Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Chatham Glen Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Inaccurate MDS medication coding was identified for two residents. One resident was receiving a diuretic for fluid retention and another was receiving an antidepressant for depression, but both MDS assessments incorrectly indicated those medication categories were not being taken. The DON stated the sections had been coded incorrectly.
Medication administration and IV care were not carried out as ordered for multiple residents. An LPN gave a BP medication despite parameters that indicated it should be held, crushed a delayed-release aspirin that was ordered not to be crushed, and staff observed an IV midline dressing peeling away with dried blood even though the dressing was due for routine change and should have been changed when contamination was seen.
Unsecured medications were found in multiple resident rooms, including creams on a bed, eye drops and nail polish remover on bedside tables, and pills/powdered medication on the floor. Residents said they used the items themselves, while an LPN and the DON stated medications should be kept secured in locked storage and not left at the bedside.
Improper PPE Use During Wound Care: An LPN provided wound care for a resident with a coccyx wound while repeatedly adjusting an untied gown and handling the gown with contaminated gloves. The resident had orders for daily Santyl wound care and enhanced barrier precautions due to wounds, and the facility policy required gowns to fully cover the torso and be fastened at the neck and waist.
A facility failed to ensure arbitration agreements included the required right for a resident or representative to rescind within 30 calendar days. Record review showed that agreements for three residents lacked this language, and the ADM acknowledged the agreement should state the 30-day rescission right. The facility policy required the agreement to explicitly grant that right.
A resident with multiple health issues, including malnutrition, did not consistently receive a prescribed nutritional supplement, Mighty Shake, with meals as ordered by the physician. Observations showed the supplement was missing from meal trays, and staff interviews confirmed the oversight. The facility's policy requires timely provision of nutritional supplements to support residents' dietary needs.
The facility failed to ensure physicians documented their rationale for disagreeing with pharmacy recommendations for two residents. One resident was recommended to taper or discontinue a low-dose antipsychotic and Vitamin C, while another had a potential drug interaction identified. In both cases, the prescribers disagreed but did not provide any rationale, contrary to facility policy.
A resident with multiple health issues, including malnutrition, did not consistently receive a prescribed nutritional supplement, Mighty Shake, with meals. Despite this, the MAR inaccurately recorded 100% consumption of the supplement. Observations showed the supplement was often missing or unopened on meal trays. Staff interviews revealed documentation inaccuracies, contrary to the facility's policy requiring factual and objective records.
The facility failed to ensure proper hand hygiene during medication administration and wound care, risking infection spread. An LPN and an RN did not perform hand hygiene after returning from the medication room and before handling medications for two residents. Additionally, a wound care nurse did not perform hand hygiene between glove changes while treating a resident's wounds. Both staff members acknowledged their lapses, and the DON confirmed the need for hand hygiene as per facility policy.
The facility did not post accurate nurse staffing data daily as required. During a tour, it was found that the staffing data was not available at the receptionist desk or nursing stations. The Administrator was unaware of the posting requirement, and later, the data was found with incorrect census information. The facility's policy requires this information to be posted at the start of each shift, but it was not done, as confirmed by a CNA/Staff Coordinator.
Inaccurate MDS Medication Coding
Penalty
Summary
The facility failed to ensure accurate MDS assessments for two residents reviewed for medication management. For Resident #122, the physician order showed Furosemide 20 mg by mouth every 12 hours for fluid retention as an active order, and the January 2026 MAR documented the medication was administered from 1/20/2026 through 1/31/2026. However, the quarterly MDS assessment documented that the resident was not taking diuretics under Section N - Medications. During interview, the Director of MDS stated the resident's diuretic medication section had been coded incorrectly and needed to be corrected. For Resident #75, the physician order showed Wellbutrin SR 150 mg by mouth every 12 hours for depression as an active order, and the January 2026 MAR documented the medication was administered from 1/20/2026 through 1/31/2026. However, the resident's MDS assessment documented that the resident was not taking antidepressants under Section N - Medications. During interview, the Director of MDS stated the resident's antidepressant medication section had been coded incorrectly and needed to be corrected. The facility policy titled MDS 3.0 Completion stated the facility conducts initially and periodically a comprehensive, accurate, and standardized assessment of each resident's functional capacity using the RAI specified by the State.
