Health inspection·November 13, 2025

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary drugs, specifically without adequate monitoring or adequate indications for use, in 1(Resident #1) out of 3 residents reviewed for unnecessary pain medications. Findings include:Review of Resident #152's physician order dated 9/19/2025 read, Oxycodone HCL oral tablet 5 mg [milligrams] give 1 tablet every 4 hours as needed for pain, for severe pain 7-10 for 3 days.Review of Resident #1's Medication Administration Record (MAR) for September 2025 documented that Oxycodone HCL tablet 5 mg was administered on 9/21/2025 at 2006 (8:06 PM) with a pain level of 3, on 9/22/2025 at 0946 (9:46 AM) for a pain level of 2, on 9/23/2025 at 0946 (9:46 AM) for a pain level of 6, on 9/24/2025 at 0930 (9:30 AM) for a pain level of 6, on 9/24/2025 at 1439 (2:39 PM) for a pain level of 6, on 9/25/2025 at 0900 (9:00 AM) for a pain level of 6, on 9/25/2025 at 2021 (8:21 PM) for a pain level of 4, on 9/26/2025 at 0936 (9:36 AM) for a pain level of 6, and at 2028 (8:28 PM) for a pain level of 3, on 9/28/2025 at 0436 (4:36 AM) for a pain level of 3, and at 0914 (9:14 AM) for a pain level of 6, and on 9/30/205 at 0920 (9:20 AM) for a pain level of 6.Review of Resident #1's October 2025 MAR documented Oxycodone HCL tablet 5 mg was administered on 10/1/2025 at 0922 (9:22 AM) for a pain level of 6, on 10/2/2025 at 0355 (3:55 AM) for a pain level of 2 and at 0920 (9:20 AM) for a pain level of 6, on 10/3/2025 at 0810 (8:10 AM) for a pain level of 6, on 10/5/2025 at 0845 (8:45 AM) for a pain level of 6, on 10/5/2025 at 0332 (3:32 AM) for a pain level of 3 and at 0832 (8:32 AM) for a pain level of 6.During an interview on 11/13/2025 at 12:40 PM Staff A, Licensed Practical Nurse (LPN) stated, I did administer the oxycodone. I did not see the parameters or that it was only for 3 days. I think she [Resident #1] asked to have that, so I gave it. I should have followed the orders. I did not follow them.During an interview on 11/13/2025 at 12:55 PM the Director of Nursing (DON) stated, I was not aware that she [Resident #1] was given her medication [oxycodone] outside the parameters or that the medication was only ordered for three days and she received it after those three days. We should have gotten another order for the medication to continue. The nurses should not have continued the oxycodone. They should not have administered it outside the parameters. If she specifically asked for it, they really should have gotten an order to administer it or get the parameters lowered or discontinued the parameters altogether.During an interview on 11/13/2025 at 3:35 PM Staff B, Registered Nurse (RN) stated, We should follow any orders that have parameters on them. If I gave it, then no, I did not follow the orders. I should have.Review of the policy and procedure titled Medication Administration with an issue date of 4/1/2022 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Procedure: 2. The Director of Nursing is responsible for the supervision and direction of all personnel with medication administration duties and functions. 3. Medications should be administered in a timely manner and in accordance with the physicians orders. Newly Residents Affected - Few Page 1 of 2 106099 106099 11/13/2025 Villages Healthcare and Rehabilitation Center, The 900 Highway 466 Lady Lake, FL 32159

F 0757 Level of Harm - Minimal harm or potential for actual harm admitted residents may receive medications prior to delivery from the pharmacy by accessing the Emergency Drug Kit or other medication storage unit used for the purpose of storing medications when certain medications are not available. Residents Affected - Few 106099 Page 2 of 2