Inspection·September 19, 2024

F 0692 Level of Harm - Minimal harm or potential for actual harm I don't think it would cause harm if he didn't get it. His weight is becoming stable, but he needs to be getting his shakes. During an interview on 9/18/2024 at 1:25 PM, the Certified Dietary Manager stated, The dietary aide is responsible for putting the Mighty Shakes on the tray with the meals. Residents Affected - Few During an interview on 9/19/2024 at 7:48 AM, the Director of Nursing stated, I expect the nursing staff to be following physician orders. Review of the facility policy and procedure titled Nutritional and Dietary Supplements last reviewed on 5/15/2024, showed it read, Policy: It is the policy of this facility that nutritional and dietary supplements will be used to complement a resident's dietary needs in order to maintain adequate nutritional status and resident's highest practicable level of well-being. Definitions . Nutritional Supplements refers to products that are used to complement a resident's dietary needs such as calorie or nutrient dense drinks, total parenteral products, enteral products and meal replacement products (e.g. Ensure, Glucerna, Promote). Policy Explanation and Compliance Guidelines . 8. Nutritional supplements are to be provided to residents within 45 minutes of either a resident's request of less depending on the facility's scheduled time for meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106139 If continuation sheet Page 2 of 9 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 09/19/2024 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to post the accurate nurse staffing data for the facility on a daily basis. Residents Affected - Many Findings include: During an observation while conducting the initial tour of the facility on 9/16/2024 at 9:10 AM, there was no nurse staffing data on the receptionist desk, posted on the wall, in the reception area or at the nursing stations. During an interview on 9/16/2024 at 9:20 AM, the Administrator stated, I'm not sure what you are looking for. We have a list on each unit of all the staff for the day. I don't have the information you are looking for posted. During an observation on 9/16/2024 at 3:03 PM, the nurse staffing data was displayed on the counter at the receptionist desk, indicating the facility census for 9/16/2024 as 111. During an interview on entrance conference conducted on 9/16/2024 at 9:14 AM, the Administrator stated the resident census for 9/16/2024 was 110. Review of the facility's daily census dated 9/16/2024 showed total residents of 110. During an interview on 9/16/2024 at 3:05 PM, the Administrator stated, The posting is posted up front each day, but it was not there this morning when you asked me about it. It should have been there, and it should be accurate. During an interview on 9/18/2024 at 8:04 AM, Staff C, Certified Nursing Assistant/Staff Coordinator, stated that she coordinated the federal staffing posting and it wasn't posted at shift change for 9/16/2024. Review of the facility policy and procedure titled Nurse Staffing Posting Information last reviewed on 8/23/2024, showed it read, Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name, b. The current date, c. Facility's current resident census, d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses, ii. Licensed Practical Nurse/Licensed Vocational Nurses, iii. Certified Nurse Aides. 2. The facility will post the Nurse Staffing Sheet at the beginning of each shift. 3. The information posted will be: a. Presented in a clear and readable format. b. In a prominent place readily accessible to residents and visitors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106139 If continuation sheet Page 3 of 9 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 09/19/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. 2) Review of Resident #52's Pharmacist's Recommendation to Prescriber dated 8/22/2024 showed it read, Findings/Recommendation: This resident has current orders that might present a potential drug interaction: Omeprazole cap 20 mg- give 20 mg by mouth two times a day for GERD [Gastroesophageal Reflux Disease] administer whole do not crush chew or cut., in addition to Sucralfate. Recommendation: Please consider discontinuation of Sucralfate at this time, unless clinically contraindicated. If concomitant therapy is still warranted at this time, please indicate reason . Prescriber's Response: Disagree. The form did not contain the prescriber's rationale. Review of Resident #52's medical records did not reveal any rationale provided by the provider for the pharmacist's recommendation on 8/22/2024. During an interview on 9/19/2024 at 11:26 AM, the Director of Nursing (DON) stated, I just spoke to the pharmacist, and they will be changing the forms so that the physicians know they must include a rationale. Since it just said comments, I would not think I had to write anything in that section. I did not find any rationale for the action of the physician for [Resident #52's name] and [Resident #72's name]. Review of the facility policy and procedure titled Addressing Medication Regimen Review Irregularities with the last review date of 5/6/2024 showed it read, Policy: It is the policy of this facility to provide a Medication Regimen Review (MRR) for each resident in order to identify irregulates and respond to those irregularities in a timely manner to prevent the occurrence of an adverse drug event . Policy Explanation and Compliance Guidelines . 