Inspection·March 15, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm falls, UTI [Urinary Tract Infection] upon 1st admission, use of opioids and psychotropic medication . Interventions: 1/13/23: Educate resident to use call bell when assistance is needed. Review of Resident #30's Quarterly Minimum Data Set (MDS) dated [DATE], reads, Section C. Cognitive Patterns: C0500. BIMS Summary Score: 14. Residents Affected - Few During an interview on 3/14/2023 at 1:36 PM, the Director of Maintenance stated that he was aware call light was not working. He stated, We have been having problems getting parts. It is an old system. The new part has been ordered. We have not received it. During an interview on 3/14/2023 at 2:13 PM, Staff A, License Practical Nurse (LPN), Unit Manager, stated, I was not aware [Resident #102's name] call light was not working. Normally a report would be placed in the computer system. Depending what the issue is, maintenance will come and look at the bulb outside to see if that is the reason it is not turning on. If that does not work, they will order parts. During an interview on 3/14/2023 at 2:29 PM, Staff J, CNA, stated, Yes, I was aware his call light is not working. Most of the time, he will have his roommate use his call light to call staff. I did not hear the bell ring. If I am close to the room, I might hear it but if I am away from the room, I am not able to hear the bell ring. During an interview on 3/14/2023 at 2:31 PM, Staff I, LPN, stated, I was not aware [Resident #102's name] call bell was not functioning. I have not noticed the bell he has on top of his bedside table. I did not hear the bell. I was doing other things. During an interview on 3/15/2023 at 8:08 AM, the Director of Nursing stated, I was not aware of [Resident #102's name] call light. I would have offered resident if he would like to move to another room. Review of the facility policy and procedure titled Call Lights last reviewed on 1/19/2023, reads, Procedure . 3. The call light should be plugged in at all times with the exception of occurrences when the system is under repair or malfunctioning, in which case an alternative system of Staff notification for need of assistance may be utilized. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 2 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Campus Care Center and Rehab 715 E Dixie Ave Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed in a timely manner for 7 of 12 residents reviewed for resident assessments, Residents #22, #37, #68, #79, #88, #110, and #112, in a total sample of 52 residents. Residents Affected - Few Findings include: Review of the Minimum Data Set (MDS) with the MDS Coordinator revealed the following: Resident #22: Assessment Type: Quarterly, Assessment Reference Date: 2/8/2023, Status: 35 days overdue; Resident #37: Assessment Type: Quarterly, Assessment Reference Date: 2/13/2023, Status: 30 days overdue; Resident #68: Assessment Type: Quarterly, Assessment Reference Date: 2/8/2023, Status: 35 days overdue; Resident #79: Assessment Type: Quarterly, Assessment Reference Date: 1/26/2023, Status: 44 days overdue; Resident #88: Assessment Type: Quarterly, Assessment Reference Date: 2/15/2023, Status: 28 days overdue; Resident #110: Assessment Type: Quarterly, Assessment Reference Date: 2/12/2023, Status: 31 days overdue; Resident #112: Assessment Type: Quarterly, Assessment Reference Date: 2/18/2023, Status: 25 days overdue. During an interview on 3/14/2023 at 9:10 AM, the MDS Coordinator verified the completion and transmission status of the minimum data set assessments for Residents #22, #37, #68, #79, #88, #110, and #112. She verified the assessments were overdue. Review of the facility policy and procedure titled MDS Assessments issued on 4/1/2022 reads, Policy: It will be the policy of this facility to complete MDS assessments in accordance with the RAI [Resident Assessment Instrument] manual guidelines. Procedures: 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements . a . (2) Quarterly AssessmentConducted not less frequently than three (3) months following the most recent OBRA [Omnibus Budget Reconciliation Act] assessment of any type . (4) Annual Assessment (Comprehensive)- Conducted not less than once every twelve (12) months. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 3 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Campus Care Center and Rehab 715 E Dixie Ave Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care for 2 of 3 residents reviewed for comprehensive care plans, Residents #19 and #116, in a total sample of 52 residents. Findings include: 1. Review of the admission record for Resident #116 documented the diagnoses including encounter for other orthopedic aftercare, unspecified dementia, anemia, unspecified atrial fibrillation, dysphasia oral pharyngeal phase, essential primary hypertension, unspecified protein calorie malnutrition, iron deficiency anemia secondary to blood loss, heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, personal history of other venous thrombosis and embolism, thrombocytopenia, and unspecified malignant neoplasm of skin. During an observation on 3/13/2023 at 8:05 AM, Resident #116 was in bed on a low air loss mattress lying on back. During an observation on 3/14/2023 at 8:51 AM, Resident #116 was on a low air mattress in bed lying on back. During an observation on 3/14/2023 at 10:30 AM, Resident #116 was on a low air loss mattress in bed lying on back. During an observation on 3/14/2023 at 12:30 PM, Resident #116 was on a low air loss mattress in bed lying on back. During an observation on 3/14/2023 at 2:30 PM, Resident #116 was lying on back in bed. Review of the report titled Tissue Analytics dated 3/13/2023 for Resident #116 reads, Location: Buttocks. Measurements: Length: 4.04 cm. Width: 2.94 cm . Wound status: Worsening . Pressure Reduction/Offloading: Ensure compliance with turning protocol, Wedge/foam cushion for offloading. Wheelchair Cushion, Speciality [Sic.] bed. Review of Resident #116's care plan initiated on 3/12/2023 reads, Focus: [Resident #116's name] is noted to have skin impairment as follows: pressure ulcers present to bilateral buttocks, left posterior thigh, and surgical site to right stump due to recent AKA [Above Knee Amputation], friction injury to mid back . Interventions: Administer medications for wound healing as ordered, observed for effectiveness and SEs [side effects]. Provide nutritional supplements as ordered to promote wound healing. Registered Dietitian consult as needed. Pressure reducing mattress to bed. Pressure reducing cushion to w/c [wheelchair]. Keep sheets clean, dry, and as wrinkle free as possible. Use proper positioning, transferring, and turning techniques to minimize friction. Perform wound treatments as ordered. Wound care physician services to follow. Observe wound for sx/sx [signs and symptoms] of infection and for significant decline; update physician if noted. During an interview on 3/14/2023 at 2:17 PM, Staff G, Registered Nurse (RN), stated, The patient should be offloaded at all times with a wedge foam. There is not one here. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 4 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Campus Care Center and Rehab 715 E Dixie Ave Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/14/2023 at 2:25 PM, Staff F, Certified Nursing Assistant (CNA), stated, I have not assisted him in repositioning every few hours. We have been busy. He has been on his back. I don't think there is a wedge to place under him. We do have access to the care plans. We get report about the residents and if they have any new skin concerns and we report any new areas to nurses. During an interview on 3/14/2023 at approximately 2:45 PM, Staff C, Licensed Practical Nurse (LPN), stated, I have been very busy today and really don't know if he was repositioned. I don't know what the wound care doctor recommended. Review of the facility policy and procedure titled Comprehensive Assessments and Care Plans issued on 4/1/2022 reads, Standard: It will be the standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. Guidelines . 8. The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights set forth at 483.10(c)(1) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychological needs that are identified in the comprehensive assessment . 11. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will be provided by qualified persons in accordance with each resident's written plan of care and will also be culturally-competent and trauma-informed. 2. During an observation on 3/12/2023 at 10:05 AM, Resident #19 was lying in bed, resting with eyes closed. Heels were laying on top of the mattress without being offloaded. During an observation on 3/13/2023 at 7:56 AM, Resident #19 was lying in bed, with heels laying on top of the bed without being offloaded. During an observation on 3/14/2023 at 12:50 PM, Resident #19 was lying in bed, wearing non-skid socks. Both heels were on top of the mattress, without being offloaded. Review of Resident #19's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral infraction, dementia in other disease classified elsewhere, unspecified severity with other behavioral disturbance, chronic kidney disease, orthostatic hypotension, interstitial pulmonary disease, gastro esophageal reflux disease, other seizures, difficulty in walking, muscle weakness, cachexia, pain, hypothyroidism, major depressive disorder, transient cerebral