Cycle 1
Health 2025-01-29 · Fire 2025-01-29
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Leesburg, VA
Heritage Hall-Leesburg
5-star overall rating with 4-star inspections with 4 recent health deficiencies
122 Morven Park Road Nw, Leesburg, VA
(703) 777-8700
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
164
Certified beds
Average residents
144
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Heritage Hall
Operator or chain grouping
Approved since
1992-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 4 overall / 4 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.80
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
3.47
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
248
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
75.76
Composite VBP score used to determine payment impact.
Payment multiplier
1.0247
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 14.74% · Performance 13.65% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
10
Baseline 5.33% · Performance 4.41% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
10
Baseline 30.00% · Performance 21.15% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
0.30
Baseline 2.89 hours · Performance 3.12 hours · Measure score 0.30 · Achievement 0 · Improvement 0.30
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.69% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 463 · Observed rate 8.42% · Lower 95% interval 7.91% |
| Discharge to community | 51.87% |
50.57%
1.3 pts better
|
No Different than the National Rate · Eligible stays 439 · Observed rate 46.7% · Lower 95% interval 47.72% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.61% |
95.27%
4.3 pts better
|
Numerator 255 · Denominator 256 |
| Falls with major injury | 0.39% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 256 |
| Discharge self-care score | 55.62% |
53.69%
1.9 pts better
|
Numerator 99 · Denominator 178 |
| Discharge mobility score | 55.06% |
50.94%
4.1 pts better
|
Numerator 98 · Denominator 178 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 256 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 4.41% |
7.12%
2.7 pts better
|
Better than the National Rate · Eligible stays 288 · Observed rate 2.43% · Lower 95% interval 3% |
| Staff COVID-19 vaccination coverage | 2.76% |
8.2%
5.4 pts worse
|
Numerator 5 · Denominator 181 |
| Staff flu vaccination coverage | 25.68% |
42%
16.3 pts worse
|
Numerator 47 · Denominator 183 |
| Discharge function score | 55.62% |
56.45%
0.8 pts worse
|
Numerator 99 · Denominator 178 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | 98.36% |
96.28%
2.1 pts better
|
Numerator 180 · Denominator 183 |
| Resident COVID-19 vaccinations up to date | 17.99% |
25.2%
7.2 pts worse
|
Numerator 25 · Denominator 139 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.5
1 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.4
1.2 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.0%
6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.6%
0.9 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.6% · Q3 3.4% · Q4 4.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.4% |
15.7%
9.3 pts better
|
11.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 5.7% · Q3 8.4% · Q4 3.6% · 4Q avg 6.4% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
5.7%
4 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.8% · Q3 1.7% · Q4 2.7% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.0% |
20.2%
2.2 pts better
|
19.6%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 19.4% · Q3 16.9% · Q4 17.5% · 4Q avg 18.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
15.0%
5.6 pts better
|
16.7%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 11.5% · Q3 8.5% · Q4 9.1% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.9% |
17.5%
2.4 pts worse
|
16.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 11.6% · Q3 15.4% · Q4 31.4% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.9% |
15.7%
0.8 pts better
|
14.9%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 16.7% · Q3 9.7% · Q4 20.0% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.5%
0.3 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.6%
0.3 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.8% · Q3 0.9% · Q4 2.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.8% |
22.2%
0.4 pts better
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 25.7% · Q3 14.6% · Q4 26.0% · 4Q avg 21.8% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
5.2%
2.8 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.6% · Q3 2.5% · Q4 1.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
74.6%
25.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.4% |
11.7%
7.3 pts better
|
12.0%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.4% · Observed 4.1% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.6% |
73.6%
26 pts better
|
79.7%
19.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.4% |
22.0%
10.6 pts better
|
23.9%
12.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 10.6% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-21 · Fire 2022-09-21
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-05-05 · Fire 2021-05-05
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-05-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-05-17
D · Potential for more than minimal harm
2021-05-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-05-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-01-29
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-01-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-01-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-14
E · Potential for more than minimal harm
2022-09-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-09-21
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-09-21
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-09-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-11-05
D · Potential for more than minimal harm
2022-09-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-05
D · Potential for more than minimal harm
2021-05-05
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2021-06-09
D · Potential for more than minimal harm
2021-05-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-06-09
Penalties and ownership
What sits behind the stars
Ownership
American Healthcare LLC
Operational/Managerial Control · Organization
Dalton, Brad
Corporate Officer · Individual
Dalton, Robert
Operational/Managerial Control · Individual
Dalton, Robert
Corporate Officer · Individual
East, Thomas
Corporate Director · Individual
East, Thomas
Corporate Officer · Individual
Gallant, Cassandra
Corporate Officer · Individual
Hopkins, William
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Loudoun Rehabilitation And Nursing Center
Leesburg, VA
2-star overall rating with 1-star inspections with $123,589 in total fines with 54 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Ashby Ponds Inc
Ashburn, VA
4-star overall rating with 3-star inspections with $9,438 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Johnson Cntr/Falcons Landing
Potomac Falls, VA
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out