Medication Administration and IV Dressing Care Not Performed as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for two residents reviewed for medication management. One resident received Diltiazem HCl ER 240 mg even though the documented blood pressure was 118/54 mmHg and the pulse was 56 beats per minute, while the physician order directed staff to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. The LPN stated she did not see the blood pressure parameters for the medication and acknowledged that she should always follow parameters. The DON stated staff should follow parameters and notify the provider when the parameters are not followed, and that medication should be given as ordered unless the provider is aware and gives an order to administer it out of parameters. Another resident was given enteric coated aspirin 81 mg after the LPN crushed the delayed-release tablet and mixed it with chocolate pudding, despite the physician order stating not to crush, cut, or chew the medication. The LPN stated the enteric coated medication should not have been crushed, and the DON stated delayed release medication should not be crushed and the nurse should contact the provider to change the order. The facility also failed to change an IV midline dressing for another resident as ordered. The dressing on the left upper arm midline was observed peeling away with dried blood at the insertion site, and the dressing was dated several days earlier than the observation. The physician order required the transparent dressing to be changed every 7 days and as needed if soiled or dislodged, and staff stated the dressing should have been changed when blood was observed and the dressing was contaminated.
Unsecured Medications Found in Resident Rooms
Penalty
Summary
The facility failed to ensure medications were securely stored in 2 of 4 halls. During observation, Hydrocortisone Cream 1% and Zinc Oxide Ointment were found on top of a resident’s bed in her room, and the resident stated she used the creams preventively for her back because it itched at times. An LPN stated residents are not to keep medication in their rooms and that it should be secured in the medication cart, while the DON stated medications should be stored in a lock box. Additional observations found medication items left unsecured in resident rooms and on the floor. In one room, a pill and powdered substance were observed on the floor, and in another room a medication was found on the floor crushed into pieces and powder; an LPN identified both items as medications and stated the process is to stay with the resident until the medication is consumed, adding that it probably happened during the night shift. In two other rooms, eye drops were observed on bedside tables, along with nail polish remover in one room; residents stated they used the eye drops themselves and had not been told they could not keep them in their rooms. Staff stated no medication, including saline eye drops, and no nail polish remover could be left at the bedside. The facility policy stated all drugs and biologicals must be stored in locked compartments and only authorized personnel may have access to the keys.
Improper PPE Use During Wound Care
Penalty
Summary
The facility failed to ensure staff used PPE appropriately while providing wound care for a resident with a coccyx wound. During observation, an LPN began wound care by performing hand hygiene and donning gloves, then retrieved wound care supplies labeled for the resident, cleaned scissors with alcohol, and let them dry before cutting iodoform packing strip. The LPN then performed hand hygiene again and donned a gown and gloves, but the gown was not tied at the top and the shoulders were not covered. While adjusting the resident in bed and removing the old dressing from the coccyx region, the LPN repeatedly adjusted the gown at the shoulders, removed contaminated gloves, and continued adjusting the gown while walking to the sink. The LPN then performed hand hygiene, donned clean gloves, and again adjusted the shoulders of the gown before completing the wound care. The resident had physician orders dated 2/18/2026 for Santyl ointment to the coccyx wound daily and as needed for soiled or dislodged dressing, with instructions to irrigate the wound with Dakins, pat dry, sprinkle collagen flakes, apply a nickel-thick layer of Santyl, lightly pack with iodoform packing strip, and cover with a dry clean dressing. A separate order dated 1/30/2026 directed enhanced barrier precautions due to wounds every shift. The DON stated the gown should be tied to prevent staff from adjusting it with contaminated gloves and cross contamination. The facility policy stated gowns should fully cover the torso from neck to knees, arms to the end of the wrist, wrap around the back, and be fastened in back at the neck and waist.
Arbitration Agreements Missing Required Rescission Language
Penalty
Summary
The facility failed to ensure that its binding arbitration agreements granted residents or their representatives the right to rescind the agreement within 30 calendar days of signing. Record review showed that the arbitration agreements signed by Residents #58, #148, and #149 did not include the required 30-day rescission language. Resident #58’s agreement signed on 10/11/2024 lacked the rescission right, and Residents #148 and #149 each signed agreements in February 2026 that also did not include the right to rescind within 30 days. During an interview on 2/19/2026 at 2:59 PM, the Administrator stated that the facility had used a different arbitration agreement before and had changed software, and acknowledged that the agreement should state the resident has the right to rescind within 30 days. The facility policy titled Binding Arbitration Agreements, last reviewed on 5/30/2025, required the agreement to explicitly grant the resident or representative the right to rescind within 30 calendar days of signing.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to ensure that a resident received nutritional supplements as prescribed. Resident #43, who was admitted with multiple diagnoses including heart failure, respiratory failure, and protein-calorie malnutrition, had a physician's order for a Mighty Shake with each meal as a protein supplement. However, during observations on two consecutive days, the resident did not receive the Mighty Shake with breakfast and only received it with lunch on one occasion, where it remained unopened and was returned with the meal tray. Interviews with staff revealed a lack of adherence to the physician's order. A Certified Nursing Assistant confirmed the absence of the Mighty Shake on the meal tray, and the Registered Dietitian acknowledged the resident's need for the supplement, despite noting that the resident's weight was stabilizing. The Certified Dietary Manager indicated that the dietary aide was responsible for placing the Mighty Shakes on the trays, and the Director of Nursing expressed an expectation for nursing staff to follow physician orders. The facility's policy on nutritional supplements emphasized the importance of providing these within a specified timeframe to maintain residents' nutritional status.
