Heritage Hall-Leesburg

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF757Jan 29, 2025

  Based on staff interview, clinical record review, and facility document review, staff interview, the facility staff failed to maintain a resident free of unnecessary medications for one of 44 residents in the survey sample, Resident #97 (R97). The findings include: For (R97), facility staff failed to administer a prn (as needed) the pain medication Oxycodone (1) within the physician ordered pain level parameters. (R97) was admitted to the facility with a diagnosis that included but was not limited to back pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/22/2025, R97 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating (R15) was cognitively intact for making daily decisions. […]

• No harm, potential for more than minimal, patternF812Sep 21, 2022

  Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in 1 of 1 facility kitchens. The findings include: On 9/20/22 at 12:15 PM, a tour of the facility kitchen was conducted with OSM #1 (Other Staff Member) the Dietary Manager. In the walk-in freezer, a box of dinner rolls was noted to have been opened, and the bag inside with the dinner rolls was left open to air, exposing the rolls to the freezer environment. When asked if the box should be left open, OSM #1 stated that it should be closed and sealed. He removed the box and discarded it. The facility policy, Cost Containment - Food Storage: General was reviewed. This policy documented, 6. […]

• No harm, potential for more than minimal, isolatedF558Jan 29, 2025

  Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide accommodations of resident needs by ensuring the call bell (a device with a button that can be pushed to alert staff when assistance is needed) was within reach for two of 44 residents in the survey sample, Residents #19, (R19) and R67. The findings include: 1. For R19, the facility staff failed to keep the call bell within reach. R19 was admitted to the facility with a diagnosis that included by not limited to difficulty breathing. […]

• No harm, potential for more than minimal, isolatedF695Jan 29, 2025

  Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide respiratory care and services for one of 44 residents in the survey sample, Resident #32 (R32). The findings include: For R32, facility staff failed to store the incentive spirometer (1) in a sanitary manner. R32 was admitted to the facility with a diagnosis that included by not limited to generalized muscle weakness. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/23/2024, R32 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R32 was cognitively intact for making daily decisions. […]

• No harm, potential for more than minimal, isolatedF759Jan 29, 2025

  Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure a medication error rate less than five percent for one of three residents observed during the medication administration observation, Resident #23. During the medication administration observation, two errors out of 29 opportunities occurred, resulting in a 6.9 percent medication error rate. The findings include: For Resident #23 (R23), LPN (licensed practical nurse) #1 failed to administer gabapentin and Breo Ellipta per physician's orders. […]