Inspection·November 15, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cleanse wound with normal saline, pat dry, apply Medihoney and cover with clean border gauze one time a day for wound care. Review of Resident #1's TAR for October 2023 showed no entries documented for administration of wound treatment to left lateral ankle on 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, 10/18/2023 and 10/20/2023. Review of Resident #1's physician order dated 10/6/2023 reads, Wound care left medial ankle cleanse wound with normal saline, pat dry, apply Medihoney and cover with clean bordered gauze one time a day for wound care. Review of Resident #1's TAR showed no entries documented for administration of wound treatment to left medial ankle on 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, 10/18/2023 and 10/20/2023. 2. Review of Resident #10's admission record revealed the resident was admitted to the facility with the diagnoses including unspecified dementia, acquired absence of right leg below the knee, polyneuropathy unspecified, presence of cardiac pacemaker, depression, unspecified anxiety disorder, unspecified anemia, and hyperlipidemia. Review of Resident #10's physician order dated 10/27/2023 reads, Wound care, apply betadine to left medial foot daily and leave open to air every day shift for DTI [Deep Tissue Injury]. Review of Resident #10's TAR for November 2023 showed no entries documented for administration of wound treatment to left medial foot on 11/4/2023 and 11/9/2023. During an interview on 11/15/2023 at 9:35 AM, the Director of Nursing stated, All treatments should be signed and documented as completed by the nurses. There are treatments that are not documented on [Resident #1 and Resident #10's names]. There should be complete documentation. Review of the policy and procedure titled Wound Care issued on 4/1/2022 reads, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment . 6. Care procedures and treatments shall be performed according to physician orders . 10. Document in the clinical record when treatments are performed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 2 of 4 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 11/15/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review and interview, the facility failed to utilize the Quality Assessment and Process Improvement (QAPI) process to monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained for the concerns identified with documentation of wound care. Findings include: Review of the policy and procedure titled Quality Assurance and Performance Improvement (QAPI) Program issued on 4/1/2022 reads, Policy: It will be the policy of this facility, including a facility that is part of a multiunit chain, to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Procedure: 1. The facility shall maintain documentation and demonstrate evidence of its ongoing QAPI program. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . 5. The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that the QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions and services provided to residents based on performance indicator data, and resident and staff input and other information, corrective actions address gaps in systems and are evaluated for effectiveness. Review of Resident #1's physician order dated 9/21/2023 reads, Medihoney wound burn dressing external gel, apply to left inner ankle topically every day shift for stage two, cleanse with normal saline, pat dry, apply Medihoney to open area, cover with clean dry dressing. Review of Resident #1's Treatment Administration Record (TAR) for October 2023 showed no entries documented for administration of wound treatment to left inner ankle on 10/6/2023, 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, and 10/20/2023. Review of Resident #1's physician order dated 9/21/2023 reads, Medihoney wound burn dressing external gel, apply to left outer ankle topically every day shift for stage two, cleanse with normal saline, pat dry, apply Medihoney to open area, cover with clean dry dressing. Review of Resident #1's TAR for October 2023 showed no entries documented for administration of wound treatment to left outer ankle on 10/5/2023, 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, and 10/18/2023. Review of Resident #1's physician order dated 9/21/2023 reads, Xeroform oil emulsion gauze external pad apply to right knee topically every day shift for skin tear, cleanse with normal saline pat dry, apply Xeroform to open area, cover with clean dry dressing. Review of Resident #1's TAR for October 2023 showed no entries documented for administration of wound treatment to right knee on 10/5/2023, 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, and 10/18/2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 3 of 4 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 11/15/2023 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #1's physician order dated 10/6/2023 reads, Wound care left lateral ankle, cleanse wound with normal saline, pat dry, apply Medihoney and cover with clean border gauze one time a day for wound care. Review of Resident #1's TAR for October 2023 showed no entries documented for administration of wound treatment to left lateral ankle on 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, 10/18/2023 and 10/20/2023. Review of Resident #1's physician order dated 10/6/2023 reads, Wound care left medial ankle cleanse wound with normal saline, pat dry, apply Medihoney and cover with clean bordered gauze one time a day for wound care. Review of Resident #1's TAR showed no entries documented for administration of wound treatment to left medial ankle on 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, 10/18/2023 and 10/20/2023. During an interview on 11/14/2023 at 2:05 PM, the Director of Nursing (DON) stated, I was made aware that there were concerns from the EMS [Emergency Medical Services] staff. I did review the record and we did identify that after he [Resident #1] was readmitted in June. He [Resident #1] no longer had routine orders for suprapubic catheter care. There was no daily documentation of the suprapubic catheter care. There was no documentation that the staff assessed the insertion site for any problems or signs of infection. There was no documentation that the resident had his catheter bag changed and no orders to see the urologist to have the catheter changed based on the review of his medical record. We did do a PIP [Performance Improvement Plan] for this and educated staff. I have been auditing. Also, I did review the chart and that was when I found that he had no orders for care or to had his suprapubic changed. I did not realize that his wound care was not documented as completed. I suppose I should have found this when I reviewed his chart. I did not do a PIP related to documentation of wound care. I suppose I should have. I did not audit all wounds to see if wound care was being documented. Review of the policy and procedure titled Wound Care issued on 4/1/2022 reads, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment . 6. Care procedures and treatments shall be performed according to physician orders . 10. Document in the clinical record when treatments are performed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 4 of 4