Inspection·April 27, 2022

F 0641 Level of Harm - Minimal harm or potential for actual harm showed it read, .It will be the policy of this facility to complete MDS assessments in accordance with the RAI [Resident Assessment Instrument] manual guidelines. Procedures: 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements . a. (5) discharge assessment-conducted when a resident is discharged from the facility. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 2 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 provide necessary services to maintain good grooming and personal hygiene for residents who were unable to carry out activities of daily living for 1 of 3 residents reviewed for activities of daily living. Residents Affected - Few Findings: Review of Resident #140's medical record documented an admission date of 4/15/2022 with a diagnosis of encephalopathy, generalized muscle weakness, hydrocephalus, malnutrition, COVID-19 infection, chronic obstructive pulmonary disease, dementia, hypertension On 4/24/2022 at 8:18 AM Resident #140 was observed with uncombed hair with a large, matted knot at the back of her head. There was a strong odor of urine in the resident's room. The resident's teeth had visible debris that was light brown in color, and a foul-smelling mouth odor when the resident breathed out. There was a strong odor of urine when resident's daughter opened the brief, though the brief was observed to be dry. The resident did not respond to simple questions. During an interview on 4/24/22 at 8:24 AM Resident #140's daughter stated, She has not received a bath since she arrived; they have not showered her. During an interview on 4/24/2022 at 8:35 AM Staff B, Licensed Practical Nurse (LPN) stated, She does need to have her teeth brushed. I do not know when she last had that done. During an interview on 4/27/2022 at 9:03 AM Staff J, Certified Nursing Assistant (CNA) stated, She did not want to eat or drink much, daughter was attempting to help her, but she would not eat. Her lips were very dry. I did not do mouth care or shower her because she would moan. Review of the Certified Nursing Assistant's Task list revealed there was no documentation of Resident #140 having been showered or bathed since admission on [DATE]. During an interview on 04/27/2022 at 8:25 AM the Director of Nursing stated, I expect that staff will perform showers and bathing as scheduled for the residents based on their wishes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 3 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 residents received treatment and care in accordance with professional standards of practice for wound care for 2 of 3 residents reviewed for wound care, Residents #139 and #141. Residents Affected - Some Findings: Review of Resident #139's medical record documented the resident was admitted to the facility on [DATE] with a diagnosis of sepsis, cutaneous abscess of abdominal wall, peritonitis, s/p (status post) colostomy. Review of the physician orders dated 4/21/2022 read: Abdominal wound open area, NS (normal saline) wash, pat dry, moist 4 x 4's cover with ABD (abdominal) pad and secure with tape daily. On 4/24/2022 at 12:46 PM Resident #139 was observed resting in bed. When asked about her wound, without being asked, the resident pulled up her shirt and the abdominal dressing was observed to be dated 4/22/2022. During an interview on 4/24/2022 at 12:47 PM Resident #139 stated, They have not changed my dressing. On 4/25/22 at 7:12 AM Resident #139's abdominal dressing was observed with Staff I, Registered Nurse (RN). The RN verified the abdominal dressing is dated 4/22/2022. During an interview on 4/25/22 at 7:12 AM Staff I, RN stated, Her dressing is done on the evening shift and PRN (as needed). I don't know why it wasn't changed. Review of Resident #141's medical record documented the resident was admitted to the facility on [DATE] with a diagnosis of hypertension, hyperlipidemia, acute on chronic systolic heart failure, and gastrointestinal bleeding. Review of the physician orders dated 4/20/2022 read: Right arm skin tear, NS wash, apply calc [calcium] alginate and cover with dcd [dry clean dressing] daily. Right lower leg skin tear NS wash pat dry apply calc alginate and cover with dcd daily. Left lower leg scratch NS wash, pat dry apply dcd daily. On 4/24/2022 at 10:18 AM Resident #141 is observed with a dressing to the right lower leg dated 4/22/2022, a dressing to the left lower leg dated 4/22/2022, and a right arm dressing dated 4/22/2022. On 4/24/2022 at 1:25 PM the resident is observed with a dressing on the right lower leg dated 4/22/2022, a left lower leg dressing dated 4/22/2022 and a right arm dressing dated 4/22/2022. During an interview on 4/24/2022 at 1:25 PM Staff B, Licensed Practical Nurse verified the dressings on the resident's right and left lower legs and right arm were dated 4/22/2022 and the doctors' orders are for the wound dressings to be changed daily. During an interview on 