Health inspection·January 19, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #34 was observed alone and awake while she lay in bed. The call light device hung off the right side of her bed and the button touched the floor. CNA B said the resident could and had used the button, and described her cognition as, totally confused; have to constantly remind her for everything. The CNA picked up the device and acknowledged the resident was not able to reach it while she demonstrated how an adjustable clip attached to the cord was used to secure it to clothing or linen so the resident could reach and use it. RN D acknowledged the device was out of the resident's reach and it should've been secured where she could access it. The RN stated, she can push the button. 2. A review the medical record revealed resident #37, an [AGE] year old female, was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included fracture of the sacrum (tailbone), leukemia, sepsis (blood stream infection), hemiplegia (one-sided paralysis), difficulty in walking, need for assistance with personal care, lack of coordination, weakness, and malnutrition. The MDS admission 5-day assessment with ARD 12/29/23 identified a BIMS score of 14 out of 15 that indicated the resident was cognitively intact. Functional Abilities and Goals of everyday activities noted the resident required substantial/maximum assistance from staff to complete ADLs and mobility functions in and out of bed. The assessment noted the resident was always incontinent of bowel and bladder functions, had shortness of breath or trouble breathing when lying flat, a fall history within the last month, and two to six months that resulted in a fracture prior to her facility admission. The Comprehensive Care Plan focus showed the resident was dependent on staff to complete ADLs, transfer in and out of bed and to the toilet related to physical limitations, incontinence, weakness, impaired mobility, risk for fall and injury, cardiovascular (heart) complications, sacral fracture, and history of cerebral vascular accident (stroke). On 1/16/24 at 11:48 AM, and 1/17/24 at 9:18 AM, resident #37 was observed alone in her room sitting in a wheelchair beside her bed. The call light device was lying across the bed approximately three feet behind the chair. The resident stated she needed to use the restroom. She reached backwards and demonstrated she was not able to reach the call light behind her. The resident was visibly frustrated and explained she needed staff's assistance to get to the bathroom, and she had to wait for someone to come in the room if she couldn't reach the light. At 2:18 PM, the resident was again observed sitting in a wheelchair beside her bed. The call light was behind the resident lying across the bed out of the resident's reach. On 1/17/24 at 9:18 AM, resident #37's call light was observed with the cord wrapped around her right bed rail and the button was located at the head of the bed. The resident was sitting in a wheelchair beside the bed, approximately four feet out of reach from the device. In an interview on 1/18/24 at 10:48 AM, the Director of Nursing (DON) explained she expected CNAs and nurses to lay call light devices across the bed or have them clipped to clothing so residents could reach them. She said she was concerned when staff notified her of the earlier problem. Review of the facility's Quality Assurance Performance Improvement (QAPI) Plan dated 1/12/24 read, . We provide comprehensive clinical care to residents with acute and chronic disease, rehabilitative needs, as well as end-of-life care. All care is resident-centered and focused around choice and individualized treatment plans. We provide comprehensive building safety, repairs, and inspections to ensure all aspects of safety are enforced, assuring the safety and well-being for each resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105556 If continuation sheet Page 2 of 6 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 01/19/2024 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written Notice of Transfer or Discharge forms to the resident or their representative for 3 of 4 residents reviewed for hospitalizations out of a total sample of 27 residents, (#41, #154 and #303). Findings: 1. Resident #303 was admitted to the facility on [DATE] with diagnoses that included cancer to the urinary organs and bones, and neuromuscular dysfunction of the bladder. Review of resident #303's medical record revealed he was emergently hospitalized on [DATE]. A nurse's eInteract SBAR Summary for Providers dated 12/29/23 described the Advanced Practice Registered Nurse advised the nurse to call 911 due to bleeding from his genital organ. The medical record did not contain a written Notice of Transfer or Discharge form for the hospitalization. The resident returned from the hospital on [DATE]. On 1/18/24 at 3:16 PM, the Administrator confirmed they were unable to provide the form for resident #303's hospitalization on 12/2/23. Review of the facility's Transfer or Discharge Notice Policy revised December 2016 read, The resident and/or representative will be notified in writing the reason for the transfer or discharge, the effective date of the transfer or discharge, the location to which the resident is being transferred or discharged , the facility bed hold policy . 2. Resident #41 was admitted to the facility on [DATE] with diagnoses including interstitial pulmonary disease, anemia, hypertension, hyperlipidemia, hypothyroidism, atherosclerotic heart disease and benign prostatic hyperplasia. Review of resident #41's medical record revealed he was hospitalized on [DATE] due to abnormal laboratory results. The medical record did not contain a Notice of Transfer or Discharge form for the hospitalization. The resident returned from the hospital on [DATE]. 3. Resident #154 was admitted to the facility on [DATE] with diagnoses including nondisplaced fracture of right femur, unspecified dementia, chronic obstructive pulmonary disease and Alzheimer's disease Review of resident #154's medical record revealed she was hospitalized on [DATE] due to an unwitnessed fall and resident complaining of right hip pain. The medical record did not contain a Notice of Transfer or Discharge forms for the hospitalization. The resident returned from the hospital on [DATE]. On 1/18/24 at 2:02 PM, the Social Services Director (SSD) stated the nurse was responsible for completing the Notice of Transfer and Discharge Forms for residents who transferred to the hospital. She explained the forms then went to Medical Records. The SSD clarified she notified the Ombudsman of the hospital transfer monthly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105556 If continuation sheet Page 3 of 6 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 01/19/2024 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 1/18/24 at 3:16 PM, the Administrator stated she was aware the Notice of Transfer or Discharge forms were not being completed for all hospital transfers. She recalled the Medical Records Director discussed the issue in their Quality Assurance (QA) meeting on 1/14/23. The Administrator stated they had an audit and planned to address the issue but had not been able to do so. On 1/18/24 at 3:33 PM, the Medical Records Director verified she audited the transfer and discharge process to ensure the required paperwork was completed. She confirmed she identified the Notice of Transfer and Discharge forms were not being completed consistently. She stated she brought the issue to the QA Committee. The Medical Records Director reviewed the audit sheet provided by the Administrator and stated she was familiar with the form. She clarified she had been using the form since she was hired in October 2022 to audit charts. The Medical Records Director explained she reported the incomplete Notice of Transfer and Discharge forms every month in QA Meeting. She stated this was an on-going issue and had not been resolved. Event ID: Facility ID: 105556 If continuation sheet Page 4 of 6 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 01/19/2024 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 0679 Provide activities to meet all resident's needs. 