Health inspection·February 20, 2026

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents' Minimum Data Set (MDS) assessments were accurate for 2 of 6 residents reviewed for medication management (Residents #75, and #122). Findings include:1) Review of Resident #122's physician order dated 9/28/2025 read, Furosemide Oral Tablet (Furosemide), Give 20 mg [milligram] by mouth every 12 hours for fluid retention. Order Status: Active. Review of Resident #122's Medication Administration Record for January 2026 documented Furosemide was administered from 1/20/2026 to 1/31/2026.Review of Resident #122's quarterly MDS assessment dated [DATE] revealed the resident was not taking diuretics under Section NMedications.During an interview on 2/19/2026 at 12:37 PM, the Director of MDS stated, [Resident #122's name] diuretic medication section had been coded incorrectly and needed to be corrected.2) Review of Resident #75's physician order dated 8/12/2025 read, Wellbutrin SR [Sustained Release] Oral Tablet Extended Release 12 hour (Bupropion HCI [Hydrochloride]), Give 150 mg by mouth every 12 hours for Depression, Administer whole, do not crush split or chew. Order Status: Active. Review of Resident #75's Medication Administration Record for January 2026 documented Wellbutrin SR was administered from 1/20/2026 to 1/31/2026.Review of Resident #75's MDS assessment dated [DATE] documented the resident was not taking antidepressant under Section N- Medications.During an interview on 2/19/2026 at 12:37 PM, the Director of MDS stated, [Resident #75's name] antidepressant medication section had been coded incorrectly and needed to be corrected.Review of the facility policy and procedures titled MDS 3.0 Completion with the last review date of 5/30/2025 read, Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specific by the State. Residents Affected - Few Page 1 of 7 106139 106139 02/20/2026 Chatham Glen Healthcare and Rehabilitation Center 16605 SE 74th Soulliere Avenue The Villages, FL 32162

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, interview, and record review, the facility failed to ensure medications were administered as ordered by physician for 2 of 7 residents reviewed for medication management (Residents #24 and #90), and failed to ensure the intravenous (IV) catheter dressing was changed for 1 of 4 residents reviewed for intravenous therapy (Resident #140). Findings include: Residents Affected - Few 1) During an observation on 2/19/2026 at 8:13 AM, Staff G, Licensed Practical Nurse (LPN), administered Diltiazem HCI (Hydrochloride) ER (Extended Release) 240 mg (milligram) capsule to Resident #24. Electronic health record showed Resident #24's blood pressure documented as 118/54 mmHg (millimeter of mercury) and pulse as 56 beats per minute. Review of Resident #24's physician order dated 12/31/2025 read, Diltiazem HCI ER Coated Beads 240 MG capsule extended release 24 hr [hour], Give 1 capsule by mouth one time a day for HTN [hypertension] hold if SBP [systolic blood pressure] is less than 110 or HR [heart rate] less than 60. Administer whole, do not crush, split or chew. During an interview on 2/20/2026 at 8:05AM, the Director of Nursing stated, Staff should follow parameters and notify the provider when the parameters are not followed. Medication should be given as ordered, unless the provider is aware and gives the order for the medication to be given out of parameters. During an interview on 2/20/2026 at 9:09 AM, Staff G, LPN, stated, I did not see the parameters for the blood pressure medication for [Resident #24's name]. I should always follow parameters. 2) During an observation on 2/19/2026 at 9:24 AM, Staff H, LPN, poured one Enteric Coated Aspirin 81 milligram into the medication cup for Resident #90. Staff H crushed the medication and mixed it with chocolate pudding. Staff H was requested to review the physician order prior to entering Resident #90's room to administer the medication. During an interview on 2/19/2026 at 9:37 AM, Staff H, LPN, stated, Enteric Coated medication should not have been crushed. Review of Resident #90's physician order dated 2/25/2026 read, Aspirin Tablet Delayed Release, Give 81 mg by mouth one time a day for cardiac maintenance monitor for bleeding/bruising and notify provider with any concerns. Do not crush, cut or chew. During an interview on 2/19/2026 at 12:30 PM, the Director of Nursing stated, Delayed Release medication should not be crushed. The nurse should contact the provider to change the order. Review of the facility policy and procedures titled Medication Administration with the last review date of 5/30/2025 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 17. Administer medication as ordered in accordance with manufacturer specifications. c. Crush medications as ordered. Do not crush medications with do not crush instructions. 106139 Page 2 of 7 106139 02/20/2026 Chatham Glen Healthcare and Rehabilitation Center 16605 SE 74th Soulliere Avenue The Villages, FL 32162

