Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Buffalo Crossings Healthcare & Rehabilitation Cen during CMS and state inspections, most recent first.
A resident with significant medical needs did not receive a requested shower and hair wash, despite repeated requests and the ability to have her legs wrapped to accommodate wound care. Staff interviews showed inconsistencies in understanding the resident's needs and preferences, and documentation did not reflect a refusal of care. The facility did not honor the resident's preferences for personal hygiene services.
A resident with multiple skin impairments and a complex medical history was admitted without a baseline care plan addressing skin integrity, despite physician orders and documented skin issues. Staff interviews confirmed that the omission was due to incomplete assessment during admission, resulting in the lack of appropriate interventions in the initial care plan.
The facility did not administer PRN hypertension medication as ordered for a resident with elevated blood pressure readings and failed to change a wound dressing every three days as prescribed for another resident. Nursing staff and the DON confirmed that physician orders for both medication and wound care were not followed.
A resident with a history of lower extremity amputation and prosthetic use did not receive timely restorative nursing program (RNP) services after being discharged from physical therapy, due to a lapse in communication and lack of a backup process when the ADON was unavailable. The resident began receiving RNP services approximately three weeks after PT discharge, contrary to physician orders and therapy recommendations.
Two residents with chronic respiratory conditions did not have their nebulizer masks stored in accordance with professional standards, as the masks were repeatedly observed left unbagged on bedside tables. Facility leadership confirmed the improper storage and the absence of a policy for nebulizer or oxygen supply storage.
Surveyors found that food items, including waffles and a cup of liquid, were stored in nutrition rooms on three halls without proper dating or labeling. The Certified Dietary Manager confirmed these items should have been dated and labeled according to facility policy.
Multiple residents experienced incomplete or inaccurate documentation related to medication administration, wound care, and nutrition orders. For example, a resident receiving PRN antianxiety medication did not have behaviors or side effects properly documented, two residents had missing or incorrect wound care entries, and another resident's nutrition order lacked a specified amount, resulting in staff using a standard protocol. Staff interviews confirmed these documentation lapses.
A resident with a left hip prosthetic developed an infection, but the facility failed to inform the family of the change in condition or the initiation of antibiotics. Interviews with staff, including an LPN and the DON, confirmed the lack of documentation and notification, despite the standard of care requiring such communication.
The facility failed to ensure accurate MDS assessments for two residents. One resident's discharge was incorrectly documented as to a hospital instead of an ALF, and another resident's hospice care status was inaccurately recorded as not receiving hospice services despite documentation to the contrary. The MDS Coordinator acknowledged the errors and the lack of a specific MDS policy.
The facility failed to ensure complete and accurate resident records for two residents. One resident's medication refusals were not properly documented or communicated to the provider, and another resident's blood pressures were not recorded as required when administering Midodrine. Staff interviews revealed a lack of adherence to documentation protocols.
The facility failed to prevent the spread of infection by not performing hand hygiene during medication administration and not cleaning blood pressure cuff monitors between residents. An RN and an LPN were observed not following proper hand hygiene and equipment cleaning protocols, as confirmed by the DON.
Failure to Honor Resident's Shower and Hair Care Preferences
Penalty
Summary
A resident with multiple medical conditions, including muscle weakness, unsteady gait, chronic respiratory failure, COPD, congestive heart failure, and gout, reported not receiving requested care items such as tissues, a shower, and a hair wash despite repeated requests since early morning. The resident expressed a desire to have wounds on her legs covered or changed and indicated a willingness to have her legs wrapped so she could shower, even if the dressings became wet. The resident also stated that she did not receive a shower or hair wash on the day requested, only a wash-up, and emphasized the importance of these services due to an upcoming visit from her son and a friend who would do her hair. Staff interviews revealed inconsistencies regarding the resident's ability to shower independently and the provision of assistance. A CNA stated the resident could shower herself and only requested towels, while also acknowledging the need to wrap the resident's legs. An LPN described the resident as requiring assistance for showers and noted that hair care was typically provided in the salon. The DON referenced therapy notes indicating the resident was in the shower but did not find documentation of a refusal for hair washing. The DON also stated that hair washing is considered part of the shower process. The facility failed to honor the resident's preferences for showering and hair washing as requested.
Failure to Develop Baseline Care Plan for Skin Integrity Upon Admission
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a baseline care plan addressing skin integrity within 48 hours of admission for a resident with multiple skin conditions. Upon admission, the resident presented with a complex medical history, including lobar pneumonia, acute respiratory failure, hypocalcemia, hypothyroidism, depression, atopic dermatitis, and other chronic conditions. Observations and record reviews revealed the presence of a foam dressing on the resident's right lower leg, a physician's order for wound care, and documentation of multiple skin impairments such as bruising, non-blanchable redness, a small pressure area, discoloration, and a skin tear. Despite these findings, the baseline care plan did not include any focus or interventions for skin integrity. Interviews with facility staff confirmed that the omission was due to the nurse not checking off skin integrity in the comprehensive assessment upon admission. Both the Minimum Data Set Coordinator and the Director of Nursing acknowledged that the baseline care plan should have addressed the resident's skin integrity, given the documented skin issues and physician orders for wound care. The facility's policy requires that a baseline care plan be developed within 48 hours of admission, but this was not followed in this case.
