Inspection·July 28, 2022

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide services and treatments to prevent further decrease in range of motion for 2 of 3 residents reviewed for positioning and mobility of a total sample of 23 residents, (#1 and #14). Findings: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses including weakness, spinal fusion, cerebral infarction, hemiplegia and hemiparesis. Review of the Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 7/15/22 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated she had moderate cognitive impairment. She required extensive to total assistance with Activities of Daily Living (ADLs). The document revealed the resident did not exhibit any behavioral symptoms including rejection of care. The assessment indicated resident #1 had limited range of motion (ROM) to one side of her body for both upper and lower extremities. A care plan for limited physical mobility related to cerebrovascular accident with right sided hemiparesis was initiated 4/30/21 and revised 4/28/22. Interventions included monitor/document/report as needed any signs/symptoms of immobility: contractures forming or worsening, and skin breakdown; Physical Therapy/Occupation therapy referrals as ordered; and passive range of motion to right upper extremity. Review of resident #1's Medication Review Report for July 2022 revealed a physician order dated 4/23/21 for Physical Therapy (PT) to evaluate and treat as indicated and an order dated 4/23/21 for Occupational Therapy (OT) to evaluate and treat. The report did not contain an order for any splints. On 7/25/22 at 11:35 AM, 7/25/22 at 3:26 PM, 7/26/22 at 9:11 AM and 7/27/22 at 9:56 AM, resident #1 was observed in bed. Her right hand and arm were contracted and held tightly to her chest. Resident #1 did not have a splint on her right arm or hand and did not have a hand roll in her right hand. On 7/27/22 at 10:21 AM, Certified Nursing Assistant (CNA) A stated the resident was dependent on staff for most ADLs. She reported the resident was contracted on her right side and did not have a splint or assistive device. She could not recall the resident ever having a splint. CNA A explained she washed resident #1's right hand as part of ADL care and used a washcloth to clean inside her hand and between her fingers. She reported the resident expressed discomfort when she performed ADL care on her right hand. CNA A demonstrated how she washed the resident's contracted hand and the resident grimaced but allowed CNA to open her hand. At this time CNA A searched the resident's room but was unable to find a splint. On 7/27/22 at 10:44 AM, the Therapy Director stated resident #1 was not currently on therapy caseload. He recalled she had been evaluated in May 2022 and was seen up by OT from May 11 - June 23, 2022. The Therapy Director reviewed the therapy notes and reported OT worked with the resident on right upper extremity range of motion and splint tolerance for 6-8 hours. He explained resident #1 was transferred to restorative nursing program at discharge from therapy with a restorative form completed and emailed to the restorative nurse. At 11:04 AM, the Therapy Director entered resident #1's room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105556 If continuation sheet Page 2 of 7 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 105556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village on the Green 500 Village Place Longwood, FL 32779 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and assessed the resident's right hand and ROM to the right arm. The resident grimaced as he attempted to straighten her right arm. He stated the resident needed a right elbow splint and a right hand splint. He conveyed the splint would reduce pain and allow staff to clean her hands and provide nail care. He recalled an elbow splint was recommended but stated she should had a hand splint as well. The Therapy Director explained when limbs were not being used, the muscles tighten and shorten causing a contracture. He clarified that a splint would help to prevent a contracture and did not say why resident #1 did not have one. On 7/27/22 at 11:17 AM, OT B recalled resident #1 was on caseload previously with ROM to bilateral upper extremities. He stated the goal was for resident to wear a right elbow splint and a right hand splint for 6-8 hours per day to prevent contractures. He could not recall if the splint was left for the resident. He validated in the absence of a hand splint, the expected nursing intervention was to use a towel roll. On 7/27/22 at 11:43 AM, the Therapy Director reviewed the Restorative Nursing Documentation Tool and acknowledged the form did not contain any splinting information. On 7/27/22 at 11:46 AM, Restorative Aide CNA C stated she was familiar with resident #1 and reported the resident was on restorative therapy 3 times a week for upper and lower ROM. She verbalized she was aware of her right hand contracture but did not have a splint program for her. Restorative Aide CNA C reviewed the restorative program for resident #1 and verified the program contained information for Passive and Active ROM but no information for splinting. On 7/27/22 at 12:00 PM, the Administrator brought a clear plastic bag that contained a blue hard plastic splint which extended from forearm to hand and stated it was in resident #1's upper drawer of the bedside table. The Administrator explained she asked the resident if she wanted to wear the splint and the resident declined. The Administrator was informed the drawers were searched by CNA A and there was no splint in any of the drawers or in the closet. On 7/27/22 at 12:06 PM, CNA A validated she searched all drawers in the dresser, bedside table and closet and did not see a splint. She informed the Administrator that surveyors were present when she searched the room and the splint was not in the drawer at that time. The Administrator said, I wonder