Inspection·October 19, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure care plan fall precautions were fully implemented for 1 of 4 residents, Resident #18, reviewed for accidents. Findings include: Review of Resident #18's census record documented Resident #18 was admitted to the facility on [DATE]. Review of Resident #18's care plan, initiated 7/19/2023, read Resident #18 was at risk for falls and/or fall related injury related to impaired balance and a history of falls. Resident #18's care plan documented fall prevention interventions that included Keep bed in lowest position acceptable to resident. Review of Resident #18's progress notes revealed Resident #18 had fallen on 6/17/2023 with resulting complaints of back pain, had fallen on 6/20/2023 with no resulting discomfort, had fallen on 6/23/23 with resulting pain in his right hip/groin area, had fallen on 8/27/2023 with no resulting discomfort, had fallen on 8/28/2023 with no injury documented and had fallen on 9/30/2023 with no resulting discomfort. Review of the radiology results examination dated 7/6/2023, read, Impacted and displaced subcapital femoral neck fracture .Soft tissue swelling overlies the fracture. During an observation on 10/18/2023 beginning at 8:44 AM Resident #18 was observed sitting up in bed eating his breakfast meal. Resident #18's bed was raised to a high position. During an interview on 10/18/2023 at 8:48 AM, with Staff A, Licensed Practical Nurse (LPN), an observation was made of Resident #18. Resident #18's bed was in a high position. Staff A, LPN confirm the bed was in a high position and should not be. During an interview on 10/18/2023 beginning at 9:32 AM, the Director of Rehabilitation stated, [Resident #18's name] has been falling out of bed a lot lately. During an interview on 10/18/2023 at 10:21 AM, the Director of Nursing stated staff should have lowered Resident #18's bed in accordance with his care plan fall precaution interventions after they delivered his meal tray. [Resident #18's name] has fallen frequently. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 2 of 13 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 10/19/2023 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, record review, and interview the facility failed to ensure residents received treatment care and services in accordance with professional standards for 1 of 1 resident, Resident #198, with a central venous line catheter, and 1 of 6 residents, Resident #29 reviewed for pressure ulcers. Residents Affected - Few Findings include: 1. During an observation on 10/16/2023 at approximately 10:00 AM, Resident #198 was lying in bed. A signal lumen PICC (peripherally inserted central catheter) line with a transparent dressing dated 10/8/2023 was observed to the resident's right upper arm. There was dried blood observed at the insertion site. During an interview on 10/16/2023 at approximately 10:00 AM, Resident #198 stated, I came from the hospital with this IV [intravenous catheter], it has not been changed here at the facility. Review of the medical record for Resident #198 revealed Resident #198 was most recently admitted into the facility on [DATE] with diagnoses including metabolic encephalopathy, enterocolitis due to clostridium difficile, cellulitis of right and left lower leg, open wound of scalp, lymphedema, unspecified protein-calorie malnutrition, chronic kidney disease, and type 2 diabetes. Review of Resident #198's physician's order, dated 10/9/2023, read, Change dressing post PICC insertion and routinely one time for 1 day observe site for signs/symptoms of infiltration/extravasation/infection. Review of Resident #198's physician's order, dated 10/16/2023, read Change RUE [right upper extremity] Midline drsg [dressing] every evening shift every 7 days for maintenance, notify MD [Medical Doctor] of any changes, and as needed for soiled drsg. Review of Resident #198's care plan, initiated on 10/16/2023, read, Resident is at risk for complications r/t [related to] receiving IV therapy. Currently has midline IV line located RUE. Is receiving (IV ABX [antibiotics] for the treatment of: cellulitis. During an interview on 10/19/2023 at 8:15 AM, the Director of Nursing stated, Dressing changes are [done] upon admission and then changed every seven days. It [the dressing] should have been changed for both reasons for dating and soiled. Review of policy and procedure titled, P&P [Policy and Procedure] PICC IV Line, last review date of 9/29/2023, read, Dressing Changes: 1. Sterile dressing change using transparent dressing is performed: 24 hours post insertion or upon admission if not dated upon admission. If the integrity of the dressing has been compromised (wet, loose, or soiled). 