Inspection visit
Inspection
15 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 15 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0641
Ensure each resident receives an accurate assessment.
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 assessments accurately reflect the
resident's status for 1 (Resident #109) of 3 residents reviewed for range of motion and 1 (Resident #20) of
2 residents reviewed for gastrostomies.
Residents Affected - Few
Findings include:
1. During an observation on 7/21/2024 at 10:05 AM, Resident #109 was lying in bed guarding his right arm
with his left hand.
During an interview on 7/21/2024 at 10:05 AM, Resident #109 was asked if he was able to move both arms
without limitations, he nodded No and touched his right hand. When asked if he was able to move both
lower extremities without limitation he nodded No.
Review of Resident #109's admission record documented resident was admitted on [DATE] with diagnosis
including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant
side and muscle weakness.
Review of the Minimum Data Set (MDS) admission assessment dated [DATE], documented in Section GG
titled Functional Abilities and Goals that Resident #109 had no impairment in his upper or lower extremities.
Review of Resident #109's physiatry [medical specialty that focuses on function, independence and quality
of life for people with disabilities] progress note, dated 7/16/2024 read, Transition of Care: Mobility and ADL
(activity of daily living) deficits secondary to intraparenchymal hemorrhage. His condition is complicated by
muscle weakness, difficulty walking and aphasia. Chief complaint: Mobility and ADL deficits secondary to
intraparenchymal hemorrhage. His condition is complicated by muscle weakness, difficulty walking and
aphasia. History of present illness: Patient is a 53 y/o (year old) Male with PMH (past medical history)
significant for abdominal wall abscess, acute hypoxic respiratory failure, acute renal failure requiring
dialysis, anemia, aphasia, cerebral vascular accident with right-sided body involvement, constipation,
dysphagia, heart disease, hypertension, metabolic encephalopathy, neurogenic bladder, paroxysmal atrial
fibrillation, and deep vein thrombosis prophylaxis, who was admitted to South Campus Rehabilitation and
Nursing for skilled nursing and rehabilitation secondary to deficits in mobility and ADL's . Musculoskeletal
Exam: Tone: Patient with decreased tone to bilateral upper and lower extremities. Stability: Joints are stable
with no joint laxity or subluxation. Palpation: No tenderness to palpation of b/l UE and LE (bilateral upper
extremities and lower extremities). Range of Motion: Functional range of motion to left upper and left lower
extremity. Decreased range of motion to right upper extremity and right lower extremity .
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
105375
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
07/24/2024
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 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 7/23/2024 at 9:02 AM, Staff D, Certified Nursing Assistant (CNA), stated [Resident
#109 name] has impairment on his right leg; he will not do anything with that leg. He is a Hoyer lift [resident
is transferred using a mechanical lift]. I would say he has impairment on lower extremities and somewhat of
impairment on one side of upper extremities.
During an interview on 7/23/2024 at 12:23 PM, Staff E, Physical Therapist (PT), stated I took care of
resident [Resident #109]. He has right side impairment due to his cardiovascular accident.
During an interview on 7/23/2024 at 1:10 PM, Staff F, Physical Therapist Assistant (PTA), stated Resident is
moderate to maximum assist. Resident has impairment on one side of his body; the side of his stroke.
During an interview on 7/23/2024 at 1:12 PM, Staff G, Certified Occupational Therapist Assistant (COTA),
stated, Resident has right sided weakness; he is able to use his left side.
2. During an observation on 7/23/2024 at 12:30 PM Resident #20 was lying in bed, gastric tube noted on
left side of abdomen with clean dressing dated 7/23/2024. Nursing staff administering medication via
gastric tube.
Review of Resident #20's physician's order dated 4/11/2024 read, Nepro 80 ml (milliliters)/hour via g-tube
(gastric tube) on at 1800 [6:00 PM] and off at 400 [4:00 AM] two times a day for supplement on at 1800 and
off at 0400.
Review of Resident #20's physician's order dated 7/02/2024 read, Enteral Feed order every shift Nepro
continuous @ (at) 90ml/hr x 10 hours (90 milliliters per hour times 10 hours) (ON @ 1800; OFF @ 0400).
Review of the MDS Quarterly assessment dated [DATE], documented in Section K titled Swallowing
/Nutritional Status that Resident #20 had no feeding tube while a resident of the facility.
During an interview on 7/23/2024 at 1:21 PM, Staff H, MDS Coordinator stated [Resident 109's name] does
have upper and lower extremity impairments; the MDS was coded incorrectly. [Resident #20's name] does
have a gastric tube and receives feedings and medication via gastric tube. Her MDS was coded incorrectly.
