Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Club Healthcare And Rehabilitation Center At The V during CMS and state inspections, most recent first.
The facility failed to submit accurate staffing data to CMS for Q4 2024. The PBJ showed low RN staffing on a weekend due to an RN's hours being incorrectly coded for another facility. The Administrator could not provide a PBJ submission policy, and an RN confirmed their hours were misallocated.
The facility failed to maintain accurate documentation for residents' nutritional intake, wound care, and blood pressure medication. Several residents' records lacked entries for prescribed nutritional supplements, and there were discrepancies in wound care documentation. Additionally, blood pressure medications were administered outside of specified parameters without proper documentation. The DON and staff acknowledged errors in documentation and communication.
A resident with severe malnutrition and other health issues experienced significant weight loss, but the facility failed to notify the physician. Despite recommendations for an appetite stimulant, it was not ordered, and the weight loss was not communicated to the medical team. Interviews revealed a lack of communication and adherence to the facility's policy on notifying physicians of significant changes.
A resident with multiple health issues was inaccurately assessed in the MDS regarding nutrition. The MDS showed weight gain, but the resident had lost 11.7% of their weight in six months. The MDS also failed to indicate a therapeutic diet, despite orders for fortified foods and supplements. Staff interviews confirmed the resident's weight loss and errors in MDS coding.
A resident with severe malnutrition and other health issues experienced significant weight loss, but the facility failed to revise the care plan to address this change. Despite the resident's weight dropping from 76.4 lbs to 62.2 lbs, no new interventions were implemented. Interviews with the DON and MDS Coordinator revealed a lack of communication and adherence to the facility's policy on care plan revisions.
A resident with severe malnutrition and dementia experienced significant weight loss, but the facility failed to implement adequate nutritional interventions. Despite recommendations from the RD for an appetite stimulant, no order was placed, and the MD and APRN were not informed of the weight loss. The facility's policy on weight loss was not effectively followed, leading to a deficiency in providing adequate nutrition.
The facility's medication error rate exceeded the acceptable limit, reaching 6.45%. An LPN and an RN were observed preparing and attempting to administer crushed extended-release and delayed-release medications via gastric tubes, which is contraindicated. Both staff members acknowledged the error, and the Director of Nursing confirmed the policy against such practices.
The facility failed to store medications securely, as medications were found unsecured in residents' rooms. Interviews revealed that medications were either brought by family or used by nurses, and the DON confirmed that medications should be locked unless residents are assessed for self-administration.
Staff at the facility failed to use appropriate PPE for residents under enhanced barrier and contact precautions. An Activities Assistant did not wear a gown while repositioning a resident requiring EBP for wound care. An LPN flushed a midline for a resident under contact precautions for MRSA without a gown. An RN from another facility did not initially wear a gown or gloves while performing gastric tube care for a resident under EBP. Interviews confirmed the expectation for staff to wear gloves and gowns in these situations.
The facility failed to ensure food items were stored in a safe and sanitary manner in the bistro. Observations revealed undated and unlabeled food items, spillage in coolers, debris in drawers, and improper storage of pickles and ice cream. The Certified Dietary Manager confirmed these issues and acknowledged the need for cleaning and proper equipment.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS for the fourth quarter of 2024. The Payroll Based Journal (PBJ) for this period showed low weekend registered nurse (RN) staffing on September 7-8, 2024. During an interview, the Administrator explained that the low staffing trigger was due to an RN who was covering for the weekend supervisor being incorrectly coded for another sister facility instead of the current facility. The Administrator was unable to provide a policy and procedure on PBJ submission when requested. Additionally, an RN confirmed that they worked at the facility during the specified weekend but their hours were recorded for the facility they normally work at, not the one where they covered.
