Health inspection·May 26, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few score indicating the resident was cognitively intact. Section G (Functional Status) revealed Resident #368 needed extensive assistance with one person to physically assist with dressing and toilet use. Section H (Bladder and Bowel) revealed Resident #368 was frequently incontinent with seven or more episodes of urinary incontinence. Review of the medical record revealed the Task Response History for Toilet Use for the dates between 05/09/22 - 05/25/22 revealed Resident #368 needed limited to extensive assistance daily. Review of the medical record revealed the Task Response History for Urinary Continence for the dates ranging between 05/10/22 - 05/25/22 revealed Resident #368 was incontinent 37 times. Review of the medical record revealed the Task Response History for Dressing for the dates ranging between 05/09/22 - 05/25/22 revealed Resident #368 needed limited to extensive assistance daily for fastening or taking off all items of clothing. Review of the facility's policy titled, Quality of Life- Dignity, revised February 2020, revealed the Policy Statement as: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. The policy further revealed: 1. Residents are treated with dignity and respect at all times .3. Some examples of ways in which respect for choices and values are exercised include .Residents are encouraged and assisted to dress in their own clothes .c. Clothing - residents are encouraged to dress in clothing that they prefer .10. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care .11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. For example .b. Promptly responding to a resident's request for toileting assistance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 2 of 24 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 05/26/2022 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 Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to develop and implement a care plan with goals and interventions related to dentures for one resident (#14) of forty-seven residents. Findings included: During observed times on 5/23/2022 at 12:20 p.m.; 5/24/2022 at 8:10 a.m. and 12:00 p.m.; 5/25/2022 at 7:50 a.m. and 12:30 p.m.; and on 5/26/2022 at 7:30 a.m., Resident #14 was observed either being assisted with eating from staff or was lying in bed with her eyes closed and with her mouth open. Resident #14 was observed with no upper or lower dentures or natural teeth. Observations during the breakfast and lunch meal service on 5/23/2022, 5/24/2022, 5/25/2022, and 5/26/2022 revealed Resident #14 was not wearing any dentures while being assisted from staff with eating. Resident #14 was unable to speak related to her medical care and services during an attempted interview in relation to her mouth care and if she had dentures. Resident #14 could not remember if she had dentures or not. Review of the medical record also revealed a Physician's Incapacity Statement, dated 2/10/2021. On 5/25/2022 at 9:33 a.m. Staff E, Certified Nursing Assistant (CNA) confirmed Resident #14 had dentures. She revealed, usually, the resident will be assisted from staff with inserting dentures in her mouth for meal services only. She was not sure if Resident #14 had dentures in her mouth for breakfast but did confirm she was not wearing dentures currently. Staff E opened the bedside dresser drawer and pulled out an orange cup with only one denture in it. She confirmed it was the upper denture and the lower denture was missing. She was not aware of how long the lower denture was missing. On 5/25/2022 at 12:30 p.m., during the lunch meal service, Resident #14 was being assisted with eating. Staff E, CNA and Staff F, CNA both confirmed Resident #14 did not have any dentures in her mouth and further confirmed they did not offer to place the upper denture in Resident #14's mouth, prior to eating both the breakfast and lunch meal today. Also, Staff E and F confirmed they were aware they should place the denture or dentures in Resident #14's mouth for meals but did not know if they were specifically care planned. On 5/26/2022 at 8:10 a.m. Resident #14 was observed in her bed with her mouth open and with her eyes closed. Resident #14, while resting and with her mouth open wide, was observed without any teeth and without any dentures. Staff E, CNA brought a breakfast tray into the resident's room and began to set up the meal, and at 8:47 a.m. she began to take a forkful of hot cereal and brought it to the resident's mouth. Resident #14 accepted the bite of food and swallowed it. The resident received a puree textured diet. Staff E assisted with a few bites of food and she confirmed the resident did not have dentures in her mouth. Staff E was not sure exactly when the resident should have her dentures in but stated the resident does not really need dentures in while she eats, because she has a pureed texture diet. Staff E did confirm staff document in the electronic record daily when the dentures are placed in the resident's mouth. Review of the admission Record revealed Resident #14 was admitted to the facility on [DATE] and readmitted on [DATE]. The diagnoses included senile degeneration of brain, and encounter for palliative care. Review of the current Physician Order Summary Report for the month of 5/2022 revealed orders to include: No Added Salt Pureed diet texture with thin liquids, start date of 11/9/21. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 3 of 24 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 05/26/2022 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 Review of the Significant Change Minimum Data Set (MDS) assessment, dated 1/27/2022, revealed: Section C - Cognitive Patterns the Brief Interview for Mental Status score was a 4, which indicated Resident #14 was not able to be interviewed with relation to care and services; Section L - Oral/Dental Status indicated No was checked for broken or loosely fitting full or partial dentures, and No for no natural teeth. Residents Affected - Few Review of the most current Quarterly MDS assessment, dated 4/29/2022 revealed Section L -Oral/Denture Status had No checked for broken or loosely fitting full or partial dentures and Yes for no natural teeth. Review of the following assessments revealed: 1. Admission/readmission Nursing assessment dated [DATE]; Section A. evaluation revealed Resident has Full upper and Full lower Dentures and wears the dentures only when eating. Assessment further revealed the dentures fit properly. 2. Nutrition Full assessment dated [DATE]; Section K revealed the resident has Full/Partial dentures. The comments section of Section K revealed full dentures. 3. Quarterly/Annual Significant Change Nursing assessment dated [DATE]; Section IX Oral/Denture Evaluation, revealed the resident has no natural teeth and uses full upper and lower dentures, only when eating. 4. Quarterly/Annual Significant Change Nursing assessment dated [DATE]; Section IX Oral/Denture Evaluation, revealed the resident has no natural teeth and uses full upper and lower dentures, only when eating. The initial review of the current care plans, with the next review date of 8/8/2022, did not reveal any problem areas, with goals and interventions in relation to denture use, and denture maintenance. Review of the electronic medical record in the Task section, identified as the Certified Nursing Assistant [NAME] daily task sheets, indicated the areas where the Certified Nursing Assistants review, implement and document Activities of Daily Living tasks. Review of the [NAME] daily task sheet revealed a section for Denture use and care. The [NAME] daily task sheet revealed the following dates as Denture in use: a. Dentures used on 5/12/2022, during times to include 14:59 (2:59 p.m.) and 19:52 (7:52 p.m.). b. Dentures used on 5/13/2022, during times to include 20:30 (8:30 p.m.). c. Dentures used on 5/14/2022, during times to include 07:57 (7:57 a.m.). d. Dentures used on 5/15/2022, during times to include (did not use). e. Dentures used on 5/16/2022, during times to include 20:32 (8:32 p.m.). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 4 of 24 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 05/26/2022 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 f. Dentures used on 5/17/2022, during times to include 08:09 (8:09 a.m.), 17:13 (5:13 p.m.). Level of Harm - Minimal harm or potential for actual harm g. Dentures used on 5/18/2022, during times to include 07:40 (7:40 a.m.), 22:39 (10:39 p.m.). h. Dentures used on 5/19/2022, during times to include 16:16 (4:16 p.m.). Residents Affected - Few i. Dentures used on 5/20/2022, during times to include 12:03 (12:03 p.m.). j. Dentures used on 5/21/2022, during times to include 01:55 (1:55 a.m.), 08:20 (8:20 a.m.), 16:35 (4:35 p.m.). k. Dentures used on 5/22/2022, during times to include 10:48 (10:48 a.m.). l. Dentures used on 5/23/2022, during times to include 03:19 (3:19 a.m.), 17:33 (5:33 p.m.). m. Dentures used on 5/24/2022, during times to include 14:54 (2:54 p.m.). The [NAME] also indicated documentation showing Dentures cleaned and stored for dates to include: 5/14/2022, 5/16/2022, 5/17/2022, 5/19/2022, 5/22/2022, and 5/24/2022. An interview was conducted with Resident 14's family member on 5/25/2022 at 7:35 a.m. The family member confirmed the resident should have dentures and staff are to assist her with them daily. On 5/26/2022 at 10:33 a.m. an interview with Staff GG, Care Plan Coordinator/MDS Coordinator confirmed Resident #14 had been assessed upon her admission back in 2021 related to denture use, for both upper and lower dentures. He confirmed she does not have any natural teeth and was admitted with both lower and upper dentures. He was only made aware, as of 5/25/2022, of the resident missing her lower denture. He also indicated, prior to 5/25/2022, the facility did not develop a care plan problem area to identify denture use and maintenance, with goals an interventions. Staff GG confirmed they developed one now, as of 5/25/2022, but there should have been a denture use care plan developed upon her original admission back in 2021. Staff GG also confirmed the daily task sheets for the CNAs indicate Denture in use, but does not necessarily indicate if it is both, or just lower or upper in use. A review of the Care Plans, Comprehensive Person-Centered policy and procedure, with the last revision date of December 2016, revealed the policy statement