Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South Campus Care Center And Rehab during CMS and state inspections, most recent first.
A resident with vascular dementia and severe cognitive impairment, admitted for a short hospice respite stay, was discharged from the facility by his daughter without documented verification of her authority or notification and agreement from his listed emergency contact, his spouse. Staff, including an LPN and an RN, relied on the daughter’s statements that the resident’s wife wanted him home and did not independently contact the spouse, and facility records lacked documentation of any attempt to notify the responsible party or confirm consent before the resident left.
Residents were unable to independently control over-the-bed lights because pull cords were missing or too short behind multiple beds. Several residents stated the issue had been present since admission or arrival, and observations confirmed lights without usable cords in multiple rooms. The ADM and Maintenance Director acknowledged the environmental issue and noted it was an easy fix, but the deficiency remained present during survey observations.
A resident with a venous access port used for chemotherapy had the port observed with a dressing in place, but the resident-centered plan of care contained no care plan for the port. An LPN confirmed the absence of a care plan and stated one should have been in place. Facility policy requires a comprehensive assessment and documentation of triggered assessment information.
Failure to maintain grooming and clean clothing for a resident with dementia and muscle weakness. The resident was repeatedly observed in the same visibly soiled jacket and pants with unkept facial hair and a foul body odor, despite a care plan calling for hands-on help with dressing, grooming, and bathing. Staff said the resident often picked the same outfit and could refuse showers, while the DON noted refusals should be reported and documented.
Improper care and maintenance of an implanted venous port was identified for one resident with a tunneled venous access catheter used for chemotherapy. The resident’s port was observed covered by a dated dressing, and an LPN stated the dressing should have been changed per facility policy requiring weekly Huber needle and dressing changes.
Incomplete oxygen and code status documentation was found for a resident who returned from the hospital after RSV and was observed on 2 L O2 via NC with an oxygen concentrator. The transfer form documented continuous oxygen, but there was no physician order for O2 therapy in the record, and the chart also contained conflicting advance directive information showing both DNR and Full Code status.
Two residents were found to be living in rooms with significant environmental deficiencies, including missing tiles, stained bathtubs, and damaged baseboards with debris. Facility staff acknowledged these conditions did not meet cleanliness or maintenance expectations, and policy requires a safe, comfortable, and homelike environment.
A resident with diabetes did not have blood glucose levels or insulin administration properly documented by an LPN, who later admitted to forgetting to chart these actions. Additionally, wound care documentation for the same resident was incomplete, with missed entries and a treatment marked as completed when it was not, despite the wound having resolved. The DON and wound care nurse confirmed that documentation should accurately reflect care provided and that orders should be discontinued when no longer needed.
Surveyors observed deficiencies in food storage and sanitation practices in the dietary department. Expired cottage cheese, unlabeled fruit mixture, and improperly stored chemicals were found. Additionally, there was a buildup of dirt and grime in the kitchen, and bread products lacked open dates. The Dietary Manager confirmed these issues, which violated the facility's policies on food storage and kitchen sanitation.
The facility failed to ensure accurate MDS assessments for two residents. One resident with hemiplegia was incorrectly documented as having no impairments, despite staff confirming right-sided impairments. Another resident with a gastric tube was inaccurately recorded as having no feeding tube. The MDS Coordinator acknowledged the incorrect coding, highlighting a failure to follow assessment guidelines.
A resident with multiple health conditions, including COPD and diabetes, was observed with long, untrimmed fingernails despite needing assistance with ADLs. The resident expressed a preference for having their nails cut, but observations over several days showed no action was taken. A CNA confirmed the need for nail care, and the DON stated that nail care is provided on shower days and as needed, indicating a lapse in following the facility's ADL care policy.
A resident received Acetaminophen for pain levels exceeding the physician's prescribed parameters, which specified administration for mild pain levels 1-3. The MAR documented instances of administration for higher pain levels, and the DON acknowledged the deviation from orders. The facility's policy requires adherence to prescribed medication guidelines.
A resident with chronic respiratory and cardiac conditions was observed receiving oxygen at higher levels than prescribed. Despite a physician's order for 2 LPM, the resident was given 3.5 and 4 LPM on different occasions. Staff interviews confirmed the discrepancy, indicating a failure to follow the facility's policy on respiratory care.
