Above 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-leesburg during CMS and state inspections, most recent first.
Facility staff did not follow the physician’s order for administering prn Oxycodone, giving the medication to a resident at pain levels below the specified threshold. An LPN confirmed the order was not followed, and the facility’s policy requiring adherence to prescriber orders was not met.
Staff did not ensure that the call bell was within reach for two residents, one with moderate cognitive impairment and difficulty breathing, and another with severe cognitive impairment and muscle weakness. In both cases, observations found the call bell inaccessible while the residents were in bed, contrary to facility policy and staff statements that the call bell should always be within reach and checked regularly.
A resident with generalized muscle weakness and a physician's order for incentive spirometer use was observed with the device improperly stored, as the mouthpiece was left hanging outside its plastic bag and resting on the bedside table. An LPN confirmed that the mouthpiece should be kept inside the bag to prevent contamination, and facility leadership was notified of the issue.
An LPN administered two capsules of gabapentin instead of one and did not assist a resident with rinsing her mouth after giving Breo Ellipta, contrary to physician orders. These actions resulted in two errors out of 29 observed medication administrations, causing the facility's medication error rate to exceed five percent.
Failure to Follow Physician Orders for PRN Pain Medication Administration
Penalty
Summary
Facility staff failed to ensure that a resident’s drug regimen was free from unnecessary medications by not adhering to the physician’s order for administering prn (as needed) Oxycodone. The physician’s order specified that Oxycodone 5 mg should only be given by mouth every six hours as needed for pain rated greater than 6 out of 10. However, documentation in the electronic medication administration record (eMAR) showed that the resident received Oxycodone on multiple occasions when their reported pain level was below the ordered threshold, including pain levels of five and three. The resident involved was admitted with a diagnosis that included back pain and was assessed as cognitively intact, scoring 15 out of 15 on the Brief Interview for Mental Status (BIMS). Staff interviews confirmed that the physician’s order was not followed regarding the administration of Oxycodone. The facility’s medication administration policy requires medications to be administered according to prescriber orders and for staff to seek clarification if an order appears inappropriate, but this protocol was not followed in this instance.
Failure to Ensure Call Bell Accessibility for Two Residents
Penalty
Summary
Facility staff failed to ensure that the call bell was within reach for two residents, resulting in unmet needs for assistance. For one resident with moderate cognitive impairment and a diagnosis including difficulty breathing, observation revealed that the call bell was not accessible while the resident was in bed; it was found hanging from the underside of the bed, and the resident was unable to locate or reach it. The resident confirmed she could not access the call bell when asked. Staff interviews indicated that the call bell should be clipped to the blanket in front of the resident and checked each time staff enter the room, as per facility policy, but this was not followed in this instance. For another resident with severe cognitive impairment and a diagnosis including muscle weakness, observation showed the resident was slouched in bed and the call bell was clipped to the top left corner of the mattress at the head of the bed, out of the resident's reach. A CNA confirmed that the call bell was not within reach for this resident. The facility's policy requires that the call bell be accessible to residents in bed, on the toilet, in the shower, or on the floor, but this standard was not met for these two residents.
Incentive Spirometer Not Stored Sanitarily
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care for one resident by not storing the incentive spirometer in a sanitary manner. The resident, who was admitted with generalized muscle weakness and was cognitively intact according to the most recent BIMS assessment, had a physician's order to use the incentive spirometer every shift as tolerated for respiratory therapy. During two separate observations, the incentive spirometer was found on top of the bedside table inside a plastic bag, but the mouthpiece was hanging outside of the bag and resting directly on the bedside table. Interviews with the resident confirmed use of the spirometer, and an LPN stated that the spirometer, including the mouthpiece, should be kept in a plastic bag to prevent contamination. Facility administrative staff, including the administrator, assistant administrator, and director of nursing, were made aware of these findings. No additional information was provided prior to the survey exit.
Medication Error Rate Exceeds Five Percent Due to Administration Errors
Penalty
Summary
Facility staff failed to maintain a medication error rate below five percent during medication administration observation. Specifically, out of 29 observed medication administration opportunities, two errors were identified, resulting in a 6.9 percent error rate. The errors involved a resident with physician orders for gabapentin 100 mg to be administered as one capsule in the morning for pain, and Breo Ellipta 100/25 mcg to be administered as one inhalation in the morning for chronic obstructive pulmonary disease, with instructions to rinse the mouth after use. During the observed medication pass, an LPN administered two capsules of gabapentin instead of the prescribed one capsule and did not assist the resident with rinsing her mouth after administering Breo Ellipta. The LPN acknowledged both errors upon review of the physician's orders. The facility's medication administration policy requires staff to review and confirm medication orders prior to administration, but this was not followed in these instances.
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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) |
|---|---|---|---|---|
| Loudoun Rehabilitation And Nursing Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Ashby Ponds Inc | 8.9 mi | ★★★★★ | 0 | 0 |
| Johnson Cntr/falcons Landing | 11.6 mi | ★★★★★ | 0 | 0 |
| Potomac Falls Health & Rehab Center | 12 mi | ★★★★★ | 0 | 0 |
| Dulles Health & Rehab Center | 15.9 mi | ★★★★★ | 18 | 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.