Review of the facility policy and procedure titled, MDS Assessments with a last review date of 11/29/2023,
read, Policy: It will be the policy of this facility to complete MDS assessments in accordance with the RAI
(Resident Assessment Instrument) manual guidelines.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105375
If continuation sheet
Page 2 of 10
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
07/24/2024
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, interview and record review, the facility failed to ensure residents who needed assistance to
perform activities of daily living (ADLs) received assistance for 1 of 3 residents reviewed for ADL care,
Resident #367.
Residents Affected - Few
Findings include:
Review of Resident #367's admission record showed the resident was most recently admitted on [DATE]
with the diagnoses including acute respiratory failure with hypoxia, morbid (severe) obesity due to excess
calories, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, difficulty in walking, need
for assistance with personal care, other abnormalities of gait and mobility, muscle weakness,
hyperlipidemia, constipation, essential (primary) hypertension, low back pain, gout, opioid dependence,
personal history of malignant neoplasm of prostate, gastrointestinal hemorrhage, headache, obstructive
sleep apnea, hypo-osmolality and hyponatremia, chronic diastolic (congestive) heart failure, chronic kidney
disease, and anemia.
During an observation on 7/21/2024 at 10:16 AM, Resident #367 had long and untrimmed fingernails with
dark substance under nail beds.
During an interview on 7/21/2024 at 10:16 AM, Resident #367 stated, I like my fingernails to be cut. Last
time they were cut at home.
During an observation on 7/22/2024 at 8:13 AM, Resident #367 had long and untrimmed fingernails with
dark substance under nail beds.
During an observation with Staff D, Certified Nursing Assistant (CNA), on 7/23/2024 at 8:25 AM, Resident
#367 had long and untrimmed fingernails with dark substance under nail beds.
During an interview on 7/23/2024 at 8:25 AM, Staff D, CNA, confirmed that the Resident #367's fingernails
were long and untrimmed with dark substance underneath, and they needed to be cut.
Review of Resident #367's care plan dated 7/11/2024 showed it read, Focus: Resident needs assist with
ADLs . Interventions . Assist/provide ADL care and support as needed.
During an interview on 7/23/2024 at 8:56 AM, the Director of Nursing (DON) stated, They [residents] get
nail care on shower days and as needed.
Review of the facility policy and procedure titled ADL Care and Assistance issued on 4/1/2022 and last
reviewed on 11/29/2023 showed the policy read, Policy: IT will be the policy of this facility to provide the
resident with Activities of Daily Living (ADL) care and assistance while attempting to maintain the highest
practicable level of function for the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105375
If continuation sheet
Page 3 of 10
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
07/24/2024
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
Based on interview and record review, the facility failed to ensure the residents received medication per
physician orders for 1 (Resident #37) of 7 residents reviewed for medication administration.
Residents Affected - Few
Findings include:
Review of Resident #37's physician's order, dated 1/14/2024, read Acetaminophen Tablet 325mg
(milligrams) give 2 tablets by mouth every 4 hours as needed for mild pain, level 1-3, related to pain,
unspecified (R52) not to exceed 3gm (grams)/3000mg per 24 hours .
Review of Resident #37's Medication Administration Record (MAR) for June 2024 documented the resident
received Acetaminophen Tablet 325mg on June 2 at 0429 [4:29 AM] for a pain level of 4, June 3 at 0500
[5:00 AM] for a pain level of 5, June 6 at 0929 [9:29 AM] for a pain level of 7, June 7 at 0053 [12:53 AM] for
a pain level of 7, June 13 at 1423 [2:23 PM] for a pain level of 4, June 14 at 0447 [4:47 AM] for a pain level
of 4, June 15 at 1907 [7:07 PM] for a pain level of 10, June 16 at 0500 [5:00 AM] for a pain level of 5, June
26 at 0101 [1:01 AM] for a pain level of 7, June 27 at 0050 [12:50 AM] for a pain level of 7 and at 2352
[11:52 PM] for a pain level of 8.
Review of Resident #37's Medication Administration Record (MAR) for July 2024 documented the resident
received Acetaminophen Tablet 325mg on July 10 at 0453 [4:53 AM] for a pain level of 4, July 11 at 0610
[6:10 AM] for a pain level of 7, July 13 at 2118 [9:18 PM] for a pain level of 4, July 21 at 1610 [4:10 PM] for
a pain level of 7 and on July 23 at 0508 [5:08 AM] for a pain level of 4.
During an interview on 7/23/2024 at 11:20 AM, the Director of Nursing (DON) stated I did see where the
nurses gave the medication when [Resident 37's name] pain level exceeded the ordered parameters. The
nursing staff are expected to follow the parameters when they are in place and if any questions should get
clarification from the medical doctor.