The facility failed to securely store medications, as observed in one unit where several residents had unsecured packets of zinc oxide formula barrier cream in their rooms. The residents did not have physician orders for self-administration, and the DON confirmed that these residents were not capable of self-administering medication. This was contrary to the facility's policy requiring safe and secure storage of medications.
Staff at the facility failed to perform proper hand hygiene and use appropriate PPE, leading to potential infection control issues. A CNA was observed assisting residents with meals without washing hands between interactions, and an RN did not wear a gown while providing care to a resident under enhanced barrier precautions. These actions were contrary to the facility's policies on infection prevention.
The facility did not post daily nurse staffing information as required. An observation revealed that the staffing information at the entrance lobby was outdated, confirmed by an LPN Supervisor. The Administrator stated that the Staffing Coordinator prepared the information, but it was not displayed by the receptionist. The facility's policy requires daily posting of this information.
Failure to Notify Resident Representative Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to notify and obtain agreement from the resident’s designated representative prior to discharge. One resident was admitted for a 5‑day hospice respite stay with diagnoses including vascular dementia with agitation and a cognitive summary score indicating severe problems with memory and thinking. The resident’s admission record listed his spouse as emergency contact #1, and there was no Power of Attorney documented in the file. Despite this, the resident’s daughter came to the facility, stated that the resident’s spouse wanted him home, and removed him from the facility. Progress notes and other records did not show that staff verified the daughter’s authority, confirmed the spouse’s awareness or approval, or notified the spouse of the resident’s removal. Staff interviews confirmed that nursing staff relied on the daughter’s statements and an assumption that the spouse was on the phone, without independently contacting the spouse or confirming her consent. An LPN reported that a couple arrived around 8 p.m., said the “mom wanted him home,” and that the resident did not object to leaving; the LPN then involved a supervisor but did not verify the responsible party. An RN similarly recalled that the daughter said the mother wanted the resident home and was not aware of anyone calling the wife. The Administrator and DON acknowledged that the spouse was listed as emergency contact #1, that the daughter was not believed to be the Power of Attorney, and that there was no documentation that the spouse had been notified or had agreed to the discharge. Record review showed no documentation of attempts to contact the emergency contact or to verify the identity and authority of the person removing the resident from the facility.
Residents Lacked Access to Over-the-Bed Light Pull Cords
Penalty
Summary
The facility failed to maintain a homelike physical environment when residents did not have independent access to the pull cords for the over-the-bed lighting fixtures behind their beds. During interviews, Resident #128 stated that since admission he could not turn on his over-the-bed light because there was no string to pull and that he had told nursing about it. At the time of observation, the light behind Resident #128's bed was off and there was no cord attached to the pull chain. Resident #125 stated that the environment needed repair and that she could not access the light cord behind her bed; observation showed the cord was not long enough for her to control the light. Resident #45 also stated that he could not turn on the light behind his bed because there was no string and that the condition had been present since arrival. Observation showed Resident #45 sitting up in bed with the head of bed elevated, and there was no cord attached to the pull chain for the wall light behind his bed, leaving him without independent control of that light. The Administrator stated that department leaders made daily rounds and entered work orders for environmental issues, and the Maintenance Director stated that attaching a cord to the light chain was an easy fix. On a later observation, eight rooms were found to have light cords that were either missing or not long enough for residents to use while in bed.
Missing Care Plan for Venous Access Port
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #50’s venous access port. During interview, the resident stated the port was used when she was receiving chemotherapy. On observation, the resident had a venous access port near the left shoulder with a dressing covering it, and the dressing was dated 12/5/2025. Review of the resident-centered plan of care showed no care plan for the venous access port. During interview, the Unit Manager/LPN stated there was no care plan for the resident’s access port and that there should have been a plan of care for it. Facility policy titled Comprehensive Assessments and Care Plans states that the facility will make a comprehensive assessment of a resident’s needs and include documentation of summary information regarding additional assessments triggered by the MDS.
