Inspection·September 23, 2021

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, staff interview, telephone interview with the Ombudsman and review of facility policies and procedures, the facility failed to ensure notification of transfers was made to the Office of the State Long-Term Care Ombudsman for one (#79) of three residents reviewed for transfer and discharge rights. Findings included: Review of Resident #79's admission Record revealed she was originally admitted to the facility in June of 2021, re-admitted on [DATE], and discharged to a local hospital on 9/1/2021. A review of a nursing progress note dated 9/1/2021 noted: Resident discharged to hospital via Emergency Medical Services due to respiratory distress. A review of the Nursing Home Transfer and Discharge Notice (AHCA Form 3120) revealed no indication that the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer. On 9/22/21 at 10:59 AM, the local Long-Term Care Ombudsman Council (LTCOC) was contacted via telephone. The ombudsman stated that they had not received any notice of transfers from this facility. On 9/22/21 at 1:00 PM, the Nursing Home Administrator confirmed that transfer notices were not being sent to the LTCOC on a regular basis or in a monthly log format. A review of the facility's policy titled Transfer or Discharge Notice revised December 2016 revealed: 1. A resident, and/or his or her representative (sponsor), will be given a thirty (30)-day advance notice of an impending transfer or discharge from our facility. 2. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility . 4. A copy of the notice will be sent to the Office of the State-Long Term Care Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 2 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105302 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Haven Rehab and Nursing Center 919 Old Winter Haven Rd Auburndale, FL 33823 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure accuracy of functional status in the comprehensive assessment for one (Resident #20) of 29 residents sampled. Findings included: A review of Resident #20's medical record revealed that Resident #20 was admitted to the facility on [DATE] with diagnoses to include Urinary Tract Infection, Abnormalities of Gait and Mobility, Muscle Weakness, and Need for Assistance with Personal Care. A review of Resident #20's admission Minimum Data Set (MDS) Assessment, dated 07/08/2021, revealed under Section G - Functional Status the following information related to Resident #20's self-performance: - Bed Mobility: 7 - Activity occurred only once or twice. - Transfer: 7 - Activity occurred only once or twice. - Walk in room: 7 - Activity occurred only once or twice. - Locomotion on unit: 7 - Activity occurred only once or twice. - Locomotion off unit: 7 - Activity occurred only once or twice. - Dressing: 7 - Activity occurred only once or twice. - Eating: 7 - Activity occurred only once or twice. - Toilet Use: 7 - Activity occurred only once or twice. - Personal hygiene: 7 - Activity occurred only once or twice. On 09/23/2021 at 10:35 AM, the MDS Coordinator stated that the purpose of the MDS Assessment was to get an overall picture of the resident related to areas such as functionality, cognition, and therapy services. The MDS staff obtained information related to the resident's functional status by speaking with care providers, such as the Certified Nurses Aide (CNA) to assess for self performance of Activities of Daily Living (ADLs). An interview was also conducted with the resident to assess for things such as range of motion and functional abilities. Resident assistance needs are documented in the tasks portion of the resident's record and therapy would document what type of assistance the resident needed. The MDS Coordinator stated that entries would be coded as only occurred once or twice if they did not have three occurrences of the particular task happening. For example, if the resident was in bed for 5 out of the 7 days assessed, then the task would be marked as only occurred once or twice. The MDS Coordinator stated that coding some tasks, such as Eating as only occurred once or twice would not make sense because the resident eats three times a day. The MDS Coordinator continued on to state that marking all of the self-performance section with activity occurred only once or twice would not give a complete picture of the resident's functional status. The MDS Coordinator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 3 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105302 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Haven Rehab and Nursing Center 919 Old Winter Haven Rd Auburndale, FL 33823 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated that the staff member that completed the assessment was no longer at the facility, but stated the staff member could have reviewed other documentation in the resident's record to get an idea of their functional status. A review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual Version 1.17.1, dated October of 2019, revealed under the section titled Overview that the RAI helps nursing home staff in gathering definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. The manual also revealed under section G0110: Activities of Daily Living (ADL) Assistance coding instructions that for each ADL activity, consider all episodes of the activity that occur over a 24-hour period during each day of the 7-day look-back period, as a resident's ADL self-performance and the support required may vary from day to day, shift to shift, or within shifts. There are many possible reasons for these variations to occur, including but not limited to, mood, medical condition, relationship issues (e.g., willing to perform for a nursing assistant that he or she likes), and medications. The responsibility of the person completing the assessment, therefore, is to capture the total picture of the resident's ADL self-performance over the 7-day period, 24 hours a day (i.e., not only how the evaluating clinician sees the resident, but how the resident performs on other shifts as well). A request for a policy related to MDS Assessments was made on 09/21/2021 at 02:44 PM to the facility's Nursing Home Administrator (NHA). The policy was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 4 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105302 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Haven Rehab and Nursing Center 919 Old Winter Haven Rd Auburndale, FL 33823 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, policy review, and review of the