Inspection·April 29, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. 2) During an observation on 4/29/2025 at 12:00 PM with the DON Resident #1 had a wound dressing on his left leg dated 4/26. Residents Affected - Few Review of Resident #1's physician order dated 3/26/2025 read, Wound care to left lateral malleolus: cleanse w/NS [with normal saline], apply Iodosorb & [and] cover w/border gauze. Review of Resident #1's Wound Assessment Report dated 4/16/2025 documented the left lateral malleolus wound had a resolved status. Review of Resident #1's Treatment Record Administration for the month of April 2025 for wound care to the left lateral malleolus wound documented blank entries on 4/10/2025, 4/13/2025, 4/15/2025, 4/17/2025, 4/18/2025, 4/21/2025, 4/22/2025, and 4/27/2025. Review of Resident #1's Treatment Record Administration for the month of April 2025 for the left lateral malleolus wound care documented on 4/28/2025 wound care was provided. During an interview on 4/29/2025 at 1:45 PM the DON stated, [Resident #1's name] wound had resolved since April 16. The nurse should have discontinued the order. The staff should be checking off when the wound care is completed and not checking off the treatment record if treatment is not being done, only signing off if the treatment is completed. The treatment record is to be filled out accurately to represent the care provided. During an interview on 4/29/2025 at 2:53 PM Staff B, Registered Nurse/Wound Care Nurse stated, [Resident #1's name] wound was healed about a week ago, it was healed. I should have discontinued the order and put in a progress note regarding the wound being resolved. If the staff are doing the wound care nurses should check it off in the treatment record, if they are not doing the wound care, it should not be checked off. If they have any questions, they can let me know or reach out to the provider. During an interview on 4/29/2025 at 5:51 PM Staff C, LPN stated, I didn't do wound care for Resident #1 on 4/28/2025. I checked off doing the treatment by mistake. Review of the facility policy and procedure titled Wound Care with an issued date of 4/1/2022 read, 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. Procedure: 10. Document in the clinical record when treatments are performed. Review of the facility policy and procedure title Charting and Documentation with an issued date of 4/1/2022 read, Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Procedure: Observations, medication administration, services performed, etc., should be documented in the resident's clinical records. Based on record reviews and interviews the facility failed to document blood glucose levels and administration of insulin for one of 3 residents, Resident #1, reviewed for medication administration, and 1 of 3 residents, Resident #1, reviewed for wound care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 2 of 3 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 04/29/2025 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 0842 Findings include: Level of Harm - Minimal harm or potential for actual harm 1) Review of Resident #1's medical record documented a medical diagnosis of diabetes mellitus (DM) type 2. Residents Affected - Few Review of the physician order dated 2/20/2025 for Resident #1 read, Insulin Lispro subcutaneous solution pen 100 unit/ml (milliliter), inject 4 units subcutaneously before meals for DM and Insulin Glargine Solostar Subcutaneous Solution Pen-Injector 100 unit/ml, inject 15 units subcutaneously at bedtime for DM. Review of the physician order dated 2/21/2025 for Resident #1 read, Glucose monitoring before meals and at bedtime for DM. Review of the medication administration record for April 2025 for Resident #1 did not provide documentation of the administration for Insulin Lispro for April 27th at 4:30 PM, Insulin Glargine for April 27th at 9:00 PM, and did not provide documentation of Resident #1's blood glucose levels for April 27th at 4:30 PM and 9:00 PM. During an interview on 4/29/2025 at 3:17 PM Staff A, License Practical Nurse (LPN) stated, I worked a double shift that day and I forgot to document the blood glucose levels and the administration of the insulin. During an interview of 4/29/2025 at 5:25 PM the Director of Nursing (DON) stated, My expectations are that the nurses document glucose serum levels and medication administration accurately in real time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105375 If continuation sheet Page 3 of 3