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 individual activities and interests significant to support well-being were provided for 1 of 1 resident reviewed for Activities from a total sample of 27 residents, (#37). Residents Affected - Few Findings: A review of the medical record revealed resident #37, an [AGE] year old female was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included fracture of sacrum (tailbone), leukemia, sepsis (blood stream infection), hemiplegia (one-sided paralysis), difficulty in walking, need for assistance with personal care, lack of coordination, weakness, and malnutrition. The Minimum Data Set (MDS) admission 5-day assessment with Assessment Reference Date 12/29/23 identified a Brief Interview for Mental Status (BIMS) score of 14 out of 15 that indicated the resident was cognitively intact. Functional Abilities and Goals of everyday activities showed the resident required substantial/maximum assistance from staff to complete Activities of Daily Living (ADLs) and mobility functions in and out of bed. The assessment noted it was important to the resident to be able to listen to music she liked, keep up with the news, and do her favorite activities. The Lifestyles Evaluation for Activity Interests and Preferences and Activity Assessment Evaluation dated 12/31/23 indicated the resident preferred to spend her leisure time on individual pursuits and practices, had a strong preference for specific music, an [NAME], and she was formerly a [NAME] and ballroom [NAME]. The Comprehensive Care Plan Focus' noted the resident was dependent on staff to complete ADLs related to physical limitations including weakness, and impaired mobility, with a sacral fracture and history of cerebral vascular accident (stroke). The plan of care did not include a focus for individualized activities for psychosocial and mental well-being support. On 1/16/24 at 11:48 AM, and 1/17/24 at 9:18 AM, resident #37 was observed sitting in a wheelchair beside her bed. The television (TV) was turned off and the remote control was observed on a table directly under the TV on the wall, approximately 8 feet away from the resident's bedside table in her close proximity. Review of resident #37's January 2023 Task List Report for Certified Nursing Assistants (CNAs) use included intellectual, social, physical, and other visit or service Life Enrichment tasks. The schedule showed over eighteen days, one CNA marked the tasked items were offered. On 1/18/24 at 10:04 AM, resident #37 was observed in her room lying in bed. She explained she enjoyed watching ballroom dancing music programs on the TV, and she was familiar with available stations she could access to watch them. The remote control was on the table directly under the TV on the wall in the same location as previously observed. The resident said she would like to watch TV; however, she did not have the remote. In an interview on 1/18/24 at 10:30 AM, the Lifestyle Supervisor said she was responsible for creating and implementing residents' individualized activities program. She explained, an evaluation was completed within a few days after a resident was admitted to the facility that included finding out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105556 If continuation sheet Page 5 of 6 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 01/19/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few what types of individual or group activities the resident enjoyed, even if their preference was to stay in their room. She said residents who enjoyed music were offered access through the facility's TV music channels, and staff noted what was offered and the resident's participation status on monthly paper logs. Review of resident #37's Daily Activities Attendance record dated January 2024 included item lines for TV and music. The record did not include any entries to note staff had offered the resident music or TV. During a joint observation with the Lifestyle Supervisor on 1/18/24 at 11:30 AM, resident #37's TV remote control was observed in the same previously observed location on a table under the TV. The Lifestyle Supervisor stated the resident knew how to use it, and acknowledged the remote was not, but should have been within the resident's reach. The resident replied, yes after she asked her if she would like to listen to music on the TV. She attempted to turn the TV on, and found the remote control was broken or malfunctioned. On 1/18/24 at 11:30 AM, the Lifestyle Supervisor checked the medical record and acknowledged resident #37's Comprehensive Care Plan was missing a Focus for activities and mental and psychosocial well-being support. She stated it was important that residents were offered and had access to their preferred activities because they could become bored and depressed which affected overall health. She added, residents need activities as, joy helps with recovery, even TV. On 1/18/24 at 11:46 AM, the MDS Coordinator checked the medical record and said resident #37's Comprehensive Care Plan was signed off as completed on 1/10/24. She explained, the Lifestyle and Activities Focus was not included, should have been part of the plan of care, and must have been missed in error. The facility's standards and guidelines titled Health Center Lifestyle Department and Programs dated 5/15/18 read, The purpose of this policy is to . ensure person-centered care and purposeful programming that meets the individual needs of each resident are provided . 10. Competent Lifestyle department team members will provide person-centered care through planning, implementing, and documenting all Lifestyle programs that meet the individual needs of each resident . The facility's Quality Assurance and Improvement plan read, Scope: The scope of the QAPI program encompasses all segments of care and services provided by (facility name) that impact clinical care, quality of care, quality of life, resident choices, and care transitions with participation from all departments. Lifestyle We provide enriching and stimulating activities to every resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105556 If continuation sheet Page 6 of 6