Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 North Campus Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Unsecured, unlabeled, and expired medications were found in a resident’s room and in multiple med carts. An RN identified bedside morning meds, while staff also found expired insulin, unlabeled capsules, opened insulin without open dates, and loose pills in a cart drawer; an LPN and the DON stated the items should not have been left that way.
Unsafe food handling and improper food storage: The DONS was observed plating lunch trays, then touching the microwave and returning to food service without hand hygiene. Two dietary aides handled plated food without gloves, and one aide touched the inner food-contact surface of a plate and the mashed potatoes with a bare thumb before placing the tray on the cart. An opened container of Med Pass was also found in a nourishment room refrigerator without an opened date, despite the label requiring use within 4 days after opening.
Medication Rooms Not Kept Clean and Orderly: Observations found 3 of 3 medication rooms with dirty sinks, brown residue, papers and medication caps in the basins, and sticky floors with trash and other items on the floor. The DON confirmed the rooms were not clean, one sink was non-working, and the ESD stated the rooms had not been cleaned regularly and were not on a routine cleaning schedule.
A resident admitted with a new diagnosis of Brief Psychotic Disorder had a Level I PASARR that indicated a Level 2 PASARR was needed, but the record did not contain the required Level 2 review. The DON and DSD stated the review was still being completed and had been submitted previously, but it was closed by the healthcare management partner.
The facility failed to implement care plan interventions for a resident at risk for falls and two residents requiring oxygen therapy. One resident’s care plan called for bilateral floor mats for safety, but mats were not observed beside the bed during multiple observations, and staff were unsure the intervention was in place. Two other residents had physician orders and care plan interventions for continuous O2, but one was observed with oxygen equipment that could be easily bumped and another was observed receiving less O2 than ordered.
Improper Midline Catheter IV Medication Administration: An RN administered IV Cefepime through a resident’s midline catheter without scrubbing the needleless connector, verifying line placement, or using the push-pause flush method. The resident had cellulitis and other infections, and the DON confirmed the RN should have checked placement and used the push-pause method per policy.
Failure to document responses to pharmacy recommendations for a resident with multiple psychiatric and medical diagnoses. Pharmacy reviews noted PRN IM lorazepam lacked behavioral parameters, a dose-reduction review for multiple psychotropic meds had an unsigned and undated response, and a recommendation to discontinue one of two similar Seroquel orders had no documented response. The DON stated responses should include provider rationale, and no policy and procedures for pharmacy recommendations were provided.
An LPN and an RN failed to perform hand hygiene and follow EBP during medication administration. The LPN administered meds to multiple residents without hand hygiene before or after resident contact, after glove removal, or after handling the med cart; one resident spit meds into the LPN’s gloved hand. The RN cared for a resident with a midline catheter on EBP without wearing a gown, did not cleanse the needleless connector, did not verify placement, and administered NS and IV meds.
The facility failed to securely store medications, as observed with two residents. One resident had an unauthorized dietary supplement at their bedside, while another had sodium pills left from the previous night. The ADON confirmed that medications should not be left at the bedside without proper assessment and care planning.
The facility failed to maintain proper food storage and sanitation in the kitchen and nourishment rooms. Observations revealed unlabeled and improperly stored food items, dirty kitchen equipment, and structural issues like cracked and flaking paint above the dishwasher. These deficiencies were confirmed by the Regional Certified Dietary Manager, indicating non-compliance with the facility's food handling policies.
The facility failed to provide proper respiratory care for three residents. A resident's nebulizer mask was improperly stored next to a soiled cushion, despite needing regular treatments for chronic respiratory conditions. Another resident received oxygen at a higher rate than prescribed, and a third resident's nebulizer equipment was left uncovered. These actions were contrary to the facility's policy, as confirmed by staff.