Failure to Follow Physician Orders for Medication Administration and Wound Care
Penalty
Summary
The facility failed to follow physician-ordered parameters for administering hypertension medication for one resident with multiple diagnoses, including essential hypertension, hypertensive heart and chronic kidney disease, atrial fibrillation, and hyperlipidemia. Despite having a physician order to administer Hydralazine HCl 10 mg orally every 8 hours as needed for systolic blood pressure (SBP) greater than 160 mmHg, the medication was not given on multiple occasions when the resident's SBP exceeded this threshold. Review of the Medication Administration Record (MAR) for June and July showed no administration of the medication on these dates. Interviews with nursing staff and the Director of Nursing confirmed that the medication should have been administered according to the order, and staff were unaware of or did not follow the PRN order. Additionally, the facility failed to ensure wound dressing changes were performed as ordered for another resident with a skin tear. The physician's order specified cleansing the skin tear and applying an adaptic and foam dressing every three days. Observations revealed that the dressing on the resident's right lower leg was not changed for at least five days, as indicated by the date on the dressing. Staff interviews confirmed the dressing change was overdue and that there was confusion regarding the correct leg for the order. The Director of Nursing acknowledged that the dressing should have been changed according to the specified frequency.
Delay in Initiation of Restorative Nursing Program After PT Discharge
Penalty
Summary
A deficiency occurred when a resident did not receive timely restorative nursing program (RNP) services following discharge from physical therapy (PT). The resident, who had a history of left lower extremity amputation and used a prosthetic limb, was discharged from PT with orders to begin RNP for active range of motion (AROM) exercises and assistance with transfers and prosthetic management three times a week. Despite these orders, there was a delay in initiating the RNP services, as the resident did not begin receiving restorative care until approximately three weeks after PT discharge. Interviews with facility staff revealed that the delay was due to a lapse in communication and process. The Assistant Director of Nursing (ADON), who is responsible for entering restorative program orders, was out for an extended period, and no alternative process was in place to ensure timely initiation of services. The Rehabilitation Director stated that orders are typically placed in the ADON's mailbox, but there was no backup procedure if the ADON was unavailable. The Director of Nursing confirmed that there is no regulated timeframe for starting restorative services, but acknowledged that the resident should have been placed on the program as soon as possible after PT discharge.
Failure to Properly Store Nebulizer Masks for Residents Receiving Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care services consistent with professional standards of practice for two residents who were receiving oxygen therapy. For both residents, observations on multiple occasions revealed that their nebulizer masks were left on top of their bedside tables and were not stored in bags as required. Photographic evidence was obtained to document these findings. Both residents had active physician orders for Ipratropium-Albuterol nebulizer treatments to be administered multiple times daily for chronic respiratory conditions, including COPD and chronic respiratory failure. Interviews with facility leadership confirmed the improper storage of the nebulizer masks. The Director of Nursing acknowledged that the masks were not stored appropriately, and the Administrator stated that the facility did not have a policy regarding the storage of nebulizer or oxygen supplies. The lack of proper storage practices and absence of a relevant policy contributed to the deficiency in providing safe and appropriate respiratory care for the affected residents.
Failure to Date and Label Food Items in Nutrition Rooms
Penalty
Summary
Surveyors observed that the facility failed to ensure food items were properly dated, labeled, and stored in sealed containers in nutrition rooms across three residential halls: Prairie, [NAME], and Meadows. Specifically, an undated and unlabeled package of 12 waffles was found in the refrigerator on both the Prairie and Meadows Halls, and an undated and unlabeled Styrofoam cup of liquid was found on the counter in the nutrition room on the [NAME] Hall. During interviews, the Certified Dietary Manager confirmed that these items should have been dated and labeled when removed from their original containers and placed in the nutrition rooms. Review of the facility's policy indicated that a date marking system is required to ensure the safety of ready-to-eat, time/temperature control for safety food.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate in several instances involving medication administration, wound care, and nutrition orders. For one resident receiving PRN Lorazepam for anxiety and restlessness, the Medication Administration Record (MAR) showed the medication was administered multiple times, but documentation of observed behaviors and side effects was incomplete. Nursing progress notes did not include entries related to the behaviors that prompted the administration of the medication, and staff interviews confirmed that documentation was not accurately completed at the time of administration. In the review of wound care, two residents had incomplete or inaccurate documentation in their Treatment Administration Records (TAR). For one resident, there were missing entries on specific dates for daily wound care, and staff interviews revealed that dressing changes were performed but not documented, or documentation was forgotten. Another resident had a dressing on the right leg that was not changed according to the physician's order, and the order itself incorrectly referenced the left leg instead of the right. Staff acknowledged documentation errors and confusion regarding the correct anatomical site. Additionally, a nutrition order for another resident lacked a specified amount for a prescribed supplement, leading to staff administering a standard amount based on protocol rather than a clear physician directive. The DON confirmed that the order should have included a precise amount. These findings collectively demonstrate failures in maintaining complete and accurate medical records in accordance with professional standards.
