Inspection·May 25, 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. Based on observation, interview, and record review the facility failed to implement comprehensive resident centered care plan interventions for 2 (Resident #9, #338) of 12 residents review for accidents and pressure ulcers. Photographic evidence obtained. Findings include: 1) During an observation on 5/22/2023 at 10:03 AM Resident #9 was lying in bed, one fall mat was placed on the floor on the right side of the bed while the left side of the bed there was no fall mat on the floor. During an observation on 5/23/2023 at 9:00 AM Resident #9 was lying in bed, one fall mat was placed on the floor on the right side of the bed while the left side of the bed there was no fall mat on the floor. During an observation on 5/24/2023 at 8:30 AM Resident #9 was lying in bed, one fall mat was placed on the floor on the right side of the bed while the left side of the bed there was no fall mat on the floor. During an observation on 5/24/2023 at 12:30 PM AM Resident #9 was lying in bed, one fall mat was placed on the floor on the right side of the bed while the left side of the bed there was no fall mat on the floor. During an interview on 5/24/2023 at 1:38 PM Staff B, License Practical Nurse (LPN) stated, I am not sure why [Resident #9's name] only has one fall mat maybe its due to her side table being placed on the side with no floor mat. If the Kardex (Certified Nursing Assistant Point of Care system for the comprehensive care plan] states bilateral floor mats, staff should ensure it is followed. During an interview on 5/24/2023 at 2:25 PM Director of Nursing stated, Staff are expected to follow what is documented on the Kardex. Review of Resident #9's admission record documented an admission date of 2/14/2023 with diagnoses to include muscle weakness, altered mental status, abnormal posture, presence of right artificial hip joint, and dementia. Review of Resident #9's comprehensive care plan with a revision date of 10/14/2022 read, Focus [problem]. I am at risk for falls related to decreased mobility, weakness, unsteady gait, and medication contributors. Interventions. Bilateral floor mats at bedside while in bed. Review of the policy and procedure titled Comprehensive Care Plans with implemented date of 10/24/2022 read, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 2.) During on observation on 05/22/2023 at 8:27 AM, Resident #338 was lying on his back in bed, without bilateral heels off loaded [allow weight of the leg to 'settle' into an offloading device such (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106139 If continuation sheet Page 2 of 4 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 106139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatham Glen Healthcare and Rehabilitation Center 16605 SE 74th Soulliere Avenue 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 0656 as pillow, wedge or boot]. Level of Harm - Minimal harm or potential for actual harm During an observation on 05/23/2023 at 9:28 AM Resident #338 was lying in bed watching television without bilateral heels off loaded. Residents Affected - Few During an observation on 05/24/2023 at 11:02 AM Resident #338 was lying in bed watching television without bilateral heels off loaded. During an observation on 05/24/2023 at 1:45 PM Resident #338 was lying in bed visiting with family. Bilateral heels were not off loaded. During an interview on 5/24/2023 at 10:00 AM Resident #338 stated, They do not put anything on my feet, or under my heels while I am lying in bed. During an interview on 5/24/2023 at 1:55 PM Staff C, Licensed Practical Nurse stated, It is the responsibility of the Certified Nursing Assistants (CNA's) and the nurses to make sure the care plan is being followed. Review of Resident #338's physician's orders dated 5/20/2023 read Offload Bilateral heels while in bed every shift for Prophylaxis. Review of Resident #338's care plan dated 5/20/2023 read Risk for skin breakdown related to decreased mobility. Administer skin treatment as ordered. Minimize pressure to boney prominences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106139 If continuation sheet Page 3 of 4 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 106139 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chatham Glen Healthcare and Rehabilitation Center 16605 SE 74th Soulliere Avenue 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 - Some 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 was stored in accordance with professional standards for food service safety in the dry storage food area and in the walk-in freezer in the main kitchen. Findings include: During the initial tour of the kitchen dry good storage area conducted with the Certified Dietary Manager on 5/22/23 at 9:25 AM, a plastic scoop was observed in the oatmeal storage bin lying on top of the oatmeal and a small metal scoop was observed in the brown sugar storage bin on top of the brown sugar. During a tour conducted with the Certified Dietary Manager on 5/22/23 at 9:30 AM of the facility's walk-in freezer, there was a container of fried chicken with the cover opened on the corner, a partially used bag of lasagna sheets not fully closed and a partially used bag of preformed cookie pucs [formed, uncooked cookie dough] not fully closed. During an interview conducted on 5/24/23 at 9:47 AM the Certified Dietary Manager stated that her expectation for food stored in the freezer be labeled, dated and fully closed and that no scoops should be kept on top of the food in the dry food storage bins. Review of policy and procedure titled Food Safety Requirements implemented 3/18/23 read, Policy: It is a policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with the delivery of the food to the residents. Elements of this process including the following: .b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including the growth of microorganisms 8. Additional strategies to prevent foodborne illness include, but are not limited to: .d. Proper refrigeration of meat, poultry, and pasteurized dairy products. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106139 If continuation sheet Page 4 of 4