Failure to Maintain Grooming and Clean Clothing
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary assistance to maintain good grooming and clean clothing. Resident #33, who had diagnoses including metabolic encephalopathy, vascular dementia, and muscle weakness, was observed on multiple occasions wearing the same visibly soiled jacket and pants, with partially fallen clothing, unkept facial hair, and a foul or sour body odor. The resident was also observed standing in the doorway or hallway and later walking in the unit while still wearing the same soiled clothing. The resident’s care plan documented a self-care deficit with dressing, grooming, and bathing related to generalized weakness and visual limitations, with interventions to provide hands-on assistance with dressing, grooming, and bathing as needed. The care plan also documented a need for assistance with ADLs related to muscle weakness. The record did not document shower refusals or behavior concerns with ADL care, and progress notes found no documentation of refusal of showers. Staff stated the resident could refuse showers and was difficult, while another staff member stated the resident dressed himself and often picked the same outfit each day. The administrator stated the shower documentation was in error and that the resident’s clothing had a peculiar odor from re-wearing the same items.
Improper Care and Maintenance of Implanted Venous Port
Penalty
Summary
The facility failed to adhere to professional standards of practice for the care and maintenance of a venous access catheter port for one resident. Resident #50 had a tunneled venous access catheter in place for chemotherapy for cancer. During an interview, the resident stated the port had been placed for chemotherapy and was not being used at the time. During observation, the resident had a venous access port near the left shoulder with a dressing covering it, and the dressing was dated 12/5/2025. During an interview, the Unit Manager/Licensed Practical Nurse stated the facility’s policy was that an access port needed weekly changes of the Huber needle and dressing, and that the dressing should have been changed. Review of the facility policy titled, "Implanted Venous Port," stated that a transparent sterile dressing should cover the needle and be labeled with the date, time, and initials of the person performing the procedure, and that a folded sterile gauze may stay in place for 7 days if used under the needle wings.
Incomplete Oxygen and Code Status Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident reviewed for advance directives and respiratory services. The resident had an initial admission date of 12/2/25 and a re-admission date of 1/3/26. On 1/5/26, the resident was observed wearing oxygen via nasal cannula at 2 liters with an oxygen concentrator, and the resident’s significant other stated the resident had recently been hospitalized for RSV, returned to the facility after being told by the hospital that the resident was stable, and had never been on oxygen before this episode. The resident was again observed on oxygen at 2 liters on 1/6/26 and 1/7/26. Record review showed the Medical Certification for Medicaid LTC Services and Patient Transfer Form dated 1/3/26 documented transfer on 2 liters of continuous oxygen, but physician orders for the period of 1/3/26 through 1/7/26 contained no oxygen therapy order. The clinical record also contained a DNR document signed and dated 9/8/25, and progress notes dated 12/4/25 stated the resident’s spouse was the DPOA and the resident was currently a DNR. However, physician orders dated 1/3/25 documented the resident’s advanced directive as Full Code. The Administrator stated the code status should have been checked on admission by nursing, and the DON stated the nurse was expected to review incoming orders and transcribe them into the clinical record software, with the weekend nursing supervisor verifying that all orders were transcribed correctly.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents as evidenced by multiple environmental deficiencies observed during the survey. In one resident's room and bathroom, surveyors noted missing tiles along the wall near the sink and toilet, as well as rust-colored discoloration near the bathtub faucet and brown staining on the wall tiles. Both the Regional Plan Operator and the Environmental Services Manager acknowledged that the condition of the tiles and bathtub did not meet acceptable standards for cleanliness. In another resident's room, a loose baseboard with drywall debris was observed spanning the length of the bed. The resident reported that the damage had been present for some time and believed it was due to water damage. The Regional Plan Operator confirmed that this room had been identified in a previous report as requiring critical repairs, and the Director of Nursing stated that such issues should be addressed immediately or by the end of the day, depending on severity. The facility's policy requires providing a safe, comfortable, and homelike environment, which was not met in these instances.