4/26/2022 at 1:15 PM the Director of Nursing (DON) stated, Our dressings (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 4 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete should be completed when they are scheduled to be done. I can understand that occasionally dressings get missed, but not for more than one shift. I am trying to get the nurses more accountable for the care they are providing and to assess and document. We have had to use agency frequently and we are in the process of hiring more permanent staff. That has made a difference. But it is a slow process. Review of the policy and procedure titled, Wound Care issue date of 1/1/2022 read: Policy: It will be the policy of this facility to provide assessment and identification of residents at risk for developing pressure injuries, other wounds and the treatment of skin impairment. Procedure: 2. Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse. 10. Document in the clinical record when treatments are performed. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. Event ID: Facility ID: 106095 If continuation sheet Page 5 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy and procedure review, the facility failed to provide care consistent with professional standards of practice to prevent the development or worsening of pressure ulcers for 1 of 4 residents reviewed for pressure ulcers, Resident #197. Residents Affected - Few Findings: Review of the medical record for Resident #197 documented the resident was admitted to the facility on [DATE] with a diagnosis of pressure ulcer of other site Stage 4, dementia without behavioral disturbances, hypertension, and hyperlipidemia. Review of the physician orders dated 4/4/2022 read: Right ischium - cleanse with Dakin's solution, moisten gauze dressing with Dakin's solution then pack it into the wound bed and cover with a dry gauze. May change dressing PRN (as needed). Every day shift for wound care. During an interview on 4/25/22 at 10:53 AM Resident #197 was resting quietly, when asked if he had a wound he stated, On my butt and on my heel. My dressing has not been changed since last Thursday. I have not refused wound care to my butt. The wound doctor comes but she never sees my butt only my heel. During an observation of Resident #197 it showed a dressing on the right ischium dated 4/20/2022, with a moderate amount of serosanguinous drainage noted on the old dressing, no odors appreciated. Review of the admission Nursing Comprehensive Evaluation dated 4/4/2022 read: Section 10: skin integrity Site: 31 Right buttock open area; 50) left heel redness. Review of the Weekly skin assessment dated [DATE] read: skin check observation: No new skin impairments. Review of Resident #197's medical record did not provide for additional weekly skin assessments completed since 4/9/2022. Review of the Treatment Administration Record (TAR) documented on 4/9/22 there was no documentation of wound care being provided. Dated 4/15/2022 there was no documentation of wound care being provided. Dated 4/17/2022 there was no documentation of wound care being provided. Dated 4/21/2022 the TAR was documented with a 9. Dated 4/22/2022, 4/23/22, and 4/24/22 there was no documentation of wound care being provided. Review of the nursing progress note e-Mar (electronic medication administration record) general note from e-record dated 4/21/22 at 2:21 PM read: Resident not available for tx [treatment] completion will advise oncoming nurse. Review of the nursing progress note titled skin/wound note dated 4/7/2022 at 9:09 AM read: Member refused to allow writer to change drsg [dressing] to Right Ischium-md [medical doctor] notified care plan updated. The record did not document further refusal of wound care by Resident #197. Review of the Wound Care Progress note dated 4/25/2022 Tissue Analytics read: Wound location Right (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 6 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Buttock, Length 1.49 cm [centimeters] Width 0.67 cm depth 5.00 cm. Wound status: First assessment of existing wound by new care provider. There was no additional assessments of the wound in the medical record. During an interview on 4/26/22 at 7:51 AM the Director of Nursing (DON) stated, I did [Resident #197's name] dressing yesterday. I did see that it was dated from Thursday. We got wound care to evaluate his wound yesterday. I don't know why it was not completed before this. We do not have any documentation of what the wound measurements were, so I have no ability to compare his wound. There are no skin assessments completed. We should have done better. During an interview on 4/27/2022 at 12:00 PM the Advanced Practice Nurse Practitioner (APRN) stated, I was seeing [Resident #197's name] beginning on 4/13/2022 for a right heel DTI [deep tissue injury]. I was not aware of his ischial wound until 4/25/2022 when I did the initial assessment and measurements. That is the first time that I completed measurements. Review of the policy and procedure titled, Pressure Ulcer Treatment with a revision date of September 2013 and approval date of 10/27/2021 read: Purpose: The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. Documentation: The following information should be recorded in the resident's medical record, treatment sheet or designated wound form: 1. The date and time the dressing was changed. 