2. During an observation on 10/16/23 at 10:36 AM, Resident #29 was sitting in his wheelchair in his room. There was a wound dressing on Resident #29's right forearm with no date and a wound dressing on his left elbow with no date. During an observation on 10/17/2023 at 8:15 AM, Resident #29 was sitting in his wheelchair in his room. There was a dressing on his right forearm with no date and a dressing on his left elbow with no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 3 of 13 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 10/19/2023 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 date. Level of Harm - Minimal harm or potential for actual harm During an observation on 10/17/2023 at 11:05 AM, with Staff G, Licensed Practical Nurse (LPN) Resident #29 had redness and skin break down on his bilateral hips and an open redden area on his lower back. Residents Affected - Few During an interview on 10/17/2023 at 11:05 AM Staff G stated, Resident #29 has no orders for wound care but I know he does have a small opening on his back. The wound dressings should be dated. I do not see a date on his arm or elbow [dressings]. Resident #29 has an open area on his back, and I see [Resident 29's name] has an area there on his right heel. Review of Resident #29's physician's orders, dated 10/08/2023, read, apply house barrier cream to buttock/coccyx every shift for preventive for 14 days. Apply skin prep to heels as needed for preventive. Review of Resident #29's admission Assessment, dated 10/8/2023, documented, Section I Skin Condition: right toe: 3rd digit amputated: open area, right heel open area, right elbow skin tear, right trochanter open area, left trochanter open area, right buttock open area. Review of Resident #29's Medical Certification For Medicaid Long-Term Care Services and Patient Transfer form, dated 10/08/2023, read, T. Skin Care-Stage & Assessment: 1. Bilateral Hips. 2. Stage II Buttocks. 3. Bilateral Heels. During an interview on 10/18/2023 at 10:59 AM, the Director of Nursing stated, I did a full skin assessment on Resident #29 on 10/17/2023. It looks like what he has on his back is an area that has reopened from a previous wound. Staff upon admission should do a full body assessment and should notify the provider and obtain orders for wound care. The wound care doctor was here on Monday but did not see him. [Resident #29's name] will be seen by wound care this coming Monday. Review of the policy and procedure titled, P&P [Policy and Procedure] Wound Care, last review date of 9/28/2023, read, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. Procedure: 3. Nurses are to be notified to inspect skin if newly developed skin changes are identified. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, ect. [etcetera]. 12. Contact physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 4 of 13 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 10/19/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the residents' environment was free of accident hazards for 1 of 4 residents, Resident #18, reviewed for accidents. Findings include: Review of Resident #18's medical record documented Resident #18 was admitted to the facility on [DATE]. Review of Resident #18's care plan, initiated 7/19/2023, read Resident #18 was at risk for falls and/or fall related injury related to impaired balance and a history of falls. Resident #18's care plan documented fall prevention interventions that included Keep bed in lowest position acceptable to resident. Review of Resident #18's progress notes revealed Resident #18 had fallen on 6/17/2023 with resulting complaints of back pain, had fallen on 6/20/2023 with no resulting discomfort, had fallen on 6/23/23 with resulting pain in his right hip/groin area, had fallen on 8/27/2023 with no resulting discomfort, had fallen on 8/28/2023 with no injury documented and had fallen on 9/30/2023 with no resulting discomfort. Review of the radiology results examination dated 7/6/2023, read, Impacted and displaced subcapital femoral neck fracture .Soft tissue swelling overlies the fracture. During an observation on 10/18/2023 beginning at 8:44 AM Resident #18 was observed sitting up in bed eating his breakfast meal. Resident #18's bed was raised to a high position. During an interview on 10/18/2023 at 8:48 AM, with Staff A, Licensed Practical Nurse (LPN), an observation was made of Resident #18. Resident #18's bed was in a high position. Staff A, LPN confirm the bed was in a high position and should not be. During an interview on 10/18/2023 beginning at 9:32 AM, the Director of Rehabilitation stated, [Resident #18's name] has been falling out of bed a lot lately. During an interview on 10/18/2023 at 10:21 AM, the Director of Nursing stated staff should have lowered Resident #18's bed in accordance with his care plan fall precaution interventions after they delivered his meal tray. [Resident #18's name] has fallen frequently. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 5 of 13 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 10/19/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure initial weights were obtained for 4 of 6 residents, Residents #93, #28, #196, and #198, upon admission to the facility. Residents Affected - Some Findings include: 1) Review of Resident #93's record documented Resident #93 was admitted to the facility on [DATE]. Review of Resident #93's care plan, read Resident #93 was at risk for alteration in nutrition and/or hydration related to variable intake, depressive mood, anemia, hypoparathyroidism and macular degeneration. Review of Resident #93's dietary profile, dated 10/15/23, read List Other Dietary Interventions: None (Hospital wt [weight] used for assessment d/t [due to] no facility wt [weight] at time assessment completed). During an interview on 10/18/23 at 10:12 AM, the Director of Nursing stated We weigh residents upon admission. If they refuse, we try again, and go back within hours. Someone should have asked again. She [staff that weighs the residents] comes in on Mondays and does my weights. She [Resident #93] refused to get weighed. I don't know what happened, but they should have charted it. Review of Resident #93's record did not provide documentation of Resident #93 refusing to be weighed at the time of admission. During an interview on 10/19/2023 at 8:05 AM, the Registered Dietician stated, Initial weights are important because you don't know if the hospital weight is correct or not. [I] Would need an accurate weight so I could do an accurate assessment and treat the patient for what I need to treat them for. A lot of patients we get in are malnourished or have not been eating or have wounds. 2) Review of Resident #28's medical record documented the resident was admitted into the facility on 8/15/2023 with diagnoses that included radiculopathy cervical region, adult failure to thrive, major depressive disorder, gastro esophageal reflux disease, and pain. Review of Resident #28's weights documented the first weight dated 8/21/2023, six days after the resident's admission. Review of Resident #28's care plan, initiated on 8/22/2023, read, [Resident #28's name] is at risk for an alteration in nutrition and/or hydration r/t [related to]: has chewing problem, receives mechanically altered diet, hx [history] of weight loss, dx [diagnosis] of failure to thrive, Depressive D/O [disorder], GERD [gastroesophageal reflux disease], HTN [hypertension]. 3) Review of Resident #196's medical record documented the resident's most recent admission into the facility on [DATE] with diagnoses of metabolic encephalopathy, sepsis, urinary tract infection, hypokalemia, and anemia. Review of Resident #196's medical record had no weights documented for the current admission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 6 of 13 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 10/19/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Review of Resident #196's physician's order, dated 10/10/2023, read, regular diet, mechanical soft texture, thin consistency. Review of Resident #196's physician orders, dated 10/16/2023, read House Nutritional Supplement. House protein. Residents Affected - Some Review of Resident #196's dietary profile, dated 10/15/2023, read, Weights: B. 185, five days after the resident's admission. Review of Resident #196's dietary progress note, dated 10/15/2023, read, Res [resident] states his appetite is so-so. On Mech [mechanical} Soft diet and ST [speech] to evaluate. Has open area on coccyx. Eating 25-75% of meals. Will recommend House Supplement 120ml [milliliters] po bid [by mouth two times a day] and House Protein 30ml po bid [milliliters by mouth two times a day]. Review of Resident #196's care plan, initiated 10/15/2023, read, Is at risk for an alteration in nutrition and/or hydration r/t [related/to] has a chewing problem, receives mechanically altered diet. Has variable intake . 4) Review of the medical record for Resident #198 documented the resident's most recent admission was dated as 10/9/2023 with diagnoses that included metabolic encephalopathy, enterocolitis due to clostridium difficile, cellulitis of right and left lower leg, open wound of scalp, lymphedema, unspecified protein-calorie malnutrition, chronic kidney disease, and type 2 diabetes. Review of Resident #198's physician's order, dated 10/09/2023, read Weigh weekly on every day shift Mon [Monday] for 4 weeks and one time only for 1 day. Review of Resident #198's dietary profile, dated 10/12/2023, read, Weights (lbs): 279. Three days following admission. Review of Resident #198's care plan, initiated dated 10/15/2023, read, [Resident #198's name] is at risk for alteration in nutrition and/or hydration r/t [related to]: is morbidly obese, receives diuretics, C-Diff [enterocolitis due to clostridium difficile], IV [intravenous] antibiotic, Cellulitis BLE [bilateral lower extremities], CKD 3 [chronic kidney disease], Wound on scalp, PVD [peripheral vascular disease] , HPLD [hyperlipidemia], Protein-Calorie Malnutrition, CAD [coronary artery disease, Polyneuropathy. Interventions: Weights as ordered and as needed. Notify physician of significant weight changes if noted. Review of the policy and procedure titled, Weights and Weight Loss, last reviewed 9/28/2023, read Policy: It will be the practice of this facility to implement the following systems regarding weight documentation. Procedure: New Admits and readmissions will be weighed upon admission, monthly and/or as ordered by the physician. 