Failure to Document Insulin Administration and Wound Care
Penalty
Summary
The facility failed to properly document blood glucose levels and insulin administration for a resident with a diagnosis of type 2 diabetes mellitus. Physician orders required glucose monitoring before meals and at bedtime, as well as administration of Insulin Lispro before meals and Insulin Glargine at bedtime. On a specific date, there was no documentation of the resident's blood glucose levels or the administration of either insulin at the required times. During an interview, an LPN admitted to forgetting to document these actions after working a double shift. The DON confirmed that the expectation is for nurses to document glucose levels and medication administration accurately and in real time. Additionally, the facility failed to accurately document wound care for the same resident. Although the resident had a physician order for wound care to the left lateral malleolus, the wound was documented as resolved on a specific date. The treatment record for April showed multiple blank entries on days when wound care should have been provided, and on one occasion, a nurse checked off that wound care was completed when it was not. Both the DON and the wound care nurse acknowledged that the wound order should have been discontinued once the wound healed, and that documentation should only reflect care that was actually provided. Facility policies require accurate documentation of treatments and services performed.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and sanitation standards in the dietary department, as observed during a survey. During an initial walk-through of the kitchen, surveyors found two large containers of cottage cheese with an expiration date that had passed, and a large metal bowl of fruit mixture without any identifying label or date. Additionally, a dirty cloth and metal scrubby were left on the sink instead of being placed in a sanitizing container. Chemicals for the dish machine were improperly stored on the floor. The Dietary Manager confirmed these observations, acknowledging that the expired cottage cheese should have been discarded, the fruit mixture should have been labeled, and the chemicals should not have been stored on the floor. A follow-up walk-through revealed a significant buildup of dirt, grime, and debris on the walls, ceiling, and conduit pipes throughout the kitchen, particularly near the food steam table. Furthermore, five packages of bread products were found without open dates. The Dietary Manager confirmed the visible buildup of dirt and grime and acknowledged that the facility's cleaning policy required regular cleaning of non-food contact surfaces to prevent such accumulation. The facility's policies on refrigerated storage and kitchen sanitation were reviewed, indicating that refrigerated items should be properly labeled and maintained, and that the kitchen should be kept clean and sanitary.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments of residents' conditions, as evidenced by discrepancies in the Minimum Data Set (MDS) assessments for two residents. Resident #109, who was admitted with a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, was observed to have impairments in his right upper and lower extremities. However, his MDS admission assessment inaccurately documented no impairments in these areas. Interviews with staff, including a CNA, PT, PTA, and COTA, confirmed the resident's right-sided impairments, which were not reflected in the MDS assessment. Similarly, Resident #20, who had a gastric tube for enteral feeding, was inaccurately documented in the MDS quarterly assessment as having no feeding tube. Observations and interviews confirmed the presence of a gastric tube and its use for medication and feeding. The MDS Coordinator acknowledged the incorrect coding for both residents, indicating a failure to adhere to the facility's policy of completing MDS assessments in accordance with the RAI manual guidelines.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who required such care. Resident #367, who was admitted with multiple diagnoses including acute respiratory failure, morbid obesity, COPD, type 2 diabetes, and chronic kidney disease, was observed on multiple occasions with long, untrimmed fingernails and a dark substance under the nail beds. The resident expressed a preference for having their fingernails cut, indicating that the last time this was done was at home, suggesting a lapse in the facility's provision of personal care. The resident's care plan, dated 7/11/2024, indicated a need for assistance with ADLs, including personal care. Despite this, observations on 7/21/2024, 7/22/2024, and 7/23/2024 confirmed the lack of nail care. Staff D, a CNA, acknowledged the condition of the resident's nails and the need for them to be trimmed. The Director of Nursing stated that nail care is provided on shower days and as needed, yet the resident's condition suggested this policy was not adequately followed. The facility's policy on ADL care, last reviewed on 11/29/2023, emphasizes maintaining the highest practicable level of function for residents, which was not achieved in this instance.