ischemic attack, hypotension, cramp and spasm, polyneuropathy, and anorexia. Review of the physician order dated 8/4/2022 for Resident #19 reads, Offload heels when in bed. Review of Resident #19's care plan initiated on 5/28/2021 reads, Focus: [Resident #19's name] has a potential for skin impairment/pressure ulcers r/t [related to]: impaired mobility, incontinence of bowel, incontinence of bladder, need for staff assistance, receives ASA and anticoagulant. She presents with skin tear to R [right] thigh- resolved . Interventions . Float heels while in bed. Date Initiated date: 7/13/2022. During an interview on 3/14/2023 at 1:26 PM, Staff A, License Practical Nurse (LPN), Unit Manager, confirmed that Resident #19 was lying in bed with heels not being offloaded. She stated that she expected Resident #19 to be offloaded every time she is lying in bed. Staff A was not able to locate offloading boots for resident in the room. Staff A stated she would go find a pair of boots to place on Resident #19's feet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 5 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Campus Care Center and Rehab 715 E Dixie Ave Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 3/15/2023 at 10:25 AM, the Director of Nursing (DON) stated, [Resident #19's name] has no skin concerns at this time. I do not feel that her feet needed to be offloaded. Review of the facility policy and procedure titled Repositioning and Support last reviewed on 1/19/2023, reads, Policy: It will be the policy of this facility to provide evaluation of the resident's repositioning needs, to aid in the development of a care plan for repositioning as needed, to promote comfort for all bed-bound or chair-bound residents, to attempt to prevent skin breakdown, promote circulation and provide pressure relief for residents. Event ID: Facility ID: 105375 If continuation sheet Page 6 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Campus Care Center and Rehab 715 E Dixie Ave Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were administered in a timely manner for 3 of 7 residents observed for medication administration, Residents #79, # 371, and #30, and failed to ensure physician ordered bed rail adaptations were in place 1 of 6 residents reviewed for safety, Resident #83. Residents Affected - Few Findings include: 1. During an observation on 3/14/2023 at 10:12 AM, Staff H, License Practical Nurse (LPN), entered Resident #79's room and informed the resident the medication was late and asked if she would like to take her medication. Resident #79 agreed to take her medication. Staff H administered one tablet of Aspirin 325 milligrams (mg), one tablet of Amlodipine Besylate 10 mg and 120 milliliters (ml) of Med Pass 2.0. During an interview on 3/14/2023 at 10:20 AM, Staff H, LPN, stated, Medications are late due to facility not allowing medication pass when food is being delivered or when residents are eating. Review of Resident #79's Medication Administration Record (MAR) for March 2023 revealed Amlodipine Besylate tablet 10 mg scheduled for 9:00 AM, Buffered Aspirin tablet 325 mg scheduled for 9:00 AM, and 120 milliliters of Med Pass 2.0 scheduled for 9:00 AM. Review of Resident #79's Medication Admin Audit Report dated 3/14/2023 revealed scheduled time of 9:00 AM and administration time of 10:17 AM for Amlodipine Besylate tablet 10 mg, scheduled time of 9:00 AM and administration time of 10:24 AM for Med Pass 2.0, and scheduled time of 9:00 AM and administration time of 10:17 AM for Buffered Aspirin tablet 325 mg. During an observation on 3/14/2023 at 10:28 AM, Staff C, LPN, entered Resident #371's room and administered Risperidone 0.25 mg and 90 milliliters of Med Pass 2.0. During an interview on 3/14/2023 at 10:32 AM, Staff C, LPN, stated, This is my first time here in the facility. I had to do an IV medication administration. Then a surveyor came to speak to me. Then pharmacy came and I had to stop, and I had to put away meds. The unit manager was busy. Review of Resident #371's MAR for March 2023 revealed Risperidone oral tablet 0.25 mg scheduled for 9:00 AM and House Nutritional Supplement scheduled for 9:00 AM. Review of Resident #371's Medication Admin Audit Report dated 3/14/2023 revealed scheduled time of 9:00 AM and administration time of 10:33 AM for Risperidone Oral Tablet 0.25 mg and scheduled time of 9:00 AM and administration time of 10:32 AM for House Nutritional Supplement 90 ml. During an observation on 3/14/2023 at 10:51 AM, Staff I, LPN, entered Resident #30's room and administered 10 mg of Baclofen, 220 mg of Zinc Sulfate, 325 mg of Ferrousul, one capsule of Lactobacillus, and 500 mg of Vitamin C. During an interview on 3/14/2023 at 10:51 AM, Staff I, LPN, stated, Medication