Chatham Glen Healthcare And Rehabilitation Center
CHATHAM GLEN HEALTHCARE AND REHABILITATION CENTER in THE VILLAGES, FL — inspection on February 20, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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 N- Medications.
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.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
106139 02/20/2026
Chatham Glen Healthcare and Rehabilitation Center 16605 SE 74th Soulliere Avenue The Villages, FL 32162
Review of Resident #140's intravenous team note dated 2/7/2025 at 7:55 PM read, 14 cm
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 02/20/2026
Chatham Glen Healthcare and Rehabilitation Center 16605 SE 74th Soulliere Avenue The Villages, FL 32162
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 02/20/2026
Chatham Glen Healthcare and Rehabilitation Center 16605 SE 74th Soulliere Avenue The Villages, FL 32162
refuse.
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
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.
wound care (Resident #13) to prevent the possible spread of infection and communicable
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.
106139 02/20/2026
Chatham Glen Healthcare and Rehabilitation Center 16605 SE 74th Soulliere Avenue The Villages, FL 32162