Failure to Document Physician Rationale for Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician documented their rationale for disagreeing with pharmacy recommendations for two residents. For one resident, the pharmacist recommended tapering or discontinuing a low-dose antipsychotic medication and discontinuing Vitamin C supplementation. The prescriber disagreed with both recommendations but did not provide any rationale in the medical records. Similarly, for another resident, the pharmacist identified a potential drug interaction between Omeprazole and Sucralfate and recommended discontinuing Sucralfate. The prescriber disagreed but again failed to document any rationale. The facility's policy requires that the attending physician document in the resident's medical record that the identified irregularity has been reviewed and what action, if any, has been taken. If no change is made, the physician should document their rationale. However, in these cases, the prescribers did not provide any rationale for their decisions, which was confirmed during an interview with the Director of Nursing. The forms used by the facility did not clearly indicate that a rationale was required, contributing to the oversight.
Inaccurate Documentation of Nutritional Supplement Administration
Penalty
Summary
The facility failed to ensure accurate documentation of nutritional supplement administration and the percentage of supplement consumed for a resident reviewed for nutrition. The resident, who was admitted with multiple diagnoses including heart failure, respiratory failure, and protein-calorie malnutrition, had a physician's order for a Mighty Shake with meals as a protein supplement. However, during observations, it was noted that the Mighty Shake was not consistently present on the resident's meal tray, and when it was present, it was not consumed by the resident. Despite these observations, the Medication Administration Record (MAR) inaccurately documented that the resident consumed 100% of the Mighty Shake on several occasions. Interviews with staff revealed a lack of adherence to proper documentation practices, as the LPN responsible for documenting the consumption of the supplement recorded it inaccurately. The Director of Nursing acknowledged the need for accurate documentation and stated that the amount consumed should not be documented if the resident did not receive the supplement. The facility's policy on documentation emphasizes the importance of factual and objective record-keeping, which was not followed in this instance.
Failure in Hand Hygiene During Medication and Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during medication administration and wound care, leading to potential risks of infection spread. During medication administration, two staff members, an LPN and an RN, did not perform hand hygiene after returning from the medication room and before handling medications for two residents. The LPN also sanitized her pen and hands with a Sani wipe without using gloves, while the RN entered another resident's room with medication in hand without performing hand hygiene. Both staff members acknowledged their lapses in hand hygiene during interviews. In a separate incident, a wound care nurse, LPN, did not perform hand hygiene between glove changes while providing wound care to a resident with multiple wounds. The nurse admitted to not using hand sanitizer between glove changes due to its unavailability in the room. The Director of Nursing confirmed that staff should perform hand hygiene between wound care steps and after removing gloves, as per the facility's hand hygiene policy.
Failure to Post Accurate Nurse Staffing Data
Penalty
Summary
The facility failed to post accurate nurse staffing data on a daily basis, as required by their policy. During an initial tour of the facility, it was observed that there was no nurse staffing data available at the receptionist desk, on the wall in the reception area, or at the nursing stations. The Administrator, when interviewed, was unaware of the requirement to have this information posted and mentioned that a list of staff for the day was available on each unit but not posted as required. Later in the day, the nurse staffing data was observed on the receptionist desk, but it contained inaccurate information regarding the facility census. The facility's policy mandates that nurse staffing information be readily available in a readable format to residents and visitors at any given time, with specific details such as the facility name, current date, resident census, and staffing hours for each shift. However, the staffing data was not posted at the beginning of the shift on the day in question, as confirmed by Staff C, the Certified Nursing Assistant/Staff Coordinator. The facility's daily census showed a discrepancy in the number of residents reported, further indicating a failure to comply with the policy of posting accurate and timely nurse staffing information.
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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) |
|---|---|---|---|---|
| Villages Healthcare And Rehabilitation Center, The | 0.2 mi | ★★★★★ | 10 | 0 |
| Lady Lake Specialty Care Center And Rehab | 1.7 mi | ★★★★★ | 10 | 2 |
| Freedom Pointe Health Center | 3.2 mi | ★★★★★ | 7 | 0 |
| Buffalo Crossings Healthcare & Rehabilitation Cen | 6.3 mi | ★★★★★ | 0 | 0 |
| Club Healthcare And Rehabilitation Center At The V | 6.6 mi | ★★★★★ | 0 | 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.