was late because during breakfast. We are not supposed to pass out medication until trays are removed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 7 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Campus Care Center and Rehab 715 E Dixie Ave Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #30's MAR for March 2023 revealed Ferrousul Tablet 352 mg scheduled for 9:00 AM, Lactobacillus Capsule scheduled for 9:00 AM, Vitamin C tablet 50 mg scheduled for 9:00 AM, Zinc Sulfate tablet 220 mg scheduled for 9:00 AM, and Baclofen tablet 10 mg scheduled for 9:00 AM. Review of Resident #30's Medication Admin Audit Report dated 3/14/2023 revealed scheduled time of 9:00 AM and administration time of 10:51 AM for Baclofen tablet 10 mg, scheduled time of 9:00 AM and administration time of 10:51 AM for Lactobacillus Capsule, scheduled time of 9:00 AM and administration time of 10:51 AM for FerrouSul tablet 325 mg, scheduled time of 9:00 AM and administration time of 10:51 AM for Vitamin C tablet 500 mg, and scheduled time of 9:00 AM and administration time of 10:51 AM for Zinc Sulfate tablet 220 mg. During an interview on 3/15/2023 at 8:13 AM, the Director of Nursing (DON) stated, Staff are able to pass out medications while breakfast is served. It is a misinterpretation because we do not allow cleaning while trays are out on the floor. Review of the facility policy and procedure titled Medication Administration with a last review date of 1/19/2023, reads, Procedure . 3. Medications should be administered in a timely manner and in accordance with the physician's orders . 2. During an observation on 3/12/2023 at 9:52 AM, Resident #83 was sitting in bed watching television. There was no padding on his 1/4 side rails. During an observation on 3/13/2023 at 7:50 AM, Resident #83 was resting in bed with eyes closed. There was no padding on his 1/4 side rails. During an interview on 3/13/2023 at 7:50 AM, Resident #83 stated, The facility has not put pads on his side rails before. I have never refused. Resident #83 confirmed he has a history of seizures but has not had a seizure in the facility. Review of Resident #83's admission records revealed the resident was admitted to the facility on [DATE] with a diagnosis including psychotic disorder with hallucinations due to known physiology condition, other muscle spasm, paranoid schizophrenia, delusional disorders, lack of coordination and seizures. Review of the physician order dated 12/5/2022 for Resident #83 revealed, Padded side rails due to seizure. During an interview on 3/13/2023 at 1:21 PM, Staff A, License Practical Nurse, Unit Manager, confirmed that Resident #83 had an order for padded side rails and the side rails were not padded. During an interview on 3/14/2023 at 2:20 PM, Staff A, LPN, Unit Manager, stated, [Resident #83's name] has padded side rails as a precaution, just in case he has seizure activity, the padding will protect him from injuring himself. [Resident #83's name] has not had a seizure since he has been here in the facility. During an interview on 3/15/2023 at 8:10 AM, the DON stated, I would expect for staff to follow orders and make sure the pads were in place. If a resident has a seizure, they move around in bed. Review of the facility policy and procedure titled Bed Rails with a last review date of 1/19/2023, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 8 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Campus Care Center and Rehab 715 E Dixie Ave Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 reads, Procedure . 2. Bed rails with padding may be used to prevent resident injury in situations of uncontrollable movement disorders such as epilepsy, seizure disorder or Huntington's Chorea. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 9 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Campus Care Center and Rehab 715 E Dixie Ave Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure residents received the necessary services for personal hygiene for 2 of 2 residents sampled for activities of daily living, Residents #25 and #87, in a total of 52 residents. Residents Affected - Few Findings include: During an interview on 3/12/2023 at 10:38 AM, Resident #25 stated, I do not get a shower sometimes because they do not have enough linens and towels to do it. When I get a bed bath or shower, it is often late in the day due to waiting for linens and I like to get up in my wheelchair in the mornings. Review of Resident #25's admission record revealed the resident was admitted to facility on 9/24/2016 with diagnoses including osteoarthritis, major depressive disorder, multiple sclerosis, chronic fatigue, pain, contracture left hand, abnormal posture, and muscle weakness. Review of Resident #25's Quarterly Minimum Data Set (MDS) dated [DATE] denoted the resident as total dependence for bathing with two persons physical assistance. During an observation on 3/13/2023 at 9:45 AM, Tuscany linen cart had no towels, washcloths, sheets or bed pads available. During an interview on 3/13/2023 at 2:22 PM, Staff K, Certified Nursing Assistant (CNA), stated, We sometimes have a problem having the linens to do our showers in the AM. I try to get my showers started before breakfast if I have linens to do them. During an interview on 3/14/2023 at 10:30 AM, Resident #87 stated, I do not get my showers on the second shift sometimes due to the staff saying they do not have linens to do the showers. Review of Resident #87's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including central cord syndrome at unspecified level of cervical spinal cord, spinal stenosis cervical region, need for assistance with personal care, muscle weakness, hemiplegia unspecified affecting right dominant side, pain, and hypertension. Review of Resident #87's Quarterly MDS dated [DATE] denoted the resident needed one-person physical assistance for personal hygiene and two-persons physical assistance for transfer. Review of Resident #87's intervention/ task list for February 2023 and March 2023 revealed 97- Not Applicable for 2/10/2023, 2/22/2023, 2/27/2023, 3/1/2023, 3/3/2023, and 3/13/2023, and no information 2/20/2023, 2/24/2023, and 3/10/2023. During an interview on 3/14/2023 at 11:03 AM, the Laundry Manager stated, There is not a laundry staff working from 10 PM until 6 AM. The linens are stocked every day when they are cleaned. Towels are getting thrown away. Some of the laundry staff thought that they could not bring out clean linens during the meal delivery. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 10 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Campus Care Center and Rehab 715 E Dixie Ave Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents with central venous access devices, Resident #106. Residents Affected - Few Findings include: During an observation on 3/14/2023 at 7:41 AM, Staff C, Licensed Practical Nurse (LPN), entered Resident #106's room to administer a normal saline flush (used before and after medication administration to prevent mixing of medication). Staff C administered 10 milliliters of normal saline intravenously. Staff C did not check for line patency via blood return, (the procedure used to determine line patency, to verify the line is opened and not blocked), prior to administering the normal saline flush. During an observation on 3/14/2023 at 8:42 AM, Staff C, LPN, administered Cefepime (an antibiotic) IV (intravenous) to Resident #106. Staff C did not administer a normal saline flush or check PICC (peripherally inserted central catheter) line patency prior to administering the medication. Review of the admission record for Resident #106 documented the resident was admitted to the facility on [DATE] with the diagnoses including local infection of the skin and subcutaneous tissue unspecified, type 2 diabetes mellitus with diabetic polyneuropathy, morbid obesity, pressure ulcer of sacral region, essential (primary) hypertension, unspecified atrial fibrillation, heart failure, unspecified, gastroparesis, acquired absence of right leg below the knee, and major depressive disorder. Review of the physician orders dated 3/8/2023 for Resident #106 reads, Normal Saline flush solution (Sodium Chloride Flush) use 10 cc [cubic centimeter] intravenously for prophylaxis. Flush central venous catheter with 10 ml [milliliter] before and after medication administration. During an interview on 3/14/2023 at 9:15 AM, Staff C, LPN, stated, I did not check to see if there was a blood return before I gave the normal saline and the antibiotic. I should have. During an interview on 3/14/2023 at 2:10 PM, Staff D, Registered Nurse, Unit Manager, stated, We need to flush the PICC line. We should verify line placement prior to using a central line. Review of the facility policy and procedure titled IV Infusions issued on 4//1/2022 reads, Policy: It is the policy of this facility to provide administration of intravenous fluids, medications and electrolytes for the purposes of hydration and management of infections or other medical conditions. Procedure . 