2. Wound appearance, including wound bed, edges, presence of drainage. 5. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. Review of the policy and procedure titled, Wound Care issue date of 1/1/2022 read: Policy: It will be the policy of this facility to provide assessment and identification of residents at risk for developing pressure injuries, other wounds and the treatment of skin impairment. Procedure: 2. Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse.10. Document in the clinical record when treatments are performed. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 7 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 residents receive respiratory care services for oxygen administration consistent with professional standards of practice for 2 of 6 residents reviewed oxygen administration, Residents #139 and #141. Residents Affected - Some Findings: Review of the medical record for Resident #139 documented the resident was admitted to the facility on [DATE] with a diagnosis of sepsis, cutaneous abscess of abdominal wall, peritonitis, s/p (status post) colostomy, acute and chronic respiratory failure with hypoxia, chronic pulmonary edema, diabetes mellitus type II, CAD (coronary artery disease) s/p (status post) CABG (coronary artery bypass graft) chronic kidney disease, PAD (peripheral artery disease) s/p carotid stenting, and hypertension. Review of the physician orders dated 4/22/2022 read: Oxygen at 2 L NC [2 liters via nasal cannula] for 28 days and as needed. On 4/24/22 at 10:08 AM Resident #139 was observed being administered oxygen at 4 liters via nasal cannula. On 4/25/22 at 7:30 AM Resident #139 was observed being administered oxygen at 4 liters via nasal cannula. On 4/25/2022 at 7:30 AM Staff E RN stated, I don't know what her rate is supposed to be, but the concentrator is set at 4 liters. Let me check the orders. I usually check on the settings of oxygen when I am doing my meds, I guess I forgot to check. Review of the medical record for Resident #141's documented the resident was admitted to the facility on [DATE] with a diagnosis of hypertension, hyperlipidemia, acute on chronic systolic heart failure, and gastrointestinal bleeding. Review of the physician orders dated 4/18/2022 read: Oxygen at 2 liters/minute via n/c [nasal cannula] humidified. On 4/24/2022 at 8:20 AM Resident #141 was observed with both legs off the bed on floor mats with the bed in the lowest position. Staff was at the resident's bedside assisting him at that time. The Resident was being administered oxygen at 4 liters via nasal cannula with a humidification bottle that was empty. On 4/24/2022 at 1:45 PM Resident #141 was observed in bed with oxygen being administered at 4 liters via nasal cannula with the humidification bottle empty. On 4/24/2022 at 1:45 PM an observation was made with Staff B, Licensed Practical Nurse (LPN) of Resident #141's oxygen being administered at 4 liters per minute and the humidification bottle was empty. During an interview on 04/24/2022 at 1:46 PM Staff B, LPN stated, He is supposed to have 2 liters (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 8 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0695 of oxygen and his bottle should not be empty. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/26/2022 at 1:00 PM the Director of Nursing (DON) stated, I expect staff to assess oxygen administration during med pass. They should administer based on physician orders. Residents Affected - Some Review of the policy and procedure titled, Oxygen Administration with a revision date of October 2010, and an approval date of 10/27/2021 read: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician order for this procedure. Review the physician orders or facility protocol for oxygen administration. Steps in the procedure: 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 9 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift in a prominent place available to residents and visitors. Residents Affected - Few Findings: During an observation conducted on 04/24/22 at 09:15 AM, the facility's federal staffing posting was observed to be dated 4/22/22. (Photographic evidence obtained.) During an interview conducted on 04/26/22 at 10:07 AM the facility's Human Resource Manager stated, It is the responsibility of the weekend supervisor to post the federal staffing every day. Review of the policy and procedure titled, Posting Direct Care Daily Staffing Numbers dated January of 2022 read, 1. Within 2 hours of the beginning of each shift, the number of Licensed Nurses .and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 10 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with current professional standards in 3 of 3 medication carts and 1 of 2 medication rooms reviewed for medication labeling and storage. Findings: During an observation on [DATE] at 9:34 AM of medication cart #1 with Staff B, Licensed Practical Nurse (LPN) it showed there was one opened bottle of Lantus insulin without an open date or expiration date, one opened Lantus insulin pen without an open or expiration date, and 10 (ten) Ipratropium Bromide Albuterol 0.5-3mg (milligrams)/3ml (milliliter) without a resident identifier or original pharmacy packaging. During an interview on [DATE] at 9:38 AM Staff B, LPN stated, The insulins should be labeled when they are opened. I don't know who the passive neb (nebulizer - Ipratropium Bromide Albuterol) treatments are for they should be in the pharmacy package they were delivered in. During an observation on [DATE] at 9:46 AM of medication cart #2 with Staff C, LPN it showed there was one opened Humalog insulin pen without an open date or expiration date, one bottle of latanoprost eye drops that is unopened and a label on the package read refrigerate until opened, one unopened Lantus insulin pen labeled refrigerate until opened, one opened Lantus insulin bottle without an open date or expiration date, and two Humulin N insulins without open dates or expiration dates. During an interview on [DATE] at 9:55 AM Staff C, LPN stated, All insulin should be labeled when they are opened and thrown away if they are expired. The unopened eye drops, and the insulin should have stayed in the refrigerator until we were ready to use them. During an observation on [DATE] at 10:04 AM of medication cart #3 with Staff D, Registered Nurse (RN) it showed one opened Trulicity pen without a resident identifier and without an open date, one opened bottle of Aspart insulin without an open or expiration date, and one opened Levemir insulin bottle with an expiration date of [DATE]. During an observation on [DATE] at 10:09 AM of medication room [ROOM NUMBER] with Staff D, RN it showed there was one opened bottle of Firvanq 50 mg ml with an expiration date of [DATE], and one unopened Moderna COVID-19 vaccine with an expiration date of [DATE] and a best used by date of [DATE]. During an interview on [DATE] 10:16 AM Staff D, RN stated, All insulin should be labeled when it is opened or when it expires. The COVID-19 vaccine is expired and should not be in the refrigerator available for use. The vancomycin [Firvanq] expired on [DATE] and should have been thrown away. Review of the policy and procedure titled, Labeling of Medication Containers with a revision date of [DATE] and an approval date of [DATE] read: Policy Statement: All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. Policy Interpretation and Implementation: 3. Labels for individual resident medications include all necessary information, such as: h. The expiration date when applicable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 11 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the policy and procedure titled, Storage of Medications with an approval date of [DATE] read: Policy statement: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation: 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 11. Medications requiring refrigeration are stored in a refrigerator. Event ID: Facility ID: 106095 If continuation sheet Page 12 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food is safely stored, covered, labeled, and/or discarded in the areas of the kitchen coolers, dry storage areas, and including emergency supply. Findings: During an observation on 4/24/22 beginning at 8:26 AM with Staff E, Dietary Aide it showed in the walk-in cooler a partially opened box located on the bottom shelf labeled breast raw chicken. The open container of raw chicken did not have a catch tray or an under liner pan on the shelving. A red watery liquid is observed dripping and pooling on the floor under the open box of chicken. A box labeled boneless pork loin raw is located on the shelf to the right of the raw chicken. Under the boneless pork loin box, on the floor, is a red watery liquid pooling on the floor. To the left of the box of raw chicken breast there is a box labeled beef roast with a red watery liquid pooling on the floor. On another shelf there is a tray with eight containers of a yellow food substance that is dated 4/19 with no identifying food label. (Photographic evidence provided) During an interview on 4/24/2022 at 8:30 AM Staff E confirmed there is a red watery liquid, which staff E called blood, on the floor under and in front of the raw chicken, pork, and beef. Staff E confirmed the tray with eight containers of a yellow food substance did not have a label. During an interview on 4/25/22 at 7:00 AM the Certified Dietary Manager (CDM) stated he is also the morning cook and could not spend a lot of time. When asked if he is aware of the findings