Cycle 1
Health 2026-01-08 · Fire 2026-01-08
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Leesburg, FL
South Campus Care Center And Rehab
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
715 E Dixie Ave, Leesburg, FL
(352) 728-3020
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Gold Fl Trust Ii
Operator or chain grouping
Approved since
1980-08-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing
LPN hours / resident day
0.89
Licensed practical nurse staffing
Aide hours / resident day
2.29
Nurse aide staffing
Weekend hours
3.60
Weekend nurse staffing
RN turnover
69%
Annual RN turnover
Total nurse turnover
66%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.2
0.8 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
97.8%
1.2 pts worse
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
2.6%
0.2 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 13.1% |
3.7%
9.4 pts worse
|
11.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.9%
1.9 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.7% |
15.7%
13 pts better
|
19.6%
16.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 3.8% |
9.8%
6 pts better
|
16.7%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.4% |
11.7%
1.3 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.7% |
9.8%
3.1 pts better
|
14.9%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.9% |
12.5%
9.6 pts better
|
19.8%
16.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.1%
1.8 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.5% |
94.3%
26.8 pts worse
|
81.7%
14.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
9.3%
1.1 pts worse
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.0% |
94.7%
16.7 pts worse
|
79.7%
1.7 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.5% |
26.2%
5.3 pts worse
|
23.9%
7.6 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-24 · Fire 2024-07-24
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-15 · Fire 2023-03-15
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2026-01-08
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Not marked corrected
D · Potential for more than minimal harm
2026-01-08
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Not marked corrected
D · Potential for more than minimal harm
2026-01-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Not marked corrected
D · Potential for more than minimal harm
2026-01-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
D · Potential for more than minimal harm
2026-01-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Not marked corrected
D · Potential for more than minimal harm
2024-07-24
K224 · Egress Deficiencies
Fire Safety
Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-24
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-24
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-30
F · Potential for more than minimal harm
2023-03-15
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-15
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-15
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-15
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-15
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-15
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-03-01
D · Potential for more than minimal harm
2026-01-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-03-01
D · Potential for more than minimal harm
2026-01-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-03-01
D · Potential for more than minimal harm
2026-01-08
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2026-03-01
D · Potential for more than minimal harm
2026-01-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-03-01
E · Potential for more than minimal harm
2025-04-29
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-04-29
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-09
E · Potential for more than minimal harm
2024-07-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-24
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-24
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-30
C · Minimal harm
2024-07-24
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-08-30
D · Potential for more than minimal harm
2023-11-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-15
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-03-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-15
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-15
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-27
Penalties and ownership
What sits behind the stars
Ownership
South Campus Nursing Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Fl Master Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Fl SNF Trust I
5% Or Greater Indirect Ownership Interest · Organization
Fl SNF Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Shelby, Jack
Corporate Officer · Individual
Wagoner, Joshua
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Lake Port Square Health Center
Leesburg, FL
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
North Campus Rehabilitation And Nursing Center
Leesburg, FL
3-star overall rating with 3-star inspections with 2 recent health deficiencies
#3
Avante At Leesburg, Inc
Leesburg, FL
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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