Deficiencies in Documentation of Resident Care
Penalty
Summary
The facility failed to ensure complete and accurate documentation of resident records, particularly concerning nutrition, wound care, and blood pressure medication. For several residents, there were missing entries in the medication administration records regarding the consumption of prescribed nutritional supplements and proteins. Despite physician orders specifying the need to document the amount consumed, records for multiple residents showed no such documentation over extended periods. In the case of wound care, there were discrepancies in the documentation of treatment for a resident with a sacral wound. The physician's orders were not accurately reflected in the treatment administration records, leading to missing entries on specific dates. The Director of Nursing confirmed that the physician order was mistakenly deleted, although wound care was reportedly provided as ordered. Additionally, there was an error in documenting the change of a midline dressing for another resident, with the nurse acknowledging the mistake in the system. Regarding blood pressure medication, there were instances where residents received medication despite their vital signs being outside the specified parameters. The medication administration records showed that blood pressure medications were administered when the residents' systolic blood pressure was below the threshold set by the physician's orders. The Medical Director noted that staff would notify him about vital signs and seek guidance on medication administration, but there was a lack of documentation in the system to reflect these communications.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident who experienced substantial weight loss. The resident, who was admitted with severe protein-calorie malnutrition, muscle wasting, dementia, acute kidney failure, and adult failure to thrive, showed a weight decrease from 76.4 lbs to 62.2 lbs over a period of less than a month. Despite the resident's malnourished state and poor oral intake, the Registered Dietitian (RD) noted that an appetite stimulant was recommended but not ordered, and the resident's weight loss was not communicated to the physician. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's weight changes. The RD stated that she had requested an appetite stimulant twice without success, and the Director of Nursing (DON) admitted to not seeing a change in condition in the system for the resident's weight changes. The Advanced Practice Registered Nurse (APRN) and Medical Doctor (MD) involved in the resident's care were not informed of the weight loss, and the facility's policy on notifying physicians and family members of significant changes was not followed. This oversight led to a deficiency in the facility's care for the resident.
Inaccurate MDS Assessment for Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident, specifically in the area of nutrition. The resident, who was admitted with diagnoses including unspecified protein-calorie malnutrition, anemia, gastro-esophageal reflux disease, and acute kidney failure, was inaccurately assessed in the MDS. The quarterly MDS indicated a weight gain, whereas the resident had actually experienced a significant weight loss of 11.7% over six months. Additionally, the MDS did not reflect that the resident was on a therapeutic diet, despite physician orders for fortified foods and nutritional supplements. Interviews with facility staff revealed that the resident had been losing weight despite nutritional interventions. The Registered Dietitian acknowledged the resident's ongoing weight loss, and the MDS Coordinator admitted to errors in coding the MDS, including incorrect information about weight changes and dietary interventions. These inaccuracies in the MDS assessment contributed to the deficiency identified by the surveyors.
Failure to Revise Care Plan for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to reassess the effectiveness of interventions and revise the care plan for a resident experiencing significant weight loss. The resident, who was admitted with severe protein-calorie malnutrition, muscle wasting, dementia, acute kidney failure, and adult failure to thrive, showed a progressive weight loss from 76.4 lbs to 62.2 lbs over a period of less than a month. Despite this significant weight loss, the care plan was not revised to address the resident's changing needs. Interviews with the Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator revealed that the care plan should have been revised after the resident's significant weight loss was identified. The facility's policy requires comprehensive assessments and care plan revisions based on resident needs, but this was not followed. The DON acknowledged that no new interventions were put in place after the weight loss, and the MDS Coordinator was unaware of the resident's weight loss, indicating a breakdown in communication and care plan management.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure adequate nutrition for a resident who experienced significant weight loss. The resident, who was admitted with severe protein-calorie malnutrition, muscle wasting, and dementia, showed a weight loss of 18.59% over a short period. Despite being on a regular diet with mechanical soft texture and nectar thick consistency, the resident's intake was variable, and no appetite stimulant was ordered, even though the Registered Dietitian (RD) recommended it. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's weight loss. The RD stated that she had encouraged the use of an appetite stimulant, but no order was placed. The Medical Doctor (MD) and Advanced Practice Registered Nurse (APRN) were not notified of the resident's continued weight loss, and the Director of Nursing (DON) acknowledged that no new interventions were implemented after the significant weight loss was noted. The facility's policy on weight loss required the RD to review admission weights and notify the physician of consistent weight loss, but this process was not effectively followed. The Dietary Manager, who started working after the resident's admission, was not aware of the significant weight loss and expected interventions to be in place. The lack of timely communication and intervention contributed to the deficiency in providing adequate nutrition to the resident.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.45%. During an observation, a Licensed Practical Nurse (LPN) was seen preparing medications for a resident with a gastric tube. The LPN crushed an extended-release Guaifenesin tablet, which is contraindicated for crushing, and was about to administer it via the gastric tube. The surveyor intervened, and the LPN acknowledged awareness of the error, stating that extended-release medications should not be administered in this manner. The resident had a physician's order for Guaifenesin ER to be given via G-tube every 12 hours for a cough, and a diet order indicating nothing by mouth. In another instance, a Registered Nurse (RN) was observed preparing medications for a different resident, including crushing a delayed-release Aspirin tablet, which was also contraindicated for crushing. The RN was about to administer the medication via the resident's gastric tube when the surveyor intervened. The RN admitted knowing that delayed-release medications should not be crushed and administered via a gastric tube. The Director of Nursing confirmed that nursing staff should not crush and administer delayed-release or extended-release medications via a gastric tube and should seek alternative medications from the provider. The facility's policy on medication errors and administration via enteral feeding tubes was reviewed, indicating that certain medications should not be crushed and that staff should consult the pharmacy if there are questions regarding medication administration.