in the walk-in cooler, the CDM said, Yes, but it was not confirmed which box the blood was from. The CDM confirmed a catch-tray or under liner should be under the boxes to prevent leaking. The dietary staff uses the restroom located in the kitchen and the rest room also has staff lockers next to the emergency supply. The CDM stated the Registered Dietician was in the building and could complete the walk through of the kitchen. During an observation on 4/26/22 beginning at 11:33 AM of the kitchen with the Registered Dietician (RD) it showed shelves of dishes that were not inverted or covered and a steam kettle with a cover bag. The RD removed the bag and there was food debris and what appeared to be pasta inside the steam kettle. A tour of the dry storage room with the RD revealed a can rack with dented cans. The tour with the RD included a look at the emergency supply products. The emergency supply products are located in a room that was identified as the Restroom. The emergency supply had 15 full cases that were labeled as Nectar-like Consistency Thickened Flavored Water with expiration dates of 9-9-21 and 12-08-21, and a case labeled Honey-Like Consistency Thickened Flavored Water with a use by date of 12-09-21. (Photographic evidence provided) An interview was conducted with the RD on 4/26/22 at 11:15 AM. The RD confirmed clean dishes were stacked and not covered or in-verted and the RD confirmed cleaned dishes should be stored inverted or with the top dish covered to maintain cleanliness during storage. There are dented cans on the can rack and dented cans had to be placed in a designated area for dented cans and not remaining on a can rack for use. The emergency supply inventory of food products is being stored in a designated restroom that was still a functional bathroom for the dietary staff. The RD stated food products should not be in an area that is not a designated storage area. The RD counted and confirmed there is 15 cases of outdated product on the shelves of the emergency supply. The product should have been rotated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 13 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 out with new products before they expired. The regular stock room has open products with both honey and nectar thickened water on the shelves that are outdated. The RD stated the staff are not using the first-in, first-out method to ensure the oldest products are used first. The RD confirmed that any equipment covered is verification the equipment is clean and ready to be used. The steam kettle had food particles and what appears to be pasta stuck to the sides of the steam kettle. Residents Affected - Many Review of the policy and procedure titled, Food Receiving and Storage dated October 2017 read, 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated with a use-by date. 13. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready to eat foods. 14.e. Other opened containers must be dated and sealed or covered during storage. Review of the policy titled, Refrigerators and Freezers dated December 2014 read, The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation: 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. 10. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. Review of the policy and procedure titled, Food Preparation and Services dated April 2019 read, 4a. Storing raw meat separately and in drip-proof containers, and in a manner that prevents cross-contamination from other foods in the refrigerator. 4d. Cleaning and sanitizing work surfaces and food-contact equipment between uses, following food code guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 14 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility quality assurance and performance improvement committee failed to implement a performance improvement plan related to pressure wounds when identified as a negative and problematic indicator of quality deficiencies. Findings: Review of the medical record for Resident #197 documented the resident was admitted to the facility on [DATE] with a diagnosis of pressure ulcer of other site Stage 4, dementia without behavioral disturbances, hypertension, and hyperlipidemia. Review of the physician orders dated 4/4/2022 read: Right ischium - cleanse with Dakin's solution, moisten gauze dressing with Dakin's solution then pack it into the wound bed and cover with a dry gauze. May change dressing PRN (as needed) every day shift for wound care. During an interview on 4/25/22 at 10:53 AM Resident #197 was resting quietly, when asked if he had a wound he stated, On my butt and on my heel. My dressing has not been changed since last Thursday. I have not refused wound care to my butt. The wound doctor comes but she never sees my butt only my heel. During an observation of Resident #197 it showed a dressing on the right ischium dated 4/20/2022, with a moderate amount of serosanguinous drainage noted on the old dressing, no odors appreciated. Review of the admission Nursing