as: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The following areas in the Policy Interpretation and Implementation sections revealed: (2.) The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. (7.) The care plan process will; (b) Include an assessment of the resident's strength and needs. (8.) The comprehensive, person-centered care plan will: (a) Include measurable objectives and timeframes; (b) Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; ( e. ) Include the resident's stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 5 of 24 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 05/26/2022 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 goals upon admission and desired outcomes; (g) Incorporate identified problem areas; (k) Reflect treatment goal, timetables and objectives in measurable outcomes; (l) Identify the professional services that are responsible for each element of care; (n) Enhance the optimal functioning of the resident by focusing on the rehabilitative program, and (o) Reflect currently recognized standards of practice for problem areas and conditions. Residents Affected - Few (9.) Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. (12.) The comprehensive, person - centered care plans is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). (13.) Assessments of residents are ongoing and care plans are revised as information about the residents and residents' condition change. (14.) The Interdisciplinary Team must review and update the care plan; (d) At least quarterly, in conjunction with required quarterly MDS assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 6 of 24 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 05/26/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and interviews, the facility failed to provide treatment and services related to not assisting one resident (#72) with donning of a palm guard of a total of 21 residents with contractures. Findings included: Resident #72 on 05/23/22 at 9:59 a.m. was observed with a left-hand contracture. The resident stated she did not know where to get a splint but would like one. An observation was made on 05/24/22 at 8:30 a.m. of Resident #72. Resident #72 was without a splint/palm protector on the left hand. Review of Resident #72's admission Record indicated an admission date of 04/04/22 with diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left-dominant side; hypo-osmolality and hyponatremia. Review of the Minimum Data Set (MDS) assessment, dated 04/10/22, revealed in Section G (Functional Status) Resident #72 needed extensive assistance with bed mobility, transfer, dressing, and toilet use. Resident #72 had an impairment to one side to the upper extremity (shoulder, elbow, wrist, hand). Section O (Special Treatment/Procedures/Programs) revealed Resident #72 was receiving occupational therapy that started on 04/05/22, physical therapy that on started 04/05/22, and no restorative programs being used. Review of the care plan, dated 04/12/22, revealed a focus area of Resident #72 having functional limitations R/T (related to) disease process. The goal stated the resident will receive appropriate therapy. The interventions are refer to OT, PT, and SLP (speech language pathology) treatment as ordered. During an interview on 05/24/22 at 4:26 p.m. with the Rehabilitation Director, he stated a resident was on a trial if it is necessary for a resident to have a palm protector or splint. The Rehabilitation Director stated the process for a resident to have a splint or palm protector was for them to go to therapy and therapy will determine if they would benefit from the splint or palm guard. He revealed once the referral was made and accepted then nursing was supposed to put in the order. He stated the Director of Nursing (DON) is supposed to put in the order. Review of the Occupational Therapy (OT) Evaluation & Plan of Treatment, dated 04/05/22, revealed a new goal for Resident #72. The goal stated patient will safely wear palm protector for L (left) hand as tolerated or at all times . The assessment summary under impressions revealed Resident #72 had a LUE (left upper extremity) shoulder/elbow/wrist and finger contracture due to old CVA (Cerebrovascular Accident).The Object Progress/Short-Term Goals revealed patient only able to tolerate rolled wash cloth this time. Review of the OT Therapy Progress Report, dated 04/18/22, revealed Resident #72 tolerated palm guard for ~ 2 hours w/o (without) c/o (complain of) pain . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 7 of 24 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 05/26/2022 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 0688 Level of Harm - Minimal harm or potential for actual harm Review of the OT Therapy Progress Report dated 05/02/22 revealed Resident #72 had no redness/irritation and no c/o pain after 2.5 hours. Review of the OT Recertification & Updated Plan of Treatment revealed on 05/05/22 the goal as Patient will safely wear palm protector for L hand as tolerated or 4 hrs (hours) on/ 4 hrs off . Residents Affected - Few Review of the OT Discharge summary, dated [DATE], revealed Resident #72 will safely wear palm protector for L hand as tolerated or 4 hrs on/ 4 hrs off . Review of the facility's Referral