medical record, the facility failed to ensure that a baseline care plan was developed and provided to one (#78) of 29 sampled residents. Findings included: A review of Resident #78's medical record revealed that he was admitted to the facility on [DATE]. Resident#78 was cognitively intact according to the Brief Interview of Mental Status (BIMS) score of 13 on his most recent Minimum Data Set (MDS) assessment dated [DATE]. On 09/21/21 at 11:13 AM, Resident#78 stated that he didn't recall participating in or being provided with a written copy of his baseline care plan. A review of Resident #78's medical record revealed no documentation related to a baseline care plan. On 9/21/2021 at 2:00 p.m., the Regional Nurse Consultant reviewed the electronic medical record for Resident #78 and confirmed that there was no baseline care plan. The Regional Nurse Consultant stated that the resident was scheduled to have a care plan meeting the following day, 09/22/21. A review of the Nursing Admission/readmission Nursing Packet dated 8/18/21 for Resident #78 revealed the section titled: Baseline Care Plan Summary was marked as n/a (not applicable), and the section titled: Baseline Care Plan provided to Resident and/or representative was marked with no answer provided. A review of the facility policy titled Care Plans- Baseline revealed: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. 4. The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: (a) the initial goals of the resident, (b) a summary of the resident's medications and dietary instructions; (c) any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and (d) any updated information based on the details of the comprehensive care plan, as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 5 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105302 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Haven Rehab and Nursing Center 919 Old Winter Haven Rd Auburndale, FL 33823 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review the facility failed to review and revise the resident centered care plan for one (#78) of 29 sampled residents related to skin issues. Residents Affected - Few Findings included: On 9/21/2021 at 10:55 a.m., Resident #78 was observed with several scabs on his arms, face and shoulders. He reported that he has had them for a few weeks and that the staff were aware. The resident stated that there have been no new orders or treatment related to the scabbed areas. On 09/21/21 at 11:00 a.m., Staff E, Licensed Practical Nurse (LPN) reported that she was unaware of any skin issues for Resident #78 and no one had informed her of any skin issues. Follow-up interview with Staff E on 09/22/21 at 1:34 p.m. revealed the doctor came in to see the resident yesterday (9/21/21) and ordered Bactroban ointment to be applied on his arms, face and legs three times a day for 10 days. She stated the resident has a rash/excoriation. She reported that she wrote a change in condition report yesterday after the surveyor had notified her of the concern. She again confirmed that the Certified Nursing Assitants (C.N.A.) had not notified her of any skin changes. She stated that skin changes were completed weekly and the last one in the medical record was on 9/15/21, which indicated that the resident's skin was intact. She further reported that there had been no new interventions for his skin change issues prior to the doctor's visit on 9/21/21. Follow-up interview with Resident#78 on 09/22/21 at 1:43 PM revealed that finally yesterday the doctor was made aware of the scabs, and they are putting a cream on my arms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 6 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105302 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Haven Rehab and Nursing Center 919 Old Winter Haven Rd Auburndale, FL 33823 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on staff interviews, medical record review, and policy review the facility failed to ensure code status was accurately reflected in the clinical record for one (#74) of two sampled residents reviewed for advance directives out of a total sample of 29 residents. Findings included: Record review of Resident #74's admission record, contained in the paper/hard chart, revealed the resident's advance directive status was recorded as FULL CODE. Additional review of the paper/hard record for Resident #74 revealed a yellow Florida Do Not Resuscitate Order signed by the resident and the attending physician on 6/22/21. A review of Resident #74's Electronic Medical Record (EMR) revealed an active physician's order with a code status of Do Not Resuscitate (DNR) dated 8/22/21. On 09/22/21 at 9:56 a.m., interview with Staff B, Licensed Practical Nurse (LPN) revealed that if there were a code, she usually checks for the resident code status in the EMR. She stated that she never checks the resident's hard chart. On 09/22/21 at 10:03 a.m., interview with Staff C, LPN revealed that if there were a code, she would look in the resident's hard chart for a signed yellow sheet that identifies the resident code status, usually DNR. She stated that the yellow sheet was signed by the resident and the resident's primary care physician. She stated that she follows the signed yellow copy in the chart and not the face sheet. She stated that she would check the resident's EMR but would follow the signed yellow copy in the hard chart. On 09/23/21 at 11:04 a.m., the Regional Director of Nursing stated that she would not expect the face sheet/admission record in Resident #74's paper chart to be updated related to her code status. She stated that when there was a code in the facility, everything related to the resident's code status was printed from the EMR. She stated that the staff respond to a code based on the information in the residents' EMR and not the face sheet/admission record. On 9/23/21 at 11:07 a.m., the Nursing Home Administrator (NHA) stated that when a code was called, the resident's hard chart was grabbed, and the nurses verify the resident's code status with the resident's EMR as a team. A review of the facility's policy titled Advance Directives revised December 2014 revealed .7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record . 20. The Director of Nursing Services or designee will notify the Attending Physician of advance directive so that appropriate orders can be documented in the resident's medical record and plan of care . A review of the facility's policy titled Do Not Resuscitate Order revised April 2017 revealed 2. A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 7 of 7