Comprehensive Evaluation dated 4/4/2022 read: Section 10: skin integrity Site: 31 Right buttock open area; 50) left heel redness. Review of the Weekly skin assessment dated [DATE] read: skin check observation: No new skin impairments. Review of Resident #197's medical record did not provide for additional weekly skin assessments completed since 4/9/2022. Review of the Treatment Administration Record (TAR) documented on 4/9/22 there was no documentation of wound care being provided. Dated 4/15/2022 there was no documentation of wound care being provided. Dated 4/17/2022 there was no documentation of wound care being provided. Dated 4/21/2022 the TAR was documented with a 9. Dated 4/22/2022, 4/23/22, and 4/24/22 there was no documentation of wound care being provided. Review of the nursing progress note e-Mar (electronic medication administration record) general note from e-record dated 4/21/22 at 2:21 PM read: Resident not available for tx [treatment] completion will advise oncoming nurse. Review of the nursing progress note titled skin/wound note dated 4/7/2022 at 9:09 AM read: Member refused to allow writer to change drsg [dressing] to Right Ischium-md [medical doctor] notified care plan updated. The record did not document further refusal of wound care by Resident #197. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 15 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the Wound Care Progress note dated 4/25/2022 Tissue Analytics read: Wound location Right Buttock, Length 1.49 cm [centimeters] Width 0.67 cm depth 5.00 cm. Wound status: First assessment of existing wound by new care provider. There was no additional assessments of the wound in the medical record. During an interview on 4/26/22 at 7:51 AM the Director of Nursing (DON) stated, I did [Resident #197's name] dressing yesterday. I did see that it was dated from Thursday. We got wound care to evaluate his wound yesterday. I don't know why it was not completed before this. We do not have any documentation of what the wound measurements were, so I have no ability to compare his wound. There are no skin assessments completed. We should have done better. During an interview on 4/27/2022 at 12:00 PM the Advanced Practice Nurse Practitioner (APRN) stated, I was seeing [Resident #197's name] beginning on 4/13/2022 for a right heel DTI [deep tissue injury]. I was not aware of his ischial wound until 4/25/2022 when I did the initial assessment and measurements. That is the first time that I completed measurements. Review of the policy and procedure titled, Pressure Ulcer Treatment with a revision date of September 2013 and approval date of 10/27/2021 read: Purpose: The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. Documentation: The following information should be recorded in the resident's medical record, treatment sheet or designated wound form: 1. The date and time the dressing was changed. 2. Wound appearance, including wound bed, edges, presence of drainage. 5. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. Review of the policy and procedure titled, Wound Care issue date of 1/1/2022 read: Policy: It will be the policy of this facility to provide assessment and identification of residents at risk for developing pressure injuries, other wounds and the treatment of skin impairment. Procedure: 2. Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse.10. Document in the clinical record when treatments are performed. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. During a QAPI (Quality Assurance and Performance Improvement) review on 4/26/2022 at 1:15 PM the Administrator stated the facility had two active performance improvement plans currently being worked on for change of condition notification and wound care documentation and assessments that began on 2/11/2022. Review of the performance improvement plan was completed and read: Objective & Goal: QAPI being carried out as a proactive approach to wound care management system. This PIP [Performance Improvement Plan] initiated to ensure accurate documentation of care provided to residents, and to ensure no other unidentified wounds are in house. Action steps: Licensed Nurses were re-educated on the components of wound care with an emphasis on: MD [Medical Doctor] order to include treatment site, type of dressing, type of treatment. During an interview on 4/26/2022 at 1:28 PM the Administrator stated, We have ongoing QAPI related to change of condition and wound care. We did implement measures, but unfortunately there was little to no follow through after we completed the PIP. I don't have evidence that we have completed the audits required in the plan after the initial audits were completed. We have not met as QAPI since (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 16 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many the Adhoc meeting we had on 2/11/2022, so no new measures have been implemented. I guess we should have when we realized that we were still having issues. I