Failure to Notify Family of Resident's Infection
Penalty
Summary
The facility failed to inform the resident's representative of a change in the resident's status, specifically regarding an infection in the surgical site of the left hip. The resident, who was admitted with a periprosthetic fracture around an internal prosthetic left hip joint, anxiety, depression, and an artificial hip joint, developed redness, edema, pain, and heat in the left hip. This condition was noted in the progress notes, and the physician ordered Cipro 250 mg twice daily for seven days due to left hip cellulitis. Interviews with the Infection Preventionist, an LPN, and the Director of Nursing revealed that there was no documentation indicating that the family was informed of the infection or the initiation of antibiotics. The Director of Nursing confirmed that any change in condition requires notification of the physician and family unless the resident is their own responsible party. However, the facility did not have a change in condition policy, and it was considered a standard of care, which was not followed in this instance.
Inaccurate MDS Assessments for Discharge and Hospice Services
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the residents' status for two residents. For Resident #106, the MDS assessment incorrectly documented the discharge destination as a hospital instead of an Assisted Living Facility (ALF), despite a progress note confirming the discharge to an ALF. For Resident #80, the MDS assessment inaccurately indicated that the resident was not receiving hospice services, even though the resident had been admitted to hospice care with a diagnosis of End Stage Heart Disease, as documented in the physician's order and care plan. The MDS Coordinator acknowledged the errors and mentioned the absence of a specific policy for the MDS, relying instead on the Resident Assessment Instrument.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate for two residents sampled for medication administration record review. Resident #92, who was admitted with multiple diagnoses including Hypertension and Atrial Fibrillation, had instances where medication refusals were not properly documented or communicated to the provider. Specifically, on two occasions, the resident refused their 9 AM and 9 PM medications, but the refusals were not reported to the doctor as required. Additionally, a nurse documented that medications were administered when they were not, and another nurse admitted to pre-signing the MAR before actually giving the medications, which is against protocol. Resident #262, admitted with diagnoses including a fracture of the left femur and orthostatic hypotension, had issues with the documentation of blood pressures and medication administration. The MAR for this resident showed that blood pressures were not recorded at the times when Midodrine was administered or held, despite the medication order requiring blood pressure monitoring. There were instances where the medication was documented as given or held without corresponding blood pressure readings, and the DON confirmed that nurses had taken blood pressures but failed to document them. Interviews with staff, including the DON, revealed that there was a lack of adherence to documentation protocols. Nurses admitted to not documenting medication refusals and blood pressure readings as required. The facility's policy on medication administration was reviewed, which mandates that medications should be signed off only after administration and that any refusals or adverse effects should be reported and documented. However, the facility did not have a specific policy on documentation, contributing to the deficiencies observed.
Infection Control Deficiency
Penalty
Summary
The facility failed to prevent the possible spread of infection by not performing hand hygiene during medication administration and not cleaning blood pressure cuff monitors between residents. During an observation of medication administration for Resident #92, a Registered Nurse (RN) was seen entering the resident's room and checking the resident's blood pressure with an automatic wrist cuff without performing hand hygiene. The RN then returned the cuff to the medication cart without cleaning it. The RN also failed to perform hand hygiene before and after preparing and administering medications to Resident #92, and before using the telephone at the nursing station. The RN admitted to not performing hand hygiene as required. In another instance, during an observation of medication administration for Resident #20, a Licensed Practical Nurse (LPN) checked the resident's blood pressure and returned the manual blood pressure cuff and stethoscope to the medication cart without cleaning them before initiating medication administration to another resident. The LPN acknowledged that the equipment should have been cleaned before use on the next resident. The Director of Nursing (DON) confirmed that the facility's policy requires hand hygiene before and after patient care and cleaning of equipment between residents. The facility's policies on medication administration, hand hygiene, and cleaning and disinfection of resident-care equipment were reviewed and found to be consistent with professional standards of practice, but were not followed by the staff involved in these observations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near The Villages
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Club Healthcare And Rehabilitation Center At The V | 3.6 mi | ★★★★★ | 0 | 0 |
| Freedom Pointe Health Center | 4.2 mi | ★★★★★ | 7 | 0 |
| Cypress Care Center | 5.1 mi | ★★★★★ | 1 | 0 |
| Lady Lake Specialty Care Center And Rehab | 5.5 mi | ★★★★★ | 10 | 2 |
| Villages Healthcare And Rehabilitation Center, The | 6.1 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.