Inspection·September 9, 2022

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 respiratory care services were provided in accordance with professional standards of practice for 1 of 2 residents reviewed for oxygen administration, Resident #17. Residents Affected - Few Findings include: During an observation on 9/6/2022 at 10:16 AM, Resident #17 was lying in bed, alert, pleasant, and head of the bed elevated. The resident was receiving oxygen via a nasal cannula (n/c) at 3.5 L/Min (liters per minute) with humidification. During an interview on 9/6/2022 at 10:16 AM, Resident #17 stated that he did not adjust his oxygen, that it was done by the nurse. During an observation on 9/7/2022 at 9:57 AM, Resident #17 was lying in bed, alert, pleasant, and head of the bed elevated. The resident was receiving oxygen via a n/c at 3 L/Min with humidification. During an observation on 9/8/2022 at 8:40 AM, Resident #17 was lying in bed, head of the bed elevated, and he was receiving intravenous fluids. The resident was receiving oxygen via a n/c at 3 L/Min with humidification. During an interview on 9/8/2022 at 8:45 AM, Staff G, Licensed Practical Nurse (LPN), confirmed Resident #17's oxygen was being administered at 3 L/Min. She stated that she had not been into the resident's room this morning yet. She stated that oxygen was checked each shift. She confirmed the order read oxygen was supposed to be at 2 L/Min. Review of the admission record for Resident #17 revealed the resident was admitted on [DATE] with diagnoses that included but not limited to chronic kidney disease, extended spectrum beta lactamase (ESBL) resistance, dehydration, fever, COVID-19 (Coronavirus 2019), chronic atrial fibrillation, chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity, venous insufficiency (chronic peripheral), atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation, localized edema, acute on chronic systolic (congestive) heart failure, and chronic obstructive pulmonary disease (COPD) unspecified. Review of the Minimum Data Set (MDS) Interim Payment assessment dated [DATE] revealed Resident #17 had a BIMS (Brief Interview for Mental Status) score of 13 (cognitively intact) and the resident used oxygen while in the facility. During an interview on 9/8/2022 at 9:00 AM, the Assistant Director of Nursing stated that she couldn't say when the nurses were to check the oxygen administration level, but she would look for a policy on oxygen administration and physician's orders. During an interview on 9/8/2022 at 9:35 AM, Staff C, Registered Nurse (RN), Unit Manager (UM), stated that the oxygen administration level should be checked each shift. She verified that Resident #17 would not be able to reach the oxygen concentrator to change the oxygen himself. She stated the nurses were expected to follow physician's orders and if the oxygen administration needed to be increased, we should call the physician for a new order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106099 If continuation sheet Page 2 of 10 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 106099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villages Healthcare and Rehabilitation Center, The 900 Highway 466 Lady Lake, FL 32159 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the comprehensive resident centered care plan dated 6/30/2022 reads, I have COPD [Chronic Obstructive Pulmonary Disease] with a goal for appropriately oxygenated without complication. Interventions include Check O2 [oxygen] sats [saturation] as ordered, and dated 7/12/22, O2 as ordered 2-3 liters via nasal cannula. Review of the comprehensive resident centered care plan dated 6/30/2022 reads, I have SOB [shortness of breath] r/t [related to] my COPD and fluid overload with a goal to have no complications related to SOB. Interventions include O2 as ordered. Review of the comprehensive resident centered care plan dated 6/30/2022 read, I use O2 @ 2-3 liters via nasal cannula with a goal to have appropriately oxygenated without complications due to SOB. Interventions include Oxygen use via NC per MD orders. Review of the physician's orders dated 7/12/22 reads, Administer oxygen 2 L/Min via n/c prn [as needed] Humidification PRN every shift for SOB. Monitor skin behind ears, neck, and face every shift for irritation or breakdown and apply tube padding PRN. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106099 If continuation sheet Page 3 of 10 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 106099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villages Healthcare and Rehabilitation Center, The 900 Highway 466 Lady Lake, FL 32159 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 - Some 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. 3. During an observation on 9/7/2022 at 9:52 AM, there was a medication cup containing several pills on the resident's overbed table with the breakfast tray in Resident 92's room. During an interview on 9/7/2022 at 9:53 AM, Resident #92 stated, I am slow going this morning, haven't gotten around to taking them yet. The nurse just left them there for me to take. During an interview on 9/7/2022 at 10:00 AM, Staff A, LPN, stated, That was my mistake. I should not have left the medication. During an interview on 9/7/2022 at 10:21 AM, Staff B, Unit 4 Manager, stated, It is not normal for nurse to leave medication at bedside unattended. Review of the policy and procedure titled Storage of Medications with an effective date of 9/2018, and last approval date of 1/22/2022, reads, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is only accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures. I. General Guidance . 2. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access . 8. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists . II. Temperature . 4. Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 degrees Fahrenheit (2 degree Celsius) and 46 degrees Fahrenheit (8 degrees Celsius) with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Controlled substances that require refrigeration are stored within a locked box within the refrigerator that is attached to the inside of the refrigerator in accordance with state regulations and facility policy . III. Expiration Dating (Beyond-Use Dating): 1. Expiration dates (beyond-use dates) of dispensed medications shall be determined by the pharmacist at the time of dispensing . 3. Certain medications or package types, such as IV solutions, multidose injectable vials, ophthalmics, nitroglycerin tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency . 4 . b. Drugs dispensed in the manufacturer's original container will carry the manufacturer's original expiration date. Once opened, these products will be acceptable to use until the manufacturer's expiration date is reached and unless the medication is . ii. An ophthalmic medication; iii, An item for which the manufacturer has specified a usable duration and open. 5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. a. The nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulation/ guidelines require different dating . 8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. Based on observation, interview, and record review, the facility failed to ensure that the drugs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106099 If continuation sheet Page 4 of 10 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 106099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villages Healthcare and Rehabilitation Center, The 900 Highway 466 Lady Lake, FL 32159 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 and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles in 3 of 6 medication carts reviewed, and the medications were not left unattended in the resident rooms. Findings include: Residents Affected - Some During an observation of Medication Cart #1 on 9/6/2022 at 9:06 AM with Staff E, Licensed Practical Nurse (LPN), there were one opened Humalog insulin pen with no opened or expiration dates, and one unopened Humalog insulin pen with the pharmacy instructions to refrigerate until opened. During an interview on 9/6/2022 at 9:10 AM, Staff E, LPN, stated, All insulin should be refrigerated if they aren't opened and have the date they were opened on them. During an observation of Medication Cart #2 on 9/6/2022 at 9:18 AM with Staff F, LPN, there were one bottle of Atropine ophthalmic solution with no opened or expiration dates, one opened bottle of Prednisolone ophthalmic solution with no opened or expiration dates, one opened bottle of Ciprofloxacin ophthalmic solution with no opened or expiration dates, one opened bottle of Latanoprost ophthalmic solution with no opened or expiration dates, one opened bottle of Timolol ophthalmic solution with no opened or expiration dates, two insulin glargine pens with no opened or expiration dates, one Humalog insulin pen with no opened or expiration dates, one Lantus insulin pen with no opened or expiration dates, and one unopened Humalog with the pharmacy instructions to refrigerate until opened. During an interview on 9/6/2022 at 9:20 AM, Staff F, LPN, stated, All eye drops and insulin should have been dated. I don't know why they aren't. During an observation of Medication Cart #3 on 9/6/2022 at 9:25 AM with Staff G, LPN, there were one Travoprost ophthalmic solution with no opened or expiration dates, one Latanoprost ophthalmic solution with no opened or expiration dates, and one Brimonidine ophthalmic solution with no opened or expiration dates. During an interview on 9/6/2022 at 9:32 AM, Staff G, LPN, stated, All the eye drops should be dated when they are opened. 2. Review of the physician orders dated 6/24/2022 for Resident #8 reads, Cosopt Solution 22.3-6.8 MG/ML [milligram/ milliliter] (Dorzolamide HCI-Timolol Mal) instill 1 drop in both eyes every morning and at bedtime for glaucoma. During an observation on 9/6/2022 at 9:55 AM, Resident #8 was sitting in his room eating breakfast. On his table, there was a bottle of Cosopt Solution 22.3-6.8 MG/ML (Dorzolamide HCI-Timolol Mal) with box next to the bottle. During an interview on 9/6/2022 at 9:55 AM, Resident #8 stated his nurse would administer the drops for him. During an interview on 9/9/2022 at 8:49 AM, Staff J, Licensed Practical Nurse (LPN), stated, Resident #8 had orders for Cosopt Solution 22.3-6.8 MGM/L (Dorzolamide HCI-Timolol Mal) but it should be administered by the nurse. Resident #8 has no order to self-administer. He should not have had that in his room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106099 If continuation sheet Page 5 of 10 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 106099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villages Healthcare and Rehabilitation Center, The 900 Highway 466 Lady Lake, FL 32159 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 During an interview on 9/9/2022 at 8:51 AM, Staff K, LPN, stated Resident #8 had no orders to self-administer medication and she might had left the medication behind in the resident room. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106099 If continuation sheet Page 6 of 10 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 106099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villages Healthcare and Rehabilitation Center, The 900 Highway 466 Lady Lake, FL 32159 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 store food in accordance with professional standards for food service safety and maintain kitchen equipment in a clean and sanitary condition in the main kitchen and 4 of 4 neighborhood kitchens, potentially affecting all 114 residents, and the facility failed to serve food in accordance with professional standards for food service safety in 1 of 2 neighborhoods observed. Findings include: 1. During the initial tour with the Food Services Manager on 9/6/2022 beginning at 9:09 AM, the following were observed: a) Chopped ham and carrots in the walk-in refrigerator that were not labeled or dated, b) Raw frozen hamburger patties open to the air in the freezer, with the plastic covering not closed over the meat, c) A plate containing a pureed meal that was unlabeled and undated in the two door cooks cooler, d) A hotel pan of French fries and a sandwich between two disposable plates that was unlabeled and undated in the dialysis refrigerator, e) a buildup of a black substance inside the door of the oven and the oven deck, f) a brown sticky substance at the top of the point of the triangular shaped opener on the table mounted can opener, g) The fryer was observed covered with baking pans. On removal of the baking pan on the left fryer, the oil was observed to have a film on top of the oil and crumbs on the shelf in the front of the fryer. There were drips of an oily substance down the side of the fryer. During an interview on 9/6/2022 at the time of initial tour, the Food Services Manager confirmed all concerns identified during the tour. 2. During breakfast food service on 9/7/2022 beginning at 9:10 AM with the Food Services Manager, the following were observed: a) Staff C, Community Chef, carried a hotel pan containing link sausages. Staff C inverted the hotel pan and dropped the sausage links into another hotel pan that was on the steam table. He then moved the sausage around in the pan on the steam table with the same gloved hand that carried the hotel pan to the steam table, b) Staff C put two slices of bacon on a plate that had a large dried green colored stain in the center of the dish. Staff C noticed debris on the plate, dumped the bacon slices back into the pan of bacon on the steam table, and put the dirty plate in the dirty dish bin. He then served that bacon on another plate, c) Staff C served oatmeal into 3 large white bowls that had visible dark colored debris in the eating surface and rims of the bowls. The bowls of oatmeal were served to residents, d) Staff C picked up two slices of pancakes with tongs and laid them on the flat surface in front of steam table, put on a glove on one hand and chopped the pancake into small pieces and put the pieces of pancake on the plate with the gloved hand. The surface in front of the steam table had been used for plates, utensils, box of alcohol swabs and thermometer and had not been sanitized or cleaned prior to placing food on the surface, e) Staff C picked up two slices of pancakes with tongs and laid them on the flat surface in front of steam table, put on a glove on one hand and chopped the pancake into small pieces and put the pieces of pancake on the plate with the gloved hand. Staff C then picked up two link sausages with tongs and put them on the flat surface in front of the steam table and chopped the sausages into small pieces and add them to the plate. During an interview on 9/7/2022 at 9:30 AM, the Food Services Manager confirmed that food should not be touched with a gloved hand that has touched other surfaces, the bacon slices should not have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106099 If continuation sheet Page 7 of 10 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 106099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villages Healthcare and Rehabilitation Center, The 900 Highway 466 Lady Lake, FL 32159 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 been put back on the steam table once it came into contact with the soiled plate, the oatmeal was served in dishes that had dark debris in the eating area of the bowl and rims and that food should not be cut up on the surface in front of the steam table as the surface is not a clean surface to place food to cut. He stated it is not normal to cut food up on the steam table this way. 3. During a tour of the neighborhood kitchens with the Food Services Manager on 9/8/2022 beginning at 7:38 AM, the following were observed: a) Neighborhood 100: The stove had grease on handles of stove and had black substances on the oven deck, b) Neighborhood 400: There were two Styrofoam containers labeled with resident names but without dates in the refrigerator, c) Neighborhood 500: The microwave had yellow greasy substances on the inside of the microwave. The stove had grease on handles of the stove and had black substances on the oven deck. Cheese and butter were open to air in the refrigerator and hot dogs were unwrapped in the freezer. The refrigerator had brown and yellow debris on the shelves and bottom of the refrigerator, d) Neighborhood 200: The oven had black substances on the oven decks. During an interview on 9/8/2022 at 8:30 AM, the Food Services Manager confirmed all concerns identified on the tour of the neighborhood kitchens. He stated there were no cleaning schedules or documentation of cleaning being completed on all food service equipment in the main kitchen or the neighborhood kitchens at this time. Review of the policy and procedure titled, Sanitation, revised in December 2008, and last reviewed on 1/22/22 reads, Policy Statement. The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation. 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free of breaks, corrosion, open seams, cracks and chipped areas that may affect their use and proper cleaning. 3. All equipment food contact surfaces and utensils shall be washed to remove and completely loosen soils by using the manual or mechanical means necessary and sanitizing using hot water and or chemical sanitizing solutions . 7. Cutting boards (acrylic or hardwood) will be washed and sanitized between uses . 11. For fixed equipment or utensils that do not fit in the dish washing machine, washing shall consist of the following steps: a. Equipment will be disassembled as necessary to allow access of the detergent/solution to all parts; b. Removable components will be scraped to remove food particle accumulation and washed according to manual or dishwashing procedures . 