Review of the facility policy and procedure titled Medication Administration' with a last review date of
11/29/2023 read, Policy: It will be the policy of this facility to administer medications in a timely manner and
as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances
such as lack of availability or medication or refusals of medications by the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105375
If continuation sheet
Page 4 of 10
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
07/24/2024
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** Based on
observation, record review, and interview, the facility failed to ensure residents received oxygen according
to physician order for 1 of 3 residents sampled for respiratory care, Resident #366.
Residents Affected - Few
Findings include:
Review of Resident #366's admission record showed the resident was admitted on [DATE] with the
diagnoses including diabetes mellitus due to underlying condition, chronic obstructive pulmonary disease,
overreactive bladder, nondisplaced fracture of lateral malleolus of right fibula, chronic systolic (congestive)
heart failure, depression, dementia, obstructive sleep apnea, atherosclerotic heart disease, repeated falls,
muscle weakness, essential (primary) hypertension, morbid (severe) obesity due to excess calories, and
anxiety disorder.
During an observation on 7/21/2024 at 9:50 AM, Resident #366 was in bed, receiving oxygen through nasal
cannula at 3.5 liters per minute (LPM).
During an interview on 7/21/2024 at 9:51 AM, Resident #366 stated, I need oxygen at 2 liters 24/7.
During an observation on 7/22/2024 at 8:15 AM, Resident #366 was in bed, receiving oxygen through nasal
cannula at 4 LPM.
During an observation on 7/22/2024 at 2:20 PM with Staff I, Registered Nurse (RN), Unit Manager,
Resident #366 was in bed receiving oxygen via nasal cannula at 4 LPM.
During an interview on 7/22/2024 at 2:20 PM, Staff I, RN, Unit Manager, confirmed that the resident was
receiving oxygen at 4 LPM and stated that it needed to be 2 LPM.
During an interview on 7/22/2024 at 2:27 PM, the Director of Nursing (DON), stated, The nurses have to
check that, and we have to follow the physician orders.
Review of Resident #366's physician order dated 7/16/2024 read, Oxygen concentrator 2 liters via nc [nasal
cannula] every shift for prophylaxis.
Review of Resident #366's care plan dated 7/16/2024 read, Focus: Resident needs oxygen constantly or
intermittently to aide in breathing. Intervention: O2 [oxygen] at 2 liters per minute . Resident needs O2
constantly or as needed.
Review of the facility policy and procedure titled Respiratory Care issued on 4/1/2022 and last reviewed on
11/29/2023 read, It is the policy of this facility to provide respiratory care and safe oxygen administration to
meet the needs of the residents. Procedure: 1. Verify that there is a physician's order for respiratory
procedures or oxygen use. Review the physician's order for oxygen administration.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105375
If continuation sheet
Page 5 of 10
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
07/24/2024
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 0732
Post nurse staffing information every day.
Level of Harm - Potential for
minimal harm
Based on observation, interview and record review, the facility failed to ensure nurse staffing information
was posted on a daily basis.
Residents Affected - Many
Findings include:
During an observation on 7/21/2024 at 9:04 AM, the nurse staffing information posted at the entrance lobby
was dated 7/19/2024.
During an interview on 7/21/2024 at 9:04 AM, Staff J, Licensed Practical Nurse (LPN) Supervisor,
confirmed that the staffing information posted at the entrance lobby was dated 7/19/2024 and it had not
been updated.
During an interview on 7/22/2024 at 3:02 PM, the Administrator stated, The Staffing Coordinator is
responsible for preparing the weekend staffing information and the receptionist is responsible for displaying
it. The information was prepared but not displayed.
Review of the facility policy and procedure titled Staff Postings issued on 4/1/2022 and last reviewed on
11/29/2023, read, Policy: It will be the policy of this facility to display staff posting information for visitors,
families, residents and staff to be able to see. Procedure: 1. Nurse Staffing Information: (1) Data
requirements. The facility will post the following information on a daily basis.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105375
If continuation sheet
Page 6 of 10
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
07/24/2024
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals
used in the facility were stored in accordance with currently accepted professional principles for unattended
medications in 1 unit of 3 units.
Findings Include:
During an observation on 7/21/2024 at 9:25 AM in Resident #109's room, there was one unopened packet
of zinc oxide formula barrier cream on top of the room drawer. [photographic evidence obtained]
Review of Resident #109's physician's orders on 7/21/2024 did not document orders for medication
self-administration.