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3) During an observation on 2/17/2026 at 9:51 AM, Resident #140 had an intravenous midline catheter on her left upper arm. The dressing was peeling away and there was dried blood at the insertion site. The dressing was dated 2/12/2026 (Photograph evidence obtained). Review of Resident #140's intravenous team note dated 2/7/2025 at 7:55 PM read, 14 cm [centimeters] midline placed in left basilic vein. + [positive] blood return. Flushed NS [normal saline], skin prep, bio patch, stat lock and Tegaderm [clear dressing]. Review of Resident #140's physician order dated 2/11/2026 read, Change (midline) transparent dressing every 7 days and PRN [as needed] if soiled or dislodged every night shift Wed [Wednesday] for infection control. Review of Resident #140's physician order dated 2/17/2026 read, Normal Saline Flush Solution 0.9% (Sodium Chloride Flush), Use 10 ml [milliliter] intravenously every 12 hours for patency. Review of Resident #140's Medication Administration Record (MAR) documented normal saline flush was administered on 2/17/2026 at 9:00 AM and 9:00 PM, and on 2/18/2026 at 9:00 AM. During an observation on 2/17/2026 at 12:27 PM, Resident #140 IV dressing was peeling away and there was dried blood at the insertion site. The dressing was dated 2/12/2026. During an interview on 2/17/2026 at 12:45 PM, Staff A, LPN, stated that the dressing had to be changed if soiled. During an interview on 2/18/2026 at 9:45 AM, Staff B, LPN, stated, I just flushed the IV [intravenous] line and seen the blood, but did not think to change the dressing. During an interview on 2/28/2025 at 1:45 PM, the Director of Nursing stated, The dressing should be changed as written by the physician every 7 days and should be changed if contaminated. It should have been changed when blood was observed and the dressing was contaminated. Review of the facility policy and procedures titled PICC/Midline/CVAD Dressing change with the last review date of 5/30/2025 read, Policy: It is the policy of this facility to change peripherally inserted catheter (PICC), midline or central venous access device (CVAD) dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. 106139 Page 3 of 7 106139 02/20/2026 Chatham Glen Healthcare and Rehabilitation Center 16605 SE 74th Soulliere Avenue The Villages, FL 32162

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observation, interview, and record review, the facility failed to ensure medications were securely stored in 2 of 4 halls. Findings include: 1) During an observation on 2/17/2026 at 10:31 AM, Resident #3 was sitting in her wheelchair in her room next to her bed. On top of her bed, there was Hydrocortisone Cream 1% and Zinc Oxide Ointment. During an interview on 2/17/2026 at 10:31 AM, Resident #3 stated, I use the creams preventively for my back because at times my back will itch. During an interview on 2/17/2026 at 11:52 AM, Staff I, Licensed Practical Nurse (LPN), stated, Residents are not to keep medication in their rooms. It should be secured in the medication cart. During an interview on 2/19/2026 at 12:40 PM, the Director of Nursing stated, Medications should be stored in a lock box. 2) During an observation on 2/17/2026 at 10:06 AM, there was a pill and powdered substance on the floor in Resident #42's room. During an observation on 2/17/2026 at 10:24 AM, there was a medication on the floor, crushed into pieces and powder, in Resident #143's room. During an interview on 2/17/2026 at 12:03 PM, Staff C, LPN, identified the items observed in Resident #42's room as medication and a powder medication for the patient's [Resident #42's] buttocks. The process is to call out the medication and stay with the resident until the medication is consumed by the resident before moving on to the next medication pass. it probably happened during the night shift. During an interview on 2/17/2026 at 12:06 PM, Staff C, LPN, identified the substance in Resident #143's room and stated, This is a pill medication. The morning staff did not inform me of medication being on the floor. 3) During an observation on 2/17/2026 at 10:01 AM, there were one bottle of Blink tears dry eye lubricating eye drops (active ingredient: Polyethylene glycol) and one bottle of nail polish removal (active ingredient: Acetone) on Resident #18's bedside table (Photograph evidence obtained). During an interview on 2/17/2026 at 10:01 AM, Resident #18 stated, I use the eye drops any time that my eyes feel dry. I've used the eye drops when I got up this morning around 7 AM. I was never told that I could not have the eye drops or the fingernail polish remover in my room. During an interview on 2/17/2026 at 12:50 PM, Staff A, LPN, stated, No medication or nail polish remover can be left at the bedside. 4) During an observation on 2/17/2026 at 9:46 AM, there was one bottle of Systane Lubricant eye 106139 Page 4 of 7 106139 02/20/2026 Chatham Glen Healthcare and Rehabilitation Center 16605 SE 74th Soulliere Avenue The Villages, FL 32162