Unsecured, Unlabeled, and Expired Medications Found in Resident Areas and Medication Carts
Penalty
Summary
Medications were found unsecured and unattended at a resident’s bedside during observation of the room, including four cups of crushed pills, one cup of clear liquid, and one clear vial of medication. Staff stated the bedside medications were part of the morning medication pass and identified the vial as eye drops. The resident’s MAR listed multiple morning medications at the bedside, including aspirin, cyanocobalamin, escitalopram oral solution, ferrous sulfate, lisinopril, acidophilus lactobacillus, cyclosporine ophthalmic emulsion, oxybutynin, hydralazine, and carbidopa-levodopa. Medication carts also contained expired, unlabeled, and improperly stored medications. One cart had expired Lantus and Novolog insulin and four capsules in a medication cup that were not in original pharmacy packaging and were unlabeled; staff identified the insulin as expired and said the capsules should have been in their container. Another cart contained expired Novolog and glargine insulin, an opened glargine and opened Novolog with open dates, another glargine with an expiration date, and an unopened Novolog that was supposed to be refrigerated until opened. A third cart had two opened glargine insulins and one Novolog insulin with no open dates. During medication administration observation, a medication cup with a small white pill and a tan pill was found in a cart drawer, not in original packaging and not labeled; staff stated they did not know what the pills were and that medications should not be left in the cart without labeling. The DON stated all medications should be labeled when opened and that there should not be any medications at bedside.
Unsafe food handling and improper food storage
Penalty
Summary
Food was not prepared and served in a sanitary manner during lunch tray assembly in the West Unit nourishment room. The Director of Food and Nutritional Services was observed wearing gloves while plating meal trays from the steam table, then removed the glove from her right hand to push a button on the microwave and remove a container. She did not perform hand hygiene before returning to the tray line, putting on a new glove, and continuing to plate food. At the same time, the Director of Food and Nutritional Services handed plates of food to Staff E, a Dietary Aide, who was not wearing gloves, and Staff E handed the plates to Staff D, another Dietary Aide, who was also not wearing gloves. Staff D was then observed touching the inner food contact surface of a plate and the mashed potatoes on the plate with the bare thumb of his right hand. He shook off his hand, placed the plate onto a tray, covered it, and placed the tray onto the tray cart. The Director of Food and Nutritional Services stated that if Staff D touched the food with his bare hand, he should have handed the plate back and had a new, fresh plate of food made. In addition, an opened container of Med Pass was observed in the [NAME] Unit nourishment room refrigerator that was approximately 3/4 empty and did not have an opened date, even though the container label stated it should be consumed within 4 days after opening if properly refrigerated. The DON stated that the Med Pass should have an opened date on it.
Medication Rooms Not Maintained in Clean and Sanitary Condition
Penalty
Summary
The facility failed to maintain the interior of 3 of 3 medication storage rooms in a sanitary and orderly manner. During observation, one medication room sink had a very thick brown sticky substance covering the entire basin, with multiple pieces of paper and medication caps in the sink, and bags and paper towels on the floor. The floor had a sticky residue when walked on, and Staff A, RN stated the sink was filthy, there were multiple things in the sink, and the floor was dirty and sticky, with the last cleaning unknown. Further observation with the DON confirmed the brown sticky substance on the sink, the papers and medication caps in the basin, and the bags, papers, and sticky residue on the floor. In another medication room, the sink had a brown residue and the floor had multiple items of paper and medication caps. In a third medication room, a plastic bag covered the sink handles, the basin was dirty and rusty, the floor was not clean with many items on it, and the floor was sticky while walking on it. The DON stated the medication rooms were not clean, the sinks were dirty and needed cleaning, trash was on the floors, the floors needed to be cleaned, and one medication room had a non-working sink that staff would not be able to use for handwashing. The Environmental Services Director stated the medication rooms had not been cleaned regularly, were in need of deep cleaning, and were not on a routine cleaning schedule.
Missing Level 2 PASARR for Resident with New Psychotic Disorder Diagnosis
Penalty
Summary
The facility failed to ensure a required Level 2 PASARR was completed for Resident #86. The resident was admitted to the facility on [DATE], and a Level I PASARR dated 02/18/2026 identified a new diagnosis of Brief Psychotic Disorder and indicated that a Level 2 PASARR should be completed. The resident’s record did not contain a Level 2 PASARR at the time of review. During interviews, the DON stated she would get with social services regarding the PASARR, and the Director of Social Services stated the resident’s Level 2 PASARR was in the process of being completed. She said they had attempted to finish it and submit it, but the healthcare management partner closed it. The facility policy stated that residents identified with a mental disorder or intellectual disability are to be evaluated and receive care and services in the most integrated setting appropriate to their needs by coordinating with the appropriate state-designated authority, and that the Social Service Director/credentialed user will complete a referral for Level II resident review when indicated.