17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Review of the policy and procedure titled, Food Preparation and Service, revised in November 2010, and last reviewed on 1/22/22 reads, Policy Statement. Food service employees shall prepare and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation. Food Service/Distribution . 6. Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. Disposable gloves are single use items and shall be discarded after each use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106099 If continuation sheet Page 8 of 10 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 106099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villages Healthcare and Rehabilitation Center, The 900 Highway 466 Lady Lake, FL 32159 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 maintain an infection prevention and control program to prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure staff performed hand hygiene and cleaned the needleless connectors of midline catheters during medication administration in 7 of 9 observations of medication administration. Residents Affected - Some Findings include: 1. During an observation of medication administration on 9/7/2022 at 7:50 AM, Staff G, Licensed Practical Nurse (LPN), did not perform hand hygiene, unlocked the medication cart, poured medications for Resident #93, entered the resident's room, and administered the resident's medications. Staff G left the resident's room and returned to the medication cart and began to prepare another resident's medications. Staff G did not perform hand hygiene. During an observation of medication administration on 9/7/2022 at 7:57 AM, Staff G, LPN, poured medications for Resident #448, entered the resident's room and administered the medications. Staff G returned to the medication cart and began to prepare medications for another resident. Staff G did not perform hand hygiene. During an observation of medication administration on 9/7/2022 at 8:02 AM, Staff G, LPN, poured medications for Resident #35, entered the resident's room and administered the medications. Staff G touched the resident and the overbed table. Staff G returned to the medication cart and began pouring medications for another resident. Staff G did not perform hand hygiene. During an observation of medication administration on 9/7/2022 at 9:21AM, Staff G, LPN, administered 5 ml (milliliters) of normal saline and 5 ml of heparin flush to Resident #18. Staff G removed the IV (intravenous) tubing. Staff G did not scrub or clean the needleless connector prior to administering the normal or the heparin. During an interview on 9/9/2022 at 7:35 AM, Staff G, LPN, stated, I don't think that I would have changed anything about my medication administration. I did not wash my hands or use hand sanitizer before I administered the medications. I should have. When I gave the normal saline and heparin, I was taking down the IV and didn't need to use alcohol. I was just taking the medication down. 2. During an observation of medication administration on 9/7/2022 at 8:10 AM, Staff A, LPN, poured medications for Resident #301, entered the resident's room and administered the medications. Resident #301 requested pain medication, and Staff A left the room, unlocked the keypad on the medication cart, reached into her pocket to remove narcotic keys, and did not find them. Staff A left the medication cart, obtained the keys from other nurse, returned to the medication cart, unlocked the cart using the keypad, unlocked the narcotic drawer, and poured the medication. Staff A entered the resident's room, administered the medication, and returned to the medication cart. Staff A did not perform hand hygiene. During an observation of medication administration on 9/7/2022 at 8:19 AM, Staff A, LPN, poured medications for Resident #302, entered the resident's room, and administered the medications. Staff A touched the resident and the overbed table. Staff A left the room and returned to the medication cart to prepare medications for another resident. Staff A did not perform hand hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106099 If continuation sheet Page 9 of 10 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 106099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villages Healthcare and Rehabilitation Center, The 900 Highway 466 Lady Lake, FL 32159 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 - Some During an observation of medication administration on 9/7/2022 at 1:45 PM, Staff A, LPN, prepared the intravenous antibiotic and entered Resident #400's room, cleansed the needleless connector for 1 second and immediately connected the antibiotic. Staff A did not verify line placement by checking for blood return. During an interview on 9/7/2022 at 1:57 PM, Staff A, LPN, stated, Oh, I did not clean the connector long enough. I did not verify that the line was in place before I gave the antibiotic. When I was doing medications, I should have washed my hands or used sanitizer. During an interview on 9/8/2022 at 2:20 PM, the Director of Nursing (DON) stated, All staff should use hand sanitizer before and after administering their medications. Review of the policy and procedure titled, Hand Hygiene, last approved on 1/22/2022 reads, Intent: It is the policy of the facility to perform hand hygiene in accordance with national standards for the Centers for Disease Control and Prevention and the World Health Organization. Procedure . 2. Alcohol-based hand rub may be used for all other hand hygiene opportunities (e.g. when soap and water is not indicated per #1 above). According to the World Health Organization, hand hygiene is to be performed: a. Prior to caring for a resident . d. After caring for a resident including after removing gloves; and e. After contact with the resident environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106099 If continuation sheet Page 10 of 10