F 0761 Level of Harm - Minimal harm or potential for actual harm drops (active ingredients: polyethylene glycol 400 (0.4%) and propylene glycol (0.3%)) on Resident #15's bedside table. During an interview on 2/17/2026 at 9:46 AM, Resident #15 stated, My wife brought those [eye drops] in and I use the drops if I need to. I used the eye drops last night. Residents Affected - Few During an interview on 2/17/2026 at 12:57 PM, Staff A, LPN, stated, No medications including saline eye drops can be left at the bedside. What happens is the families bring these medications in and don't tell us. During an interview on 2/18/2026 at 1:45 PM, the Director of Nursing stated, No medication can be left at the bedside unsecured. Review of the facility policy and procedures titled Medication Storage with the last review date of 5/30/2025 read, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication room according to the manufactures' recommendation and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines. 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerator, medication rooms) under proper temperature controls. b. only authorized personnel will have access to the keys to locked compartments. 106139 Page 5 of 7 106139 02/20/2026 Chatham Glen Healthcare and Rehabilitation Center 16605 SE 74th Soulliere Avenue The Villages, FL 32162

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Potential for minimal harm Based on record review and interview, the facility failed to ensure the arbitration agreement granted the right to rescind the arbitration agreement within 30 calendar days for 3 of 3 residents reviewed for arbitration (Residents #58, #148, and #149). Findings include: Review of Resident #58's Arbitration Agreement signed on 10/11/2024 did not include the right to rescind the agreement within 30 days after signing the agreement.Review of Resident #148's Arbitration Agreement signed on 2/16/2026 did not include the right to rescind the agreement within 30 days after signing the agreement. Review of Resident #149's Arbitration Agreement signed on 2/9/2026 did not include the right to rescind the agreement within 30 days after signing the agreement.During an interview on 2/19/2026 at 2:59 PM, the Administrator stated, We used to have another arbitration agreement and we changed software. The agreement should say the resident has the right to rescind within 30 days.Review of the facility policy and procedure titled Binding Arbitration Agreements with the last review date of 5/30/2025 read, Policy Explanation and Compliance Guidelines: 2. The agreement must: c. Explicitly grant resident or his or her representative right to rescind the agreement within 30 calendar days of signing it. Residents Affected - Many 106139 Page 6 of 7 106139 02/20/2026 Chatham Glen Healthcare and Rehabilitation Center 16605 SE 74th Soulliere Avenue The Villages, FL 32162

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 used personal protective equipment (PPE) appropriately while providing wound care for 1 of 1 residents observed for wound care (Resident #13) to prevent the possible spread of infection and communicable diseases.Findings include: During an observation on 2/20/2026 at 8:15 AM, Staff F, Licensed Practical Nurse (LPN), started providing wound care for Resident #13. Staff F performed hand hygiene and donned gloves. Wound care supplies were separately stored and labeled with Resident #13's name in plastic bags. Staff F removed 4x4 gauze, collagen, Santyl and iodoform packing strip. Staff F cleaned scissors with alcohol and let the scissors dry prior to cutting iodoform packing strip. Staff F performed hand hygiene and donned gown and gloves. Staff F did not tie top of the gown and shoulders were not covered. Staff F proceeded to adjust Resident #13 in the bed on his left side. Staff F adjusted her gown at the shoulders and then removed old dressing from coccyx region and disposed of the old dressing. Staff F adjusted her gown on shoulders and then removed the contaminated gloves, and adjusted shoulders of the gown again while walking to the sink. Staff F performed hand hygiene and donned clean gloves and then adjusted the shoulders of the gown again, having the clean gloves on. Staff F proceeded to complete the wound care by applying the Santyl, packing the wound and applying the dry clean dressing (DCD).Review of Resident #13's physician order dated 2/18/2026 read, Santyl External Ointment 250 unit/gm [gram] (collagenase). Apply to coccyx topically as needed for soiled or dislodged and apply to coccyx topically every day shift for wound care. Irrigate wound with Dakins, pat dry, sprinkle collagen flakes to wound bed, then, apply nickel thick layer of Santyl into wound bed. Lightly pack w/ [with] iodoform packing strip and cover w/ DCD. Monitor for ss [signs and symptoms] or worsening. Notify MD [Medical Doctor] w/ any concerns.Review of Resident #13's physician order dated 1/30/2026 read, Enhanced barrier precautions due to wounds every shift.During an interview on 2/20/2026 at 8:45 AM, Staff F, LPN, stated, I realized what I did after the second time that I adjusted the gown. I should not do that.During an interview on 2/20/2026 at 9:00 AM, the Director of Nursing stated the gown should be tied to prevent staff from adjusting with contaminated glove and cross contamination.Review of the facility policy and procedures titled Personal Protective Equipment with he last review date of 5/30/2025 read, Policy: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to resident, visitors, and other staff. Policy Explanation and Compliance Guidelines: Indications/considerations for PPE use: B. Gowns: i. Wear gowns to protect arms, exposed body areas, and clothing from contamination with blood, body fluids, and other potentially infectious material. ii. Gowns should fully cover torso from neck to knees, arms to end of wrist, and wrap around the back. Fasten in back at neck and waist. Residents Affected - Few 106139 Page 7 of 7