was not aware that there are no skin assessments being completed weekly as the plan indicates. During an interview on 4/27/2022 at 7:30 AM the Administrator stated, We did not follow any of our plan of correction. I have no evidence of audits; we did not implement our performance improvement plan. Review of the policy and procedure titled, Quality Assurance and Performance Improvement (QAPI) Program with a revision date of February 2021 and an approval date of 10/27/2021 read: Policy statement: The facility shall develop, implement, and maintain an ongoing, facility wide data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. Policy interpretation and Implementation: The objectives of the QAPI program are to: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 4. Establish systems through which to monitor and evaluate corrective actions. Implementation: 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include a. Tracking and measuring performance, b. establishing goals and thresholds for performance management, c. identifying and prioritizing quality deficiencies, d. systematically analyzing underlying causes of systemic quality deficiencies, e. developing and implementing corrective action or performance improvement activities, and f. monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 17 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Review of the medical record for Resident #7 documented the resident was most recently admitted into the facility on 4/12/22 with diagnoses to include Type 2 Diabetes Mellitus with diabetic neuropathy, diastolic (congestive) heart failure, chronic obstructive pulmonary disease, atrial fibrillation and chronic kidney disease stage 3. Residents Affected - Many During an observation on 04/24/22 at 08:49 AM Resident #7 was observed to have a midline (a catheter inserted in the upper arm with the tip located just below the axilla) inserted in the left upper extremity with a transparent dressing dated 4/11/22. The skin and intravenous junction was unable to be observed due to a dark red substance; a reddened semi-circular area approximately one cm (centimeter) was observed around the dark red substance. During an observation on 4/24/22 at 10:07 AM Resident #7 was observed to have a midline inserted in the left upper extremity with a transparent dressing dated 4/11/22. The skin and intravenous junction was unable to be observed due to a dark red substance, a reddened semi-circular area approximately one cm was observed around the dark red substance. (Photographic evidence obtained). Review of Resident #7's physician orders showed an order dated 04/06/22 which read may insert midline for IV (intravenous) [NAME] (antibiotics). May use 1% lidocaine for insertion. Replace due to current midline not functioning properly. During an interview on 04/24/22 at 10:08 AM with Staff D, Registered Nurse Supervisor, she confirmed Resident #7's midline dressing was dated 4/11/22 and stated, The dressing should have been changed in 7 days. During an interview on 04/27/22 at 11:26 AM, the Director of Nursing verified the date of the midline dressing and stated, It should have been changed within 7 days. 4) Review of the medical record for Resident #27 documented the resident was most recently admitted in the facility on 3/28/22 with diagnoses to include cellulitis of other sites, sepsis, lymphedema and local infection of the skin and subcutaneous tissue. During an observation on 4/24/22 at 8:54 AM, Resident #27 was observed to have a midline inserted in the right upper extremity with the dressing dated 04/16/22. There is a 4 by 4 inch gauze drain sponge with a reddish brown substance on part of the gauze underneath the transparent dressing. There is an approximately 4-5 cm area of redness noted in the split of the gauze. During an observation on 4/24/22 at 10:43 AM, Resident #27 was observed to have a midline inserted to the right upper extremity with the dressing dated 04/16/22. There is a 4 by 4 inch gauze drain sponge with a reddish brown substance on part of the gauze underneath the transparent dressing. There is an approximately 4-5 cm area of redness noted in the split of the gauze. (Photographic evidence obtained). Review of Resident #27's physician orders read dated 04/16/22 change transparent dressing. Measure external catheter length-every evening shift every Sat. (Saturday). Observe site for signs and symptoms of infection, infiltration, and/or extravasation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 18 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0880 Level of Harm - Minimal harm or potential for actual harm During an interview on 04/24/22 at 10:45 AM Staff D, Registered Nurse Supervisor confirmed Resident #27's midline dressing was dated 4/16/22 and stated, The dressing should have been changed last night. During an interview conducted on 04/27/22 at 11:26 AM, the Director of Nursing verified the date on the bandage and stated, It should have been changed within 7 days. Residents Affected - Many Review of the policy and procedure titled, Central Venous Catheter Dressing Changes [CVAD] with a revision date of April 2016, and an approval date of 10/27/2022 read: Purpose: The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled or wet dressings. General guidelines: 2. Change dressings if any suspicion of contamination is suspected. 