Improper Storage of Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with currently accepted professional principles. During observations, it was noted that medications were left unsecured in residents' rooms. Specifically, a bottle of Tylenol tablets was found on top of a drawer in one resident's room, a tube of Silver Sulfadiazine Cream was on a bedside table in another resident's room, and a tube of itch relief cream was on a bedside table in a third resident's room. These medications were accessible and not stored in locked compartments as required. Interviews with the residents revealed that the medications were either brought in by family members or used by nurses upon request. The Director of Nursing acknowledged that residents should not have medications at their bedside unless they have been assessed for self-administration, have a physician's order, and the medications are stored securely. The facility's policy mandates that all compartments containing medications must be locked when not in use, which was not adhered to in these instances.
Failure to Use Appropriate PPE for Residents Under Precautions
Penalty
Summary
The facility failed to ensure that staff used appropriate personal protective equipment (PPE) while providing care to residents under enhanced barrier precautions (EBP) and contact precautions. During an observation, an Activities Assistant donned gloves but did not wear a gown while repositioning a resident who required EBP due to wound care. The resident's room had an EBP sign and a bin with PPE, but the staff member was unaware of the resident's need for EBP. In another instance, a Licensed Practical Nurse (LPN) was observed flushing a midline for a resident under contact precautions for MRSA without wearing a gown, despite the presence of a contact-precaution sign and PPE bin outside the room. The LPN only wore gloves and a surgical mask, failing to adhere to the facility's policy for contact precautions, which requires donning a gown upon room entry. Additionally, a Registered Nurse (RN) from another facility entered a resident's room, who required EBP for gastric tube care, without wearing a gown or gloves initially. The RN donned gloves later but did not use a gown while performing high-contact activities such as checking and flushing the gastric tube. Interviews with staff, including the Director of Nursing, confirmed the expectation for staff to wear gloves and gowns when providing care to residents under EBP or contact precautions.
Failure to Maintain Sanitary Food Storage and Preparation Areas
Penalty
Summary
The facility failed to ensure food items were stored in a safe and sanitary manner in the bistro. During an observation, surveyors found four undated and unlabeled individual containers of pureed fruit, one of which was opened, an uncovered sherbet cup of granulated sugar, and a container of whipped topping with an open date of 3/3/2024. Additionally, there was spillage on the bottom edge of Cooler #1, an undated and unlabeled cut lemon wrapped in plastic wrap in Cooler #2, and two top cabinet drawers containing speckled black and brown debris. A gallon of dill pickles was stored in the sink with a warning to refrigerate after opening, there was no thermometer in the ice cream storage bin, and black and brown speckled debris was found in the ice cream scoop bin. The Certified Dietary Manager confirmed the presence of opened, undated, and unlabeled food items and acknowledged that the bistro area needed cleaning and a thermometer in the ice cream storage bin. The facility's policies on sanitation, infection control, and food storage were reviewed, which indicated that leftover foods should be dated, labeled, and used within 48 hours, and that all kitchen areas and equipment should be maintained in a sanitary manner. The policies also required freezer temperatures to be recorded daily and for every freezer to be equipped with an internal thermometer.
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What surveyors actually found near you
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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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Freedom Pointe Health Center | 3.4 mi | ★★★★★ | 7 | 0 |
| Buffalo Crossings Healthcare & Rehabilitation Cen | 3.6 mi | ★★★★★ | 0 | 0 |
| Lady Lake Specialty Care Center And Rehab | 5.1 mi | ★★★★★ | 10 | 2 |
| Villages Healthcare And Rehabilitation Center, The | 6.4 mi | ★★★★★ | 10 | 0 |
| Chatham Glen Healthcare And Rehabilitation Center | 6.6 mi | ★★★★★ | 5 | 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.