4 d. The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. Based on record review and interview, the facility failed to ensure the attending physician documented their rationale related to pharmacy recommendations for 2 of 5 residents reviewed for unnecessary medications, Residents #52 and #72. Findings include: 1) Review of Resident #72's Pharmacist's Recommendation to Prescriber dated 4/25/2024 showed it read, Findings/Recommendation: This resident is receiving a low dose antipsychotic regimen, Quetiapine Tab [tablet] 25 mg [milligram]- Give 25 mg by mouth at bedtime for paranoia . Recommendation: please consider a taper or discontinuation at this time. If reduction or tapering is clinically contraindicated, please indicate rationale below . Prescriber's Response: Disagree. The form did not contain the prescriber's rationale. Review of Resident #72's Pharmacist's Recommendation to Prescriber dated 6/23/2024 showed it read, Findings/Recommendations: This resident has an order for Vitamin C Tab 500 mg- Give 500 mg by mouth one time a day for age related deficiency . Recommendation: Please consider discontinuation of Ascorbic Acid for supplement . Prescriber's Response: Disagree. The form did not contain the prescriber's rationale. Review of Resident #72's medical records did not reveal any rationale provided by the provider for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106139 If continuation sheet Page 4 of 9 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 09/19/2024 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 0756 the pharmacist's recommendations on 4/25/2024 and 6/23/2024. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106139 If continuation sheet Page 5 of 9 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 09/19/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure accurate documentation of nutritional supplement administration and percentage of supplement consumed for 1 of 9 residents reviewed for nutrition, Resident #43. Findings include: Review of Resident #43's admission record revealed the resident was admitted on [DATE] with diagnoses including combined systolic (congestive) and diastolic (congestive) heart failure (primary diagnosis), respiratory failure, orthostatic hypotension, pulmonary embolism without acute core pulmonale, essential (primary) hypertension, muscle weakness, abnormalities of gait and mobility, protein-calorie malnutrition, hyperlipidemia, atherosclerotic heart disease of native coronary artery without angina pectoris, peripheral vascular disease, gastro-esophageal reflux disease without esophagitis, osteoarthritis, and pleural effusion. Review of Resident #43's physician order dated 9/6/2024 showed it read, Mighty Shake with meals for protein supp [supplement] 1 carton= 4 oz [ounces]. During an observation on 9/17/2024 at 9:10 AM, Resident #43 was eating his breakfast. There was no Mighty Shake on the resident's meal tray. During an observation on 9/17/2024 at 1:05 PM, Resident #43 received a lunch tray with a Mighty Shake on the tray. At 1:34 PM, the meal tray with unopened Mighty Shake carton was removed and returned to the tray return cart. During an observation on 9/18/2024 at 9:10 AM, Resident #43 was eating his breakfast on his bedside table. There was no Mighty Shake on the resident's tray. During an observation on 9/18/2024 at 12:52 PM, Resident #43 received a lunch meal tray with no Mighty Shake on the resident's tray. During an interview on 9/18/2024 at 1:10 PM, Staff A, Certified Nursing Assistant (CNA), stated, The Mighty Shake was not on the tray. It should have been on the tray, but it was not there. During an interview on 9/18/2024 at 1:17 PM, Staff B, Licensed Practical Nurse (LPN), stated, The nurse is responsible for documenting if the Mighty shake was drunk by the resident with his meals. I documented how much of the shake he drank in the MAR [Medication Administration Record]. Review of Resident #43's Medication Administration Record (MAR) showed the resident consumed 100% of Mighty Shake on 9/17/2024 at 8:00 AM, 9/17/2024 at 12:00 PM, and 9/18/2024 at 8:00 AM. During an interview on 9/19/2024 at 7:48 AM, the Director of Nursing stated, The amount consumed by a resident need to be accurately documented in the resident's record. The Mighty Shake shouldn't be documented with the amount consumed if the resident didn't receive it. I expect the nursing staff to be documenting accurately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106139 If continuation sheet Page 6 of 9 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 09/19/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy and procedure titled Documentation in Medical Record last reviewed on 2/21/2024, showed it read, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines . 4. Principles of documentation, include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. i. False information shall not be documented. Event ID: Facility ID: 106139 If continuation sheet Page 7 of 9 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 09/19/2024 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 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 ensure staff performed hand hygiene during medication administration for 2 of 4 reviewed for medication administration, Residents #481 and #101, and during wound care for 1 of 6 residents reviewed for skin conditions, Resident #13 to prevent from possible spread of infection and communicable diseases. Residents Affected - Few Findings include: 1) During an observation on 9/18/2024 at 9:03 AM, Staff B, Licensed Practical Nurse (LPN), opened the medication cart and realized she had no liquid protein in the medication cart. Staff B went to the medication room and used the keypad to open the door. Staff B returned to the medication cart and began to open and pour the liquid protein into a medication cup without performing hand hygiene. Staff B's pen fell on the floor and Staff B picked up the pen. Staff B opened the bottom drawer and removed a Sani wipe container with a purple top and sanitized the pen and her hands with the wipe without using gloves. Staff B proceeded to pour medication for Resident #481. Staff B did not have Miralax on hand in the medication cart. Staff B entered Resident #481's room leaving the oral medication locked in the medication cart and handed the liquid protein to the resident. The resident refused the medication. During an interview on 9/18/2024 at 9:36 AM, Staff B, LPN, stated, I did not realize I did not do hand hygiene when I came back from the medication room. I thought I did. 2) During an observation on 9/18/2024 at 9:59 AM, Staff D, Registered Nurse (RN), poured medications for Resident #101. Staff D did not have iron in her medication cart and went to the medication room to get the medication. Staff D opened the medication room door using the keypad. Staff D returned to the medication cart and opened and poured the iron into the medication cup without performing hand hygiene. Staff D was crossing the hallway and when another staff member exited a room and called Staff D for help, stating a resident had fallen. Staff D entered Resident #12's room with Resident #101's medication in her hand. Staff D exited Resident #12's room and without hand hygiene or disposing the medication entered Resident #101's room and administered the medication. During an interview on 9/18/2024 at 10:18 AM, Staff D, RN, stated, I should have done hand hygiene after coming back from the medication room and when I exited the resident's room before entering another resident's room. During an interview on 9/18/2024 at 10:47 AM, the Director of Nursing stated, Nursing staff should have performed hand hygiene when they return from the medication room since they are touching the keypad and the door to open the room. Staff should not walk into another resident's room with another resident's medication. Staff should hand the medication to another employee or just get rid of the medication and redraw the medication needed. 3) During an observation on 9/19/2024 at 7:25 AM, Staff E, Wound Care Nurse, LPN, entered Resident #13's room and donned personal protective equipment. Staff E removed the dressing from Resident #13's right foot. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene. Staff E cleaned the wound and removed her gloves and donned new pair of gloves without performing hand hygiene and applied the treatment. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene and applied a dressing to the resident's right foot wound. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene, repositioned (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106139 If continuation sheet Page 8 of 9 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 09/19/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident and removed the sacrum dressing. Resident #13 had a bowel movement. Staff E cleaned Resident #13's bowel movement. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene and proceeded to clean the sacrum wound. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene and applied the treatment. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene and applied the dressing. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene and proceeded to remove the left foot wound dressing. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene. Staff E cleaned the wound and changed her gloves without performing hand hygiene in between. Staff E applied the treatment to the wound. Staff E removed her gloves and donned a new pair of gloves without performing hand hygiene and applied the dressing to the resident's left foot. During an interview on 9/19/2024 at 7:56 AM, Staff E, LPN, stated, I know I should have used hand sanitizer in between removing my gloves. Yesterday, he had the hand sanitizer bottle in the room, but he did not have it today. During an interview on 9/19/2024 at 1:04 PM, the Director of Nursing (DON) stated, Staff should preform hand hygiene in between wound care steps and when they remove their gloves hand hygiene should be done. Review of the facility policy and procedure titled Hand Hygiene with the last review date of 5/6/2024 showed it read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility . Policy Explanation and Compliance Guidelines . 6. Additional Considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106139 If continuation sheet Page 9 of 9