1. Staff will be responsible for obtaining weights for these admits and will have this information available for morning stand-up meeting. Weights will be recorded. 2. Off-hour admissions (late evenings) will need to be weighed by a member of the nursing staff on the off-hour shift to obtain initial weight if possible; obtaining weight the following day for late night admissions may be acceptable for resident comfort. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 7 of 13 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 10/19/2023 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 - Few 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 drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 2 of 4 medication carts, and failed to ensure medications were secure when unattended in 1 of 2 units, the POLO unit. Findings include: During an observation on [DATE] at 9:10 AM, of Medication Cart 1 with Staff A, License Practical Nurse (LPN), there was one expired bottle of Calcium Carbonate with an expiration date of 8/23 and one open Trelegy Ellipta inhaler with no open or expiration date. During an interview on [DATE] at 9:28 AM, Staff A, LPN, stated Expired medication should be thrown out. Normally the inhaler is stored in aluminum tin foil and that is where I write the open date. I am not sure where the aluminum tin foil is. During an observation on [DATE] at 9:30 AM of Medication Cart 2 with Staff B, LPN there was one expired Humalog Kwik pen labeled with an open date of [DATE], one open Flutica-Salm Disk inhaler with no open or expiration date, and one open bottle of Pro-Stat liquid protein with no open or expiration date. Review of the manufacturer's recommendation for Pro-Stat liquid protein reads, Discard 3 months after opening. During an interview on [DATE] at 9:37 AM Staff B, LPN, stated, I do not see an open date on the bottle of Pro-Stat we should date it once it is open. The inhaler should be inside the foil where we normally write the open date, I'm not sure where the foil is. I am not sure how long insulin is good for after it is open. The insulin pen has an open date of [DATE] and it has a written expiration date of [DATE]. That was yesterday so it is expired. During an observation on [DATE] at 10:23 AM of Resident #17's room, there was an Albuterol unit dose vial on top of the nebulizer machine at bedside unattended. During an observation on [DATE] at 10:24 AM, Resident #193 was sitting in a wheelchair in her room. In front of Resident #193 there was an inhaler. During an interview on [DATE] at 10:23 AM, Resident #193 stated, I use this inhaler myself and I have another one I use for my breathing. During an observation on [DATE] at 9:30 AM, Resident #193 was sitting in her wheelchair in her room. On top of her bedside table there was a medication cup with 30 milliliters of an orange thick liquid. During an interview on [DATE] at 9:31 AM Resident #193 stated That is my medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 8 of 13 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 10/19/2023 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 - Few During an interview on [DATE] at 7:55 AM, the Director of Nursing stated, I have 11-7 [shift] check the carts every night and even the nurses make sure they check the carts. Management does weekly audits. No expired medication should be in the medication carts. Medication should be labeled with an open, and expiration date. The insulin was expired. It [insulin] is good for 28 days. [The nurses should] take it off the medication carts and dispose of it in the drug buster. A self-assessment would be done [for Residents #17 and #193] to determine if self-administration is possible and orders would be placed in the system. The self-administration for medications and orders for self-administration of medications were requested for Residents #17 and #193. None were provided. Review of the policy and procedure titled, P&P [Policy and Procedure] Medication/Biological Storage, last review date [DATE], read Policy: It will be the policy of this facility to store medications, drugs, and biologicals in a safe, secure and orderly manner. Procedure: 4. The facility shall not use discontinued, outdated or deteriorated medications, drugs or biologicals. Review of the policy and procedure titled, Self-Administration of Medications, last review date of [DATE], read, Policy: It is the policy of this facility that residents who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 9 of 13 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 10/19/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review the facility failed to ensure residents' medical records were