Failure to Implement Care Plan Interventions for Falls and Oxygen Therapy
Penalty
Summary
The facility failed to implement the care plan for Resident #86, who was identified as being at risk for falls due to generalized weakness, limited endurance, impaired balance, a history of falls, poor safety awareness, impaired vision, psychotropic medication use, and antiplatelet use. The care plan dated 04/16/2026 included bilateral floor mats for safety, but during observations on 04/20/2026 and 04/21/2026, the resident was sitting up in bed with no floor mats beside the bed. An LPN stated that the resident was supervised with two-hour checks and said she did not think the resident was care planned for floor mats, while the DON stated the resident was supposed to have bilateral floor mats for safety. The facility also failed to follow oxygen-related care plan interventions for Resident #73 and Resident #23. Resident #73 had diagnoses including COPD, chronic pulmonary edema, dependence on supplemental oxygen, CHF, and other chronic conditions, and had a physician order for continuous oxygen at 2L-3L/min via nasal cannula to maintain O2 greater than 93% every shift; however, the care plan called for oxygen saturations as ordered and oxygen administered as ordered, and an LPN stated the concentrator could be bumped and become very sensitive. Resident #23 had multiple diagnoses including metabolic encephalopathy, CHF, COPD with acute exacerbation, chronic respiratory failure with hypoxia, and other cardiac and respiratory conditions, with a physician order for oxygen at 5 liters/minute continuously via nasal cannula, but during observation the resident was on 4 liters of oxygen via nasal cannula. The DON stated that the care plan interventions should always be followed and the oxygen running correctly.
Improper Midline Catheter IV Medication Administration
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met for Resident #16, who had diagnoses including cellulitis, other bacterial infections of unspecified site, and lymphedema. The resident had a physician order for Cefepime HCL 2 grams IV every 12 hours for cellulitis for 14 days and had a left single lumen midline catheter in place. During observation of medication administration, Staff A, RN entered the resident’s room with supplies to administer the IV medication, but the midline catheter needleless connector was resting in contact with the resident’s arm. The RN did not scrub the hub of the needleless connector, attached a 10 mL normal saline syringe, did not attempt to verify line placement by assessing for blood return, and did not use the push-pause method when flushing the line. The RN stated she should have tried to verify placement and did not use the push-pause method. The DON stated the RN should have attempted to verify line placement before administering medications and should have used the push-pause method when flushing the line. The facility policy for intermittent infusion required vigorous cleansing of the needleless connector, allowing it to air dry, and verifying venous access patency.
Failure to Document Responses to Pharmacy Recommendations
Penalty
Summary
The facility failed to document in the medical record the rationales for pharmacy recommendations for 1 of 5 residents reviewed for unnecessary medications, Resident #31. Resident #31’s admission record listed multiple diagnoses including cerebrovascular disease, COPD, type 2 diabetes mellitus, schizoaffective disorder bipolar type, morbid obesity, pseudobulbar effect, chronic pain syndrome, unspecified dementia, Barrett’s esophagus with dysplasia, bipolar disorder, PTSD, obstructive sleep apnea, legal blindness, opioid dependence in remission, major depressive disorder, anxiety disorders, acute and chronic respiratory failure with hypercapnia, acute kidney failure, hypertensive heart disease without heart failure, unspecified convulsions, and metabolic encephalopathy. Review of pharmacy recommendations showed that on 3/29/2026 the pharmacist noted PRN IM lorazepam had been limited to 14 days but still lacked defined behavioral parameters and clear criteria for IM use in a resident already receiving scheduled lorazepam; the provider response was "Continue IM Ativan," and behavioral recommendations were not added. A 9/12/2025 recommendation asked whether a dose reduction could be attempted for lorazepam, trazodone, Seroquel, and oxcarbazepine, but the response was marked "psych" with no signature or date. A 6/11/2025 recommendation stated the resident was receiving 2 medications with very similar therapeutic activity and suggested discontinuing one Seroquel order and adjusting the other if necessary; no response was documented, although there was a provider signature dated 6/24/25. During interview, the DON stated she was not sure who the signature belonged to and that there should be responses to the recommendations with the nurse practitioners or doctors providing the rationale and agreeing or disagreeing with the recommendations. A request for policy and procedures for pharmacy recommendations was made, but none were provided.
