMS) summary score was documented as 10 out of 15. Resident #13 was documented as requiring supervision with eating but not as requiring physical assistance with eating. Resident #13 was documented as requiring assistance with bed mobility, dressing, toilet use, and personal hygiene. Resident #13 was assessed as having total dependence for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2021-05-12 · tag F0886 — failed to test for COVID-19 as required — pattern
  Perform COVID19 testing on residents and staff.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and facility document review, the facility staff failed to conduct COVID-19 outbreak testing for asymptomatic staff and residents during an identified facility COVID-19 outbreak for 1 of 3 staff members (LPN #2) and 3 of 3 residents (Resident #92, #109, and #116). The findings included: The facility staff failed to conduct COVID-19 outbreak testing for one asymptomatic staff member and three residents. At the time of the survey, there were currently two COVID-19 positive residents and one positive staff member. On 5/04/21 at approximately 1:45 pm during the Entrance Conference with the survey team, the administrator stated the facility currently has two COVID-19 positive residents and one positive staff member. The first COVID-19 positive result during this current outbreak was identified on 4/12/21. The administrator stated the facility is testing residents with signs and symptoms or potential exposures only and testing unvaccinated staff twice weekly.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2021-05-12 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview and clinical record review, facility staff failed to ensure the resident's right to formulate an advanced directive by failing to ensure the correct code status for 1 of 27 residents, Resident #116. The findings included: For Resident #116, facility staff failed to ensure the correct code status. Resident # 116's diagnosis list indicated diagnoses, which included, but not limited to COVID-19, Schizophrenia Unspecified, Bipolar Disorder Current Episode Manic Severe with Psychotic Features, Unspecified Dementia with Behavioral Disturbance, Unspecified Convulsions, Unspecified Atrial Fibrillation, and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 4/02/21 assigned the resident a BIMS (brief interview for mental status) score of 5 out of 15 in section C, Cognitive Patterns. Resident #116's clinical record included an active physician's order dated 3/26/21 stating Do Not Resuscitate (DNR). The Facility was unable to provide a completed DNR…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$40,517 in federal fines across 1 penalty.

• $40,517 — penalty dated 2024-11-19

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to HERITAGE HALL — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 14 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in VA