complete and accurately documented for 2 of 7 residents, Residents #4, and #198 reviewed for care treatments. Findings include: 1) During an interview on 10/18/2023 at 8:50 AM, Resident #4 stated, The nurse came yesterday and did wound care for me, they changed my dressings. During an observation on 10/18/2023 at 9:33 AM of Resident #4 it showed the wound dressing to his coccyx and left lower buttock was dated 10/17/2023. Review of Resident #4's Treatment Administration Record (TAR) for the month of October 2023, read, Wound Care Right Lower Abdomen Surgical Site. Cleanse with soap and water pat dry. Then apply skin prep, hydrogel, and cover with bordered foam, every day shift for wound care start date 9/26/2023 d/c [discontinue] 10/3/2023. The TAR had a blank entry, no staff initials to document the care was provided on 10/02/2023. Review of Resident #4's TAR for the month of October 2023, read, Wound care coccyx clean with n/s [normal saline], apply medi honey, calcium alginate, and border foam, every day shift for wound care start date 10/04/2023. The TAR had blank entries, no staff initials to document the care was provided on 10/5/2023, 10/6/2023, 10/10/2023, 10/12/2023 and 10/17/2023. Review of Resident #4's TAR for the month of October 2023, read, Wound care L [left] lower leg cleanse with normal saline, apply xeroform, nonstick dressing, cover with rolled gauze, every day shift for wound care start date 10/04/2023 and d/c date of 10/08/2023. The TAR had blank entries, no staff initials to document the care was provided on 10/5/2023 and 10/6/2023. Review of Resident #4's TAR for the month of October 2023, read, Wound care left buttock (cluster) clean with soap and water, pat dry, apply medi honey and calcium alginate and cover with bordered foam, every day shift for wound care start date 10/11/2023. The TAR had blank entries, no staff initials to document the care was provided on 10/12/2023 and 10/17/2023. Review of Resident #4's TAR for the month of October 2023, read, Wound care left buttock ischium clean with n/s [normal saline], apply medi honey, calcium alginate, cover with border gauze, every day shift for wound care start date 10/4/2023. The TAR had blank entries, no staff initials to document the care was provided on 10/5/2023, 10/6/2023, 10/10/2023, 10/12/2023, and 10/17/2023. Review of Resident #4's TAR for the month of October 2023, read, Wound care left lateral ankle clean with n/s, apply skin prep, collagen and cover with border gauze, every day shift for wound care start date 10/4/2023 d/c date10/8/2023. The TAR had blank entries, no staff initials to document the care was provided on 10/5/2023 and 10/6/2023. Review of Resident #4's TAR for the month of October 2023, read, Wound care Right buttock clean with n/s, apply medi honey, calcium alginate, cover with border gauze, every day shift for wound care start date 10/04/2023. The TAR had blank entries, no staff initials to document the care was provided (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 10 of 13 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 10/19/2023 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 0842 on 10/5/2023, 10/6/2023, 10/10/2023, 10/12/2023, and 10/17/2023. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/19/2023 at 8:10 AM, the Director of Nursing stated, The nurses did the wound care but did not document the care. The nurses should document any refusals or call the physician or get orders. The nurses should be checking off when they are providing the care. Residents Affected - Some Review of the policy and procedure titled, Charting and Documentation, last review date of 9/28/2023, read, Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. 2) During an observation on 10/16/2023 at approximately 10:00 AM, Resident #198 was lying in bed. A signal lumen PICC (peripherally inserted central catheter) line with a transparent dressing dated 10/8/2023 was observed to the resident's right upper arm. There was dried blood observed at the insertion site. During an interview on 10/16/2023 at approximately 10:00 AM, Resident #198 stated, I came from the hospital with this IV [intravenous catheter], it has not been changed here at the facility. Review of Resident #198's physician's order, dated 10/9/2023, read, Change dressing post PICC insertion and routinely one time for 1 day observe site for signs/symptoms of infiltration/extravasation/infection. Review of the TAR dated 10/10/2023 staff initialed the PICC line dressing change procedure had been completed on 10/10/2023. During an interview on 10/19/2023 at 8:16 AM, the Director of Nursing stated, Staff should be checking off the MAR [Medication Administration Record] or TAR when they actually do the procedure. Review of policy and procedure titled, PICC IV Line, last review date of 9/28/2023, read, Dressing Changes: 2. Dressing changes will be documented in the clinical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 11 of 13 