who has been in that room since then. The Administrator was informed that the splint she held was not the type of splint that was recommended by therapy. Restorative Aide CNA C was present in the hallway and confirmed she had never seen that splint and did not recall the resident wearing a splint on either her elbow or her hand. CNA A confirmed that she had never seen the splint either. The Administrator could not explain where the splint came from or why the splint was not of the recommended type. On 7/27/22 at 2:11 PM, the Therapy Director stated OT B erroneously checked completion goal for resident's hand splint but not the elbow splint. The Therapy Director confirmed he was still unsure of what happened to the hand splint. The Therapy Director recalled his earlier assessment resident #1 and reiterated she would benefit from both a hand splint and elbow splint. On 7/27/22 at 2:29 PM, the Director of Nursing (DON) stated she served as the restorative nurse. She explained when therapy determined a resident had met goals and needed a maintenance plan, the therapist created a restorative plan and emailed it to the nursing team to implement. The DON acknowledged she did not have a plan for resident #1's discharge from therapy on 6/23/22. She verbalized her expectation if a resident had a contracture with no obvious treatment or device in place, the staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105556 If continuation sheet Page 3 of 7 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 105556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village on the Green 500 Village Place Longwood, FL 32779 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 0688 Level of Harm - Minimal harm or potential for actual harm member should report it to a floor nurse, to PT or to the DON. She conveyed she would expect staff to place a rolled washcloth if a resident did not have a hand splint or refused splint. The DON stated she reviewed the current restorative plan for resident #1 and noted, Obviously there is a break in the process since we missed the form from 6/23/22. She acknowledged the possibility of a decline for resident with a contracture that was not maintained. Residents Affected - Some 2. Resident #14 was admitted to the facility on [DATE] with diagnoses of cerebral palsy, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, contractures unspecified ankle, pain in right ankle and joints of right foot, pain in left ankle and joints and muscle weakness. Review of the MDS quarterly assessment with ARD of 6/15/22 revealed resident #14 had a BIMS score of 14 which indicated she was cognitively intact. She required extensive to total assistance with ADLs. The document revealed the resident did not exhibit any behavioral symptoms including rejection of care. The assessment indicated resident #14 had limited ROM to one side of her body for both upper and lower extremities. A care plan for history of Cerebral Palsy initiated 12/23/19 and revised 7/05/21 included interventions to maintain good body alignment to prevent contractures, use braces and splints as ordered and encourage resident/caregivers to use and correctly apply all splints and braces. On 7/25/22 at 10:51 AM, resident #14 was in bed and two multi-podus boots were noted on the floor next to a recliner. The resident stated she did not wear the boots because they were stretched out and did not fit properly. She said she requested new ones from therapy but only received one. On 7/26/22 at 8:58 AM, the resident was in bed and the boots were no longer beside the recliner in her room. She stated she was not wearing them and did not know where they were. On 7/27/22 at 10:52 AM, the Therapy Director explained resident #14 had been on case load but was not currently not being seen by therapy. He recalled she had been treated for contracture management and was supposed to wear multi-podus boots to prevent plantar flexion contractures and foot drop by keeping her feet in a neutral position. He noted he was not aware the boots were too big. On 7/27/22 at 10:56 AM, resident #14 was observed in a wheel chair next to her bed. The multi-podus boots were on the floor next to her recliner. The resident stated it had been about two years since she wore them. The Therapy Director checked both boots on the floor and noted they were both large size. He located another multi-podus boot in the resident's closet which was regular size. He stated the resident should be wearing them when she was out of bed. He explained restorative nursing program would have initially been assigned to put the boots on the resident. On 7/27/22 at 11:28 AM, OT B stated he was familiar with resident #14 and recalled he recommended resident to wear her the podus boots while up in the wheel chair and when in bed. On 7/27/22 at 11:52 AM, Restorative Aide CNA C verified resident #14 had multi-podus boots and mentioned they were too big. She reviewed the restorative program for resident #14 and noted the resident was on a restorative program for the multi-podus boots to be applied during the day. On 7/27/22 at 12:02 PM, CNA D stated she was familiar with resident #14. She reported the resident had multi-podus boots that were applied by restorative CNA. She recalled the boots did not fit well. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105556 If continuation sheet Page 4 of 7 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 105556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village on the Green 500 Village Place Longwood, FL 32779 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 7/28/22 at 3:45 PM, the Therapy Director provided the Physical Therapy Plan of Care for resident #14 with an end date of 5/02/22. Review of the plan revealed resident only had one proper fitting splint at the time and the therapist was donning a brace one foot at a time while waiting for the new splint. On 4/26/22, the therapist documented therapy was on hold due to waiting on ankle brace/splint. The Therapy Director clarified the plan was to use the boot that fit and alternate ankles until the new boot arrived. He acknowledged the boots mentioned in plan were never delivered. Review of the job description for Rehabilitation Program Manager dated 2/02/22, revealed the program manager would develop programs appropriate to the needs of the residents in the facility, to assist them in achieving their highest feasible level of functioning. Review of the job description for Director of Nursing Services dated 4/05/16, revealed the DON's essential job functions included organize resident care programs which include the interdisciplinary team, resident care planning team, the restorative care program and other programs as necessary to provide optimal care. The facility's policy and procedure for Assistive Devices and Equipment provided policy interpretation and implementation guidelines that included assessing the resident for lower extremity strength, range of motion, balance and cognitive abilities when determining the safest use of devices and equipment; and, the equipment is measured to fit the resident's size and weight. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105556 If continuation sheet Page 5 of 7 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 105556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village on the Green 500 Village Place Longwood, FL 32779 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow-up on pharmacy recommendations for 1 of 5 residents reviewed for unnecessary medications of a total sample of 23 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses including hypothyroidism, cerebral infarction, and arteriosclerotic heart disease. A care plan for resident has hypothyroidism was initiated 4/30/21 with interventions for staff to administer thyroid replacement medication as ordered and obtain and monitor lab/diagnostic work as ordered. Review of the pharmacy Consultation Report for April 2022 revealed a recommendation for the facility to monitor resident #1's Thyroid Stimulating Hormone (TSH) concentration on the next convenient lab day and at least annually due to resident receiving thyroid replacement medication, Levothyroxine. The report was unsigned and did not indicate whether the physician agreed or disagreed with the recommendation. Review of the Medication Review Report for July 2022 revealed resident #1 had a physician order dated 11/17/21 for Levothyroxine Sodium Tablet 100 micrograms to be given every morning for low thyroid hormone. The report did not contain an order for labs to monitor TSH level. On 7/28/22 at 5:21 PM, the Administrator reviewed the pharmacist's recommendations and the resident #1's Electronic Medical Record and acknowledged there was not any physician order to monitor TSH levels. On 7/28/22 at 5:22 PM, the Director of Nursing (DON) stated the consultant pharmacist reviewed medications monthly. The pharmacist then emailed recommendations to the facility which were printed and put in physician binders at the nursing stations. She explained once the recommendations were reviewed and signed by the physician, they were returned to her for reconciliation. The DON stated she was ultimately responsible for following through with pharmacy recommendations and acknowledged resident #1's recommendation to complete lab work for TSH levels was missed. The facility's policy and procedure for Medication Regimen Review (MRR) dated 12/01/07 included guidelines for the facility to encourage Physician/prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either (a) accept and act upon the recommendations contained within the MRR, or (b) reject all or some of the recommendation contained in the MRR and provide an explanation as to why the recommendation was rejected. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105556 If continuation sheet Page 6 of 7 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 105556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Village on the Green 500 Village Place Longwood, FL 32779 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, record review and interview, the facility failed to ensure potentially hazardous foods were at a hot holding temperature of 135 degrees Fahrenheit, or above, to prevent foodborne illness. Residents Affected - Some Finding Review of the facility's lunch menu on 7/27/22, revealed the residents had a choice of Baked Ziti or Turkey Enchilada Casserole. The side items included [NAME] Peas, Red Potatoes and Coconut Cake. On 7/27/22 at 11:55 AM, the lunch tray line was observed. There were two cooks and several dietary aides at or near the tray line. [NAME] A stated the Baked Ziti and Turkey Enchilada Casserole were in the hot box, a full size temperature controlled, hot holding cabinet. The side items were on the steam table. The hot holding temperatures were checked with the facility's digital, bayonet style thermometer. The Turkey Enchilada Casserole had a hot holding temperature of 119 degrees Fahrenheit. Further temperatures taken of the Turkey Enchilada Casserole ranged from 119 to 129 degrees Fahrenheit. [NAME] B stated the holding temperature was supposed to be 160 degrees Fahrenheit. A few minutes later, the Chef was at the tray line and was informed of the hot holding temperatures of the food. The Chef instructed the cooks to reheat the Turkey Enchilada Casserole. When asked who took the hot holding temperatures prior to the start of tray line, [NAME] A and [NAME] B did not respond. [NAME] B indicated he did not take the temperatures as, I was too busy. The Chef stated the lunch tray line holding temperatures had not been done. The United States Food and Drug Administration's Food Code 2017, notes in chapter that potentially hazardous foods, need to be at a hot holding temperature of 135 degrees or above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105556 If continuation sheet Page 7 of 7