The Villages on MacArthur

In the surveyor’s words

From the most serious findings on record at The Villages on MacArthur, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 21, 2025

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents. The facility failed to keep a disinfectant cleaner containing four types of ammonium chloride out of Resident #1's reach to prevent the resident from drinking it. The resident was sent to the hospital after his lips began to swell and turn red. Resident #1 was diagnosed with acid burns to his oral mucosa (the mucous membrane that lines the inside of the mouth, including the cheeks, lips, floor of the mouth, and tongue) and had to be intubated for acute respiratory failure. The noncompliance was identified as past noncompliance. […]

• Actual harm, isolatedF600Jul 3, 2025

  Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #87) reviewed for abuse. The facility failed to ensure Resident #87 had the right to be free from abuse when Resident #3 physically assaulted her on 03/03/25. The noncompliance was identified as PNC. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for abuse. Findings include: Review of Resident #87's Face Sheet, dated 07/02/25, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF919Jul 3, 2025

  Based on observation, interview, and record review the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities for 7 of 7 Halls checked for functional call light system (Halls 100, 200, 300, 400, 500, 600, and 700). The facility failed to ensure there was a working call light system available to residents to use after a weather-related storm occurred on 06/25/25 which caused the call light system to stop functioning. This failure placed residents at risk of not receiving timely care/assistance, falls, fall related injuries, head trauma, and hospitalization. […]

• No harm, potential for more than minimal, patternF583Jul 30, 2026

  Based on observations, interviews, and record review the facility failed to protect the confidentiality of personal and medical records for 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7) of 8 residents observed for personal privacy and confidentiality of records.1. The facility failed to ensure the confidentiality of Resident #1's health information when there was a posted sign that reflected, Feeder on Resident #1's door on 06/06/26.2. […]

• No harm, potential for more than minimal, patternF919Jan 2, 2026

  Based on observations, interviews, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 2 of 10 residents (Residents #1 and #2) reviewed for resident call light system. 1. The facility failed to ensure Resident #1 had a call light. 2. The facility failed to ensure Resident #2's call light was placed within reach. These failures could place residents at risk of injuries and unmet needs.Findings included: 1. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. […]