3. Catheter site care should allow for the observation and evaluation of the catheter-skin junction and surrounding tissue 4. After original insertion of CVAD, the dressing will consist of gauze and TSM [transparent semi-permeable membrane]. This must be changed within 24 hours. a. Replace with sterile transparent dressing. b. If gauze is used, it must be changed every 2 days. 5. Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (when wet soiled, or not intact). 6. If gauze is used, it must be changed every 2 days. Based on observation, interview, and record review, the facility failed to ensure proper infection control standards were maintained for central line dressings for 3 of 3 residents reviewed for central line catheters, Resident #149, #7, and #27, and failed to perform hand hygiene during medication administration for 2 of 6 observations. Findings: 1) Review of the medical record for Resident #149 documented the resident was admitted on [DATE] with a diagnosis of sepsis (a serious medical condition caused by the body's response to infection), ulcerative colitis (a chronic inflammation in the digestive tract), fibromyalgia (a condition that causes all over muscle pain) and chronic pain syndrome. Review of the physician order dated 4/20/2020 read: May reinsert MIDLINE - IV [intravenous] team may use 1% lidocaine [a numbing medication] for insertion. Review of physician order dated 4/21/2022 read: Monitor right arm for s/s [signs and symptoms] of infection, redness, swelling and infiltrate and call MD [Medical Doctor]. On 4/24/2022 at 10:49 AM Resident #149 was observed with a right upper arm midline catheter which had a date of 4/20/22 on the clear occlusive dressing. There was a 2 x 2 gauze under the clear transparent occlusive dressing. During an interview on 4/24/2022 at 10:49 AM Resident #149 stated, I had that dressing put on when I got the midline, before that I had a PICC [Peripherally inserted central catheter] line in my other arm, but the staff did not always put the clamp on, and blood backed up in the tubing and it clotted so I had to get the midline put in. The dressing has not been changed since it was inserted. During an interview on 4/24/22 at 11:24 AM Staff B, Licensed Practical Nurse (LPN) stated, Her Midline is in date it was changed on 4/20/2022. Oh, I'm not sure why the gauze is under the dressing, it shouldn't be. If there is gauze under a midline it should be changed daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 19 of 20 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 106095 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Club Healthcare and Rehabilitation Center at the V 16529 SE 86th Belle Meade Circle The Villages, FL 32162 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 4/25/2022 at 2:30 PM the Director of Nursing (DON) stated, The dressing should have been change after the first twenty four hours and replaced with a transparent dressing. If there is gauze under the dressing it needed to be changed at least every 48 hours. It would be impossible to see the insertion site with the gauze over the site. 2) Medication observation on 4/25/2022 at 6:28 AM Staff D, Registered Nurse (RN) prepared medications for Resident #147, did not perform hand hygiene prior to pouring medications, and when entering the residents room. Staff D, RN did not perform hand hygiene and donned gloves, attempted to administer medication, the resident refused the medications. Staff D, RN exited the room after doffing the gloves and returned to the medication cart to prepare the next resident's medications, Staff D did not perform hand hygiene. Medication observation on 4/25/2022 at 6:57 AM Staff D, RN did not perform hand hygiene, poured medications for Resident #139, entered the resident's room. Staff D administered the medications, exited the resident's room, did not perform hand hygiene and returned to the medication cart. During an interview conducted on 4/25/2022 at 7:25 AM Staff D, RN stated, I should have used hand sanitizer before pouring medications. I don't know why I didn't just wash my hands. Review of the policy and procedure titled, Handwashing/Hand Hygiene with a revision date of August 2019, and an approval date of 10/27/2022 read: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors.7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .c. Before preparing or handling medications: . m. after removing gloves: n. before and after entering isolation precaution settings. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing health associated infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 20 of 20