6. Administer IV medications, fluids and flushes per physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 11 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Campus Care Center and Rehab 715 E Dixie Ave Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an observation on 3/12/2023 at 12:20 PM, Resident #227 was resting in bed with oxygen running at 4 liters via nasal cannula. Tubing was not labeled and dated. Residents Affected - Some During an observation on 3/13/2023 at 8:34 AM, Resident #227 was resting in bed with oxygen running at 2 liters via nasal cannula. During an observation on 3/13/2023 at 1:04 PM, Resident #227 stated, I am not able to touch the oxygen. I can't reach it and am too weak to do it. During an interview on 3/13/2023 at 1:55 PM, Staff E, LPN stated, This oxygen is not at the right amount. It should be at 3 liters via nasal cannula. Review of Resident #227's admission records documented that the resident was admitted to the facility on [DATE] with the diagnoses including malignant neoplasm (cancer) of esophagus, malignant neoplasm of the bronchus or lung, secondary malignant neoplasm of the liver and intrahepatic bile duct, unspecified protein calorie malnutrition, dysphagia (difficulty swallowing), and adult failure to thrive. Review of the physician orders for Resident #227 dated 2/24/2023 reads, Continuous O2 at 3L via NC q shift. During an interview on 3/14/2023 at 2:05 PM, the Director of Nursing (DON) stated, All oxygen should be running at the ordered amount. Nurses should check daily to make sure it is. They should be following physician orders. Review of the facility policy and procedure titled Oxygen Administration issued on 2/1/2022 reads, Procedure . 4. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter as is ordered by the physician or required to provide for the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 3 of 6 residents reviewed for oxygen administration, Residents #84, #227, and #321, in a total sample of 52 residents. Findings include: 1. During an observation on 3/12/2023 at 1:01 PM, Resident #321 was lying in bed with oxygen running at 3.5 liters per minute via nasal cannula. During an observation on 3/13/2023 at 8:43 AM, Resident #321 was lying in bed with oxygen running at 4 liters per minute via nasal cannula. Review of Resident #321's admission records revealed the resident was admitted to the facility on [DATE] with the diagnoses including contracture on right knee, right hand, and left knee, other muscle spasm, atherosclerosis of coronary artery bypass graft(s) without angina pectoris, unspecified atrial fibrillation, adult failure to thrive, sick sinus syndrome, heart failure, peripheral vascular (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 12 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Campus Care Center and Rehab 715 E Dixie Ave Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some disease, unspecified convulsions, presence of cardiac pacemaker, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, shortness of breath, and essential (primary) hypertension. Review of the physician order dated 12/2/2020 for Resident #321 reads, Continuous O2 [oxygen] at 2 L/Min [liter/minute] via NC [Nasal Cannula] q [every] shift. During an interview on 3/14/2023 at 7:44 AM, Staff A, Licensed Practical Nurse (LPN), Unit Manager, stated, The O2 is set to 2.5 liters per minute and should be set to 2 liters per minute. This is the incorrect setting. During an interview on 3/15/2023 at 9:33 AM, the Director of Nursing (DON) stated, Nurses are to look at the physician order and verify O2 settings are correct when administering oxygen. 2. During an observation on 3/12/2023 at 10:06 AM, Resident #84 was lying in bed with oxygen running at 3.5 liters per minute via nasal cannula. Oxygen machine had brown splatter stains. Passive Nebulizer treatment mask was lying on top of the right side night table. During an interview on 3/12/2023 at 10:07 AM, Resident #84 stated, The nurse will adjust my oxygen. I am not sure what the stains are. It was dirty since they gave it to me. During an observation on 3/13/2023 at 7:54 AM, Resident #84 was lying in bed resting with eyes closed. Oxygen was running at 4 liters per minute via nasal cannula. Oxygen machine had brown stains. Review of Resident #84's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including acute embolism and thrombosis of unspecified deep veins of left lower extremities, generalized anxiety disorder, psoriasis, allergic rhinitis due to pollen, anemia, morbid (severe) obesity due to excess calories, major depressive disorder, emphysema, and chronic obstructive pulmonary disease. Review of the physician order dated 1/4/2023 for Resident #84 reads, Continuous oxygen 2L [liter] via Nasal cannula every shift for prophylaxis related to chronic obstructive pulmonary disease. During an interview on 3/14/2023 at 11:00 AM, the (DON) confirmed Resident #84's oxygen was running at 3.5 liters per minute. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 13 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Campus Care Center and Rehab 715 E Dixie Ave Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide laboratory services to meet the needs of 1 of 6 residents reviewed for Medication Regimen, Resident #29. Residents Affected - Few Findings include: Review of Resident #29's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, unspecified protein-calorie malnutrition, anxiety disorder, anemia, other seizures, essential hypertension, unspecified atrial fibrillation, cardiomegaly, chronic kidney disease, major depressive disorder, and chronic obstructive pulmonary disease. Review of the physician order dated 3/7/2021 for Resident #29 reads, Keppra level every night shift every 90 day(s). Review of Resident #29's medical records did not reveal a Keppra lab result for the month or February 2023 or March 2023. Review of Resident #29's Treatment Administration Record for February 2023 revealed Keppra level was completed on 2/25/2023. Review of the Treatment Administration Record for March 2023 revealed no staff initials. Review of Resident #29's lab results report dated 11/29/2022 revealed Keppra results of lower than 5.0 ug/ml, which was flagged as L (Low). Review of Resident #29's lab results report dated 3/14/2023 reads, Cancelled. [Staff's name] has rejectedKeppra- on 3/14/2023. Reason: Specimen Hemolyzed Upon Arrival to Laboratory. Please recollect: red top. Additional info. During an interview on 3/14/2023 at 6:24 AM, the Director of Nursing (DON) stated, We did not draw labs for Keppra for [Resident #29s name] because it was scheduled for February 29, 2023. This past February only had 28 days, so the Keppra lab did not trigger in the system. During an interview on 3/15/2023 at 8:05 AM, the DON stated, Keppra labs are important because we need to monitor therapy level for seizures. Review of the facility policy and procedure titled Diagnostics Labs Radiology Notification with a last review date of 1/19/2023, reads, Policy: It will be the policy of this facility to provide or obtain timely laboratory, radiology and diagnostic services when ordered by a physician; physician assistant (PA); nurse practitioner (NP) or clinical nurse specialist (CNS) in accordance with State law, including scope of practice laws. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 14 of 15 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105375 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Campus Care Center and Rehab 715 E Dixie Ave Leesburg, FL 34748 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents with central venous access devices, Resident #106, in a total sample of 52 residents. Residents Affected - Few Findings include: During an observation on 3/14/2023 at 7:41 AM, Staff C, Licensed Practical Nurse (LPN), entered Resident #106 's room to administer a normal saline flush. Staff C did not perform hand hygiene, donned gloves and removed the peripherally inserted central catheter (PICC) line from a mesh stockinette on Resident #106's right upper arm. Staff C removed a green cap off the hub of the insertion site, turned to retrieve the normal saline flush, dropped the PICC line resulting in the hub resting on the skin of Resident #106's right arm. Staff C did not clean the needleless connector, administered 10 milliliters of normal saline intravenously and reapplied the same green cap to the hub. During an observation on 3/14/2023 at 8:42 AM, Staff C, LPN, administered Cefepime IV (intravenous) to Resident #106. Staff C did not perform hand hygiene and donned gloves. Staff C did not clean the needleless connector. Review of the admission record for Resident #106 documented the resident was admitted to the facility on [DATE] with the diagnoses including local infection of the skin and subcutaneous tissue unspecified, type 2 diabetes mellitus with diabetic polyneuropathy, morbid obesity, pressure ulcer of sacral region, essential (primary) hypertension, unspecified atrial fibrillation, heart failure, unspecified, gastroparesis, acquired absence of right leg below the knee, and major depressive disorder. Review of the physician orders dated 3/8/2023 for Resident #106 reads, Normal Saline flush solution (Sodium Chloride Flush) use 10 cc [cubic centimeter] intravenously for prophylaxis. Flush central venous catheter with 10 ml [milliliter] before and after medication administration. During an interview on 3/14/2023 at 9:15 AM, Staff C, LPN, stated, I don't need to clean the hub [needleless connector]. It has the special green cap on it. When it fell, I should have cleaned it. I should have washed my hands before I put on my gloves. During an interview on 3/14/2023 at 2:10 PM, Staff D, Registered Nurse, Unit Manager, stated, We need to clean the hub of the PICC line every time we access it to give medications or flush it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 15 of 15