Inspection·February 15, 2024

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 Based on observation, record review, and interview, the facility failed to ensure PICC (Peripherally Inserted Central Catheter) line dressing was changed for 1 of 1 resident with PICC line, Resident #69. Residents Affected - Few Findings include: During an observation on 2/12/2024 at 10:20 AM, Resident #69 had a PICC line in his right arm. The PICC line was covered with a dressing dated 2/1/24 and the clear covering was cracked and peeling at the upper left edge. During an interview on 2/12/2024 at 10:20 AM, Resident #69 stated, No one has come in to change my dressing for over a week. Review of Resident #69's physician order dated 1/24/2024 read, Change dressing 24 hours post PICC line insertion, then every week and PRN [as needed]. If gauze is used dressing must be changed every 24 hours as need . Start Date: 01/24/2024. During an interview on 2/14/2024 at 9:20 AM, Staff B, Licensed Practical Nurse (LPN), stated, His dressing is compromised and should have been changed when the nurse flushed his line. During an interview on 2/14/2024 at 9:30 AM, the Director of Nursing stated, The dressing is compromised. My expectation is that it should have been changed. The Director of Nursing confirmed the date on the bandage read, 2/1/2024. Review of the facility policy and procedures titled PICC IV [Intravenous] Line issued on 4/1/2022 read, Policy: It will be the policy of this facility to adhere to IV/PICC line administration guidelines as set forth by infection control, state and federal regulations. Licensed nurses shall provide care according to state and federal law . Dressing Changes: Sterile dressing change using transparent dressing is performed: 24 hours post-insertion or upon admission if not dated upon admission, at least weekly, If the integrity of the dressing has become compromised (wet, loose, or soiled). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106099 If continuation sheet Page 2 of 3 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 02/15/2024 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 ensure food items were properly labeled or discarded upon expiration, failed to ensure test strips were not expired, and failed to ensure the kitchen environment and equipment were kept clean (Photographic evidence obtained). Findings include: During observation on 2/12/2024 at 9:15 AM while conducting a walk-through tour of the kitchen with the Certified Dietary Manager (CDM), there were pooling of water in the dish room, dirty towels were placed under the juice containers, and test strips expired on 12/1/2023 were being used for the pot and pan sink. During an interview on 2/12/2024 at 9:35 AM, the CDM confirmed the water leak in the dish room, a leak under the juice machine, and the expired test strips being used to check the sanitation. During an observation on 2/13/24 at 7:30AM while conducting follow-up tour of the kitchen with the CDM, there were a buildup of a black and grey substance on the wall behind the dish machine and a small bucket full of water, and numerous dirty towels/rags under the juice machine. In the dry storage room, there were fourteen bags of hot cereal creamy wheat farina with an expiration date of 2/3/2024, two ½ bags of a food product with no identifying label, and one box of buttermilk biscuit mix with an expiration date of April 19, 2023. The mixer had numerous stains and dark brown and cream-colored food particles or debris inside, on the top and sides of the mixer. During an interview on 2/13/2024 at 8:28 AM, the CDM confirmed the presence of a black/grey substance on the wall behind the dish machine, numerous food particles on the top and sides of the mixer. The CDM confirmed that there were products without a label and identified the product as coconut and the expired biscuit mix and farina. The CDM stated that the products should be labeled according to the policy and that all products should be monitored for expiration dates. The CDM stated the dish machine and the juice machine had a leak. Review of the facility policy and procedures titled Kitchen Sanitation last reviewed on 1/24/2024 read, Policy: It will be the policy of the facility that the food service area and equipment shall be maintained in a clean and sanitary manner. Procedure . 14. The Food Services/ Dietary Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Review of the facility policy and procedures titled Refrigerated Storage last reviewed on 1/24/2024 read, Procedure . 4. Dietary staff will label, date, and monitor refrigerated food, including, but not limited to leftovers to ensure use by use-by dates, or frozen (when applicable) or discarded. Review of the facility policy and procedures titled Refrigerated Storage last reviewed on 1/24/2024 read, Policy: Food contact surfaces are properly cleaned and sanitized before and after use, in order to help prevent foodborne illness and minimize bacterial growth. Non-food contact surfaces are cleaned per individual facility cleaning schedule to maintain optimal cleanliness of kitchen equipment. Procedure . 3. Non-food contact surfaces are washed with soapy water per frequency identified on the facility cleaning schedule- or as visually necessary. These are then wiped down with sanitizer solution (bleach at 100 parts per million). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106099 If continuation sheet Page 3 of 3