Failure to Perform Hand Hygiene and Follow Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not perform hand hygiene and did not consistently follow enhanced barrier precautions during medication administration and IV medication delivery. During observations on 4/20/2026, an LPN prepared and administered medications to Resident #86, Resident #34, and Resident #9 without performing hand hygiene before entering resident rooms, after contact with the medication cart, or after glove removal. In one instance, Resident #86 spit out medications into the LPN’s gloved hand, after which the LPN removed the gloves, did not perform hand hygiene, donned new gloves, and administered eye drops. During another observation on 4/22/2026, an RN completed medication administration for a resident with a left single lumen midline catheter who was on enhanced barrier precautions. The RN did not perform hand hygiene before leaving the resident’s room and returning to the medication cart, retrieved keys from a uniform pocket, and then entered Resident #16’s room without donning a gown. The resident’s needleless connector contacted the resident’s arm and wheelchair arm during care. The RN did not cleanse the needleless connector with alcohol, did not check catheter placement, attached a 10-milliliter syringe of normal saline, and administered the medication. The RN then attached IV tubing and the IV medication without cleansing the needleless connector again. During interview, the RN stated she only had gloves on, should have had on a gown because the resident was on enhanced barrier precautions, should have cleaned the hub before normal saline, should have tried to verify line placement, and should have used the push-pause method. The DON stated the nurse should have worn a gown, cleaned the hub with alcohol, attempted to verify line placement before administering meds, and used the push-pause method when flushing the line. Facility policies stated hand hygiene is the primary means to prevent spread of infections, that hand hygiene is required before and after direct resident contact, handling medications, and handling invasive devices, and that enhanced barrier precautions are indicated for residents with indwelling medical devices such as a central line.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were stored securely, as observed during a survey. On one occasion, a bottle of Spring Valley Cinnamon Dietary Support Supplement was found on a resident's bedside table. The resident stated they took it for diabetes and claimed to have permission to keep it there. However, a review of the resident's medical records showed no order for the supplement and no care plan focus for having medication at the bedside. Another observation revealed a clear plastic cup containing three round white tablets on another resident's bedside table. The resident explained that the tablets were sodium pills they had not taken because they got stuck when swallowing. The cup had been there since the previous night. The Assistant Director of Nursing stated that medications should never be left at the bedside and that an assessment and care plan are required if a resident wishes to have medications at their bedside. The facility's policy on medication administration emphasizes timely administration in accordance with physician orders, which was not adhered to in these instances.
Improper Food Storage and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to ensure proper storage and sanitation of food and kitchen equipment, as observed during a survey. In the main kitchen, there was a buildup of a white substance on the exterior of the ice machine, improperly wrapped and unlabeled food items in the refrigerator, and dirty kitchen equipment, including a discolored oven and a gas stove top with caked black substance. Additionally, the ceiling above the dishwasher was cracked and flaking, with missing paint, which was confirmed by the Regional Certified Dietary Manager. In the nourishment rooms, similar issues were noted. There were undated and unlabeled food items, such as a blue lunch bag with bottled water and juice packets, a thermos of liquid, and a container of peanut butter with an unsecured lid. In the South Nourishment Room, a tray of cookies and thawed supplements without thawed-on dates were found. The facility's policies on food delivery and storage, as well as handling foods brought in from outside, were not adhered to, as confirmed by the Regional Certified Dietary Manager.
Improper Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as observed during a survey. Resident #21's nebulizer mask was repeatedly found stored improperly on a bedside table next to a soiled cushion, exposing it to potential contamination. This resident had a history of chronic obstructive pulmonary disease, chronic pulmonary edema, and other respiratory conditions, requiring regular nebulizer treatments. Despite the physician's order for Albuterol Sulfate nebulization four times a day, the mask was not stored in a clean bag as expected by the facility's policy, as confirmed by both a Licensed Practical Nurse and the Assistant Director of Nursing. Resident #36 was observed receiving oxygen at a rate of 3.5 liters per minute, contrary to the physician's order of 2 liters per minute via nasal cannula. This resident had a history of congestive heart failure and aortocoronary bypass graft. Additionally, Resident #19's nebulizer mouthpiece and tubing were found uncovered on a table, despite a physician's order for nebulizer use every six hours as needed for respiratory issues. The facility's policy required proper storage of respiratory equipment, which was not adhered to, as confirmed by a Regional Registered Nurse.
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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.
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Nursing homes near Leesburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Campus Care Center And Rehab | 0.8 mi | ★★★★★ | 11 | 0 |
| Lake Port Square Health Center | 1.2 mi | ★★★★★ | 11 | 0 |
| Avante At Leesburg, Inc | 1.4 mi | ★★★★★ | 0 | 0 |
| Chatham Glen Healthcare And Rehabilitation Center | 7.4 mi | ★★★★★ | 5 | 0 |
| Villages Healthcare And Rehabilitation Center, The | 7.5 mi | ★★★★★ | 10 | 0 |
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