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 10/19/2023 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 Based on observation, interview, and record review the facility failed to prevent the possible spread of infection when not performing hand hygiene and following infection control standards during wound care, and failed to ensure transmission-based precautions were followed. Residents Affected - Few Findings include: 1) During an observation on 10/17/2023 at 8:36 AM Staff C, License Practical Nurse (LPN) entered Resident #143's room without donning personal protective equipment [PPE]. Resident #143's room had a sign outside of the room on the door that read Contact Isolation. During an interview on 10/17/2023 at 8:40 AM, Staff C, LPN, stated, I did not see the sign on the door. I entered the room and gave Resident #143 her medication. I should have used proper PPE to enter the room. Review of Resident #143's physician order, dated 10/8/2023, showed the order read, Contact isolation ESBL [Extended Spectrum Beta-Lactamase] urine. Review of Resident #143's care plan, initiated 10/8/2023, read, Resident requires isolation precautions because of an infectious disease. Interventions: On strict isolation, all services provided in room, private room with no roommate, resident cannot leave room except for MD [Medical Doctor] appointment and outside medical services. Resident needs isolation precautions because of an infection. Follow isolation instructions on resident door. During an interview on 10/19/2023 at 8:04 AM, the Director of Nursing stated, Staff should always go into a contact isolation room with proper personal protective equipment. There is a possibility they have to provide direct care to a resident while in the room and not wearing PPE could bring the infection out to other residents. Review of the policy and procedure titled, Transmission Based Precautions, last review date of 9/23/2023, read, Contact Precautions: Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, spread by direct contact with the resident or the resident's environment . Guidelines for Contact Precautions: Gloves. 2. Wear gloves whenever touching the resident's intact skin or surfaces and articles near the resident (e.g. medical equipment, bed rails). [NAME] gloves upon entry into the room or cubicle. 3. Gloves should also be worn when handling items potentially contaminated by MDROs [Multidrug-Resistant Organism]. This may include such as bedside tables, over-bed tables, bed rails, bathroom fixtures, television and bed controls, suction, and oxygen tubing. Gowns. 1. [NAME] gown upon entry into the room or cubicle. Remove gown and observe hand hygiene leaving the resident care environment. 2) During an observation of wound care on 10/18/2023 beginning at 9:33 AM with Staff A, Unit Manager/License Practical Nurse, Staff E, Registered Nurse, and Staff F, License Practical Nurse (LPN), entered Resident #4's room for Resident #4 showed Staff F assisted Resident #4 to turn to his left side. Staff A removed a dressing dated 10/17/2023 from Resident #4's right upper coccyx area. Staff A then removed the dressing from Resident #4's left lower buttock area. Staff A removed gloves and performed hand hygiene. Staff A donned a new pair of gloves and was handed 4x4 gauze with normal saline vials by Staff E. Staff A applied the normal saline to the 4x4 gauze and cleaned Resident #4's upper right-side coccyx wound moving from the outer area of the wound to the center area. Staff A (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 12 of 13 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 10/19/2023 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 - Few cleansed multiple areas of the wound with the same side of the gauze and did not pat dry the wound. Staff A, without removing gloves and performing hand hygiene, cleansed Resident #4's left lower buttocks wound with a new gauze pad Staff E had handed to her. Staff A cleansed the lower buttock using the same side of the gauze in different areas of the wound. Staff A did not pat dry the left buttock wound. During an interview on 10/18/2023 at 10:47 AM, Staff A, Unit Manager License Practical Nurse stated, I should have treated one wound and then done the other wound. I should have pat dry the wound and not wiped multiple times the wound with the same gauze. During an interview on 10/18/2023 at 10:53 AM, the Director of Nursing stated, Nursing staff should not be doing two wounds at the same time because of the risk for infection from one wound to the other one. Staff should wash their hands in between the procedures, pat the wound dry, and not wipe multiple areas at a time using the same gauze or side of the gauze. She should pat dry to reduce the moisture from the wound. Review of the policy and procedure titled, Non-Sterile Dressing Change Audit, last reviewed 9/28/2023, read, Clean from inner edge to outer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106095 If continuation sheet Page 13 of 13