Failure to Administer Medication According to Physician Orders
Penalty
Summary
The facility failed to ensure that a resident received medication according to physician orders, specifically regarding the administration of Acetaminophen for pain management. The physician's order specified that the medication should be given for mild pain levels between 1-3, not exceeding 3000mg per 24 hours. However, the Medication Administration Record (MAR) for June and July 2024 documented multiple instances where the resident received Acetaminophen for pain levels exceeding the prescribed parameters, including pain levels of 4, 5, 7, 8, and 10. During an interview, the Director of Nursing acknowledged that the nursing staff administered the medication outside the ordered parameters and emphasized that staff are expected to follow the physician's orders. The facility's policy on medication administration requires medications to be given as prescribed unless clinically indicated otherwise. This deficiency highlights a failure in adhering to the prescribed medication administration guidelines, as evidenced by the documented instances in the MAR.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, as evidenced by the incorrect administration of oxygen. Resident #366, who has a complex medical history including chronic obstructive pulmonary disease, heart failure, and obstructive sleep apnea, was observed receiving oxygen at higher levels than prescribed. The resident's physician order specified oxygen administration at 2 liters per minute via nasal cannula, but observations on two consecutive days showed the resident receiving oxygen at 3.5 and 4 liters per minute. Interviews with the resident and staff confirmed the discrepancy between the physician's order and the actual oxygen administration. The resident stated a need for oxygen at 2 liters per minute continuously, which was corroborated by the Unit Manager, who acknowledged the incorrect oxygen level. The Director of Nursing emphasized the importance of adhering to physician orders, highlighting a lapse in the facility's compliance with its own policy on respiratory care, which mandates verification and adherence to physician orders for oxygen use.
Unsecured Medications Found in Residents' Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles, as observed in one of the three units. During observations, several residents' rooms were found to have unsecured packets of zinc oxide formula barrier cream. Specifically, in Resident #109's room, an unopened packet was found on top of the room drawer. Similarly, Resident #38 had an unopened packet on the bedside table, Resident #78 had two unopened packets on the television table, and Resident #51 had two open packets on the drawer. None of these residents had documented physician orders for medication self-administration. The Director of Nursing confirmed that medications should not be left unsecured at the residents' bedside, and the residents involved were not capable of self-administering medication. The facility's policy on Medication/Biological Storage, last reviewed in November 2023, mandates that medications, drugs, and biologicals be stored in a safe, secure, and orderly manner. The observations and interviews indicate a failure to adhere to this policy, resulting in unsecured medications in residents' rooms.
Inadequate Hand Hygiene and PPE Use by Staff
Penalty
Summary
The facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) by staff, leading to potential infection control issues. During observations, a Certified Nursing Assistant (CNA), identified as Staff A, was seen delivering meal trays and assisting residents with meals without performing hand hygiene between interactions. Staff A moved between different residents' rooms and handled items such as a trash can without washing hands, which was acknowledged by Staff A during an interview. Similarly, another CNA, Staff B, also failed to perform hand hygiene between assisting different residents with meals, which was admitted during an interview. Additionally, a Registered Nurse (RN), identified as Staff C, did not adhere to enhanced barrier precautions while providing care to a resident with a midline, who required such precautions. Staff C donned gloves but failed to wear a gown while inspecting and flushing the resident's midline, despite the presence of a sign indicating enhanced barrier precautions. This was confirmed by both the Director of Nursing and the Infection Preventionist, who stated that staff should wear gloves and gowns when providing direct care to residents under enhanced barrier precautions. The facility's policies on enhanced barrier precautions and hand hygiene were reviewed, indicating the necessity of these practices to prevent the spread of infections.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted on a daily basis, as required by their policy. During an observation, it was noted that the staffing information displayed at the entrance lobby was outdated, showing the date 7/19/2024, even though the observation took place on 7/21/2024. This was confirmed by an LPN Supervisor, who acknowledged that the information had not been updated. In an interview, the Administrator explained that the Staffing Coordinator is responsible for preparing the weekend staffing information, while the receptionist is tasked with displaying it. Although the staffing information was prepared, it was not displayed as required. The facility's policy, last reviewed on 11/29/2023, mandates that nurse staffing information be posted daily for visibility to visitors, families, residents, and staff.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Leesburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Port Square Health Center | 0.4 mi | ★★★★★ | 11 | 0 |
| North Campus Rehabilitation And Nursing Center | 0.8 mi | ★★★★★ | 12 | 0 |
| Avante At Leesburg, Inc | 1.6 mi | ★★★★★ | 0 | 0 |
| Chatham Glen Healthcare And Rehabilitation Center | 8.2 mi | ★★★★★ | 5 | 0 |
| Villages Healthcare And Rehabilitation Center, The | 8.4 mi | ★★★★★ | 10 | 0 |
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