During an observation on 7/21/2024 at 9:37 AM of Resident #38's room, there was one unopened packet of
zinc oxide formula barrier cream on top of resident's bedside table. [photographic evidence obtained]
Review of Resident #38's physician's orders on 7/21/2024 did not document orders for medication
self-administration.
During an observation on 7/21/2024 at 9:38 AM of Resident #78's room, there were two packets of
unopened oxide formula barrier cream on top of resident's television table. [photographic evidence
obtained]
Review of Resident #78's physician's orders on 7/21/2024 did not document orders for medication
self-administration.
During an observation on 7/21/2024 at 9:45 AM of Resident #51's room, there was two open packets
halfway filled of oxide formula barrier cream on top of resident's drawer. [photographic evidence obtained]
Review of Resident #51's physician's orders on 7/21/2024 did not document orders for medication
self-administration.
During an interview on 7/23/2024 at 1:25 PM, the Director of Nursing stated medications shouldn't be
unsecured at resident's bedside. [Resident #38's name, Resident #51's name, Resident #78's name and
Resident #109's name] are not able to self-administer medication.
Review of the facility policy titled, Medication/Biological Storage with a last review date of 11/29/2023, read,
Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and
orderly manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105375
If continuation sheet
Page 7 of 10
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
07/24/2024
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, interviews, and policy review, the facility failed to ensure food was stored, covered,
labeled, or discarded in the kitchen walk-in coolers and dry storage areas and maintained standards of
practice for cleaning and sanitary conditions in the dietary department.
Findings included:
An initial walk-through of the kitchen was conducted on 7/21/24 at 9:00 AM with the Dietary Manager (DM).
An observation was made at 9:08 AM of two large full containers of cottage cheese with an expiration date
of 7/14/24. An observation was made in the walk-in cooler of a large metal bowl of a fruit type mixture with
no identifying label or date. An observation was made in the kitchen of a dirty cloth and a dirty metal
scrubby left on the sink and not in a Santi-container or solution. An observation was made in the dish room
of 3 large 5-gallon containers of chemicals for the dish machine stored on the floor. (photographic evidence
obtained)
An interview was conducted with the Dietary Manager (DM) at 9:15 AM. The DM confirmed he observed
the two large cottage cheese containers with an expiration date of 7/14/24. The DM stated the containers
should have been used before the expiration date or discarded. The DM confirmed he observed the large
bowl of a fruit type mix and that the bowl did not have an identifying label or date and there should have
been a label and date on the container. The DM confirmed the 5-gallon containers were not on a shelf or
roller dolly and stated the 5-gallon containers of chemicals should not have been stored on the floor. The
DM confirmed the dirty rag and scrubby left on the 3-compartment sink counter should have been put in the
clean sanitizing container.
A follow up walk through was conducted on 07/22/24 at 06:38 AM with the DM. An observation was made
of a large buildup of dirt, grime, and debris on the walls, ceiling, and metal-type conduit pipes running up
beside the food steam table and around throughout the kitchen. An observation was made in the kitchen of
5 partial packages of hamburger and hot dog buns, sliced wheat and white bread with no open date on
each of the 5 packages. (photographic evidence obtained)
A second interview was conducted with the DM on 7/22/24 at 7:08 AM related to the buildup of dirt and
debris on the walls, ceiling and conduit pipes. The DM confirmed the buildup of dirt, grime and debris was
visible around and close to the food steam table area and throughout the kitchen and should have been
cleaned to prevent a buildup. The DM confirmed that the cleaning policy included non-food contact
surfaces.
Review of the policy titled Refrigerated Storage dated 10/01/23 and with a revision date 11/29/23 read,
Policy: Refrigerated items should be properly stored, labeled and maintained by dietary staff. 4. Dietary staff
will label, date, and monitor refrigerated food, including but not limited to leftovers to ensure use-by-dates,
or frozen are discarded.
Review of the policy titled Kitchen Sanitation dated 10/01/23 and with a revision date 11/29/23 read, Policy:
It will be the policy of the facility that the food service area and equipment shall be maintained in a clean
and sanitary manner. 13. Kitchen and dining room surfaces not in contact with food shall be cleaned on a
regular schedule and frequently enough to prevent accumulation of grime.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105375
If continuation sheet
Page 8 of 10
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
07/24/2024
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
Based on observation, interview, and record review, the facility failed to ensure staff performed hand
hygiene while providing dining services and failed to ensure staff used appropriate personal protective
equipment while providing high contact direct care to residents on enhanced barrier precautions to prevent
the possible spread of infection and communicable diseases.
Residents Affected - Few
Findings include:
1. During an observation on 7/22/2024 at 12:00 PM, Staff A, Certified Nursing Assistant (CNA), entered
Resident #105's room and delivered a meal tray. Staff A exited the room and returned with a drink. Staff A
exited the room and did not perform hand hygiene. Staff A walked down the hall and entered another
resident's room and quickly exited the room. Staff A entered Resident #12's room and without performing
hand hygiene started to assist the resident with lunch meal. Staff A stood at the room doorway and went
back into the room. Staff A lifted Resident #20's plate cover and asked if the resident was hungry and
wanted to eat. Staff A, without performing hand hygiene, returned to Resident #12's side of the room and
began to assist the resident with meal. Staff A stood next to the bed, walked to the trash can, and
readjusted the trash can closer to the side of the wall. Staff A, without performing hand washing, returned to
Resident #12's side and retrieved Resident #12's fork and continued to assist with feeding.
During an interview on 7/22/2024 at 12:23 PM, Staff A, stated, I did not perform hand hygiene in between
the residents. I should have performed hand hygiene when entering the room and after touching the trash
can.
During an observation on 7/22/2024 at 12:41 PM, Staff B, CNA, was assisting Resident #105 with the lunch
meal. Staff B exited the room and placed meal tray back on the meal cart. Staff B walked down the hall and
did not perform hand hygiene. Resident #27 was sitting in a wheelchair at the room doorway asking for a
drink. Staff B retrieved her cup and placed it on top of the meal cart. Staff B removed a clear plastic cup,
poured a drink for Resident #27 and handed the cup to the resident.
During an interview on 7/22/2024 at 12:47 PM, Staff B, CNA, stated, I should have done hand hygiene in
between the residents. [Resident #27's name] wanted iced tea. I did not do hand hygiene, and I should
have.
2. During an observation on 7/23/2024 at 11:30 AM, Staff C, Registered Nurse (RN), entered
Resident #266's room. Resident #266's room door had an enhanced barrier sign posted on the entrance
door with a bin containing personal protective equipment outside of the room. Staff C donned gloves but did
not don a gown. Staff C inspected Resident #266's midline and cleaned the needleless connector with an
alcohol swab and flushed the midline with normal saline. Staff C removed her gloves and performed hand
hygiene. Staff C exited the resident room and returned with a port protector. Staff C entered Resident
#266's room and donned gloves but did not don a gown. Staff C placed the port protector on Resident
#226's midline needleless connector.
During an interview on 7/23/2024 at 11:44 AM, Staff C, RN, stated, [Resident #266's name] is on enhanced
barrier precautions due to his midline. I should have donned a gown when administering the flush via the IV
[intravenous] line.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105375
If continuation sheet
Page 9 of 10
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
07/24/2024
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 7/23/2024 at 1:50 PM, the Director of Nursing stated, Staff are expected to wear
gloves and gown when providing direct care if a resident has enhanced barrier precautions and the staff
should be performing hand hygiene in between residents when passing out meal trays or assisting with
dinning.
During an interview on 7/23/2024 at 3:09 PM, the Infection Preventionist stated, The staff should be
donning gloves and gown when they are going to provide direct care to a resident who has enhanced
barrier precautions. The staff should be performing hand hygiene between residents. If they are assisting
with feeding a resident, the staff should perform hand hygiene, don gloves and not touch the resident's food
or anything in the room while feeding the resident.
Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of
11/29/2023, showed the policy read, Policy: It will be policy of this facility to implement enhanced barrier
precautions for preventing transmission of novel or targeted multidrug-resistant organism. Definitions:
Enhanced barrier precautions refer to the use of gown and gloves for certain residents during specific
high-contact resident acre activities that have been found to increase risk for transmission of
multidrug-resistant organisms.
Review of the facility policy and procedure titled Hand Hygiene with the last review date of 11/29/2023,
showed the policy read, Policy: This facility considers hand hygiene the primary means to prevent the
spread of infections. Procedure . 5. Use an alcohol-based hand rub containing at least 62% alcohol; or,
alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . b. Before and
after direct contact with residents . p. Before and after assisting a resident with meals.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105375
If continuation sheet
Page 10 of 10
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
15 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0224GeneralS&S Dpotential for harm
Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.
- 0325GeneralS&S Dpotential for harm
Have properly installed hallway dispensers for alcohol-based hand rub.
- 0345GeneralS&S Dpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0521GeneralS&S Dpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the July 24, 2024 survey of SOUTH CAMPUS CARE CENTER AND REHAB?
This was a inspection survey of SOUTH CAMPUS CARE CENTER AND REHAB on July 24, 2024. The surveyor cited 15 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SOUTH CAMPUS CARE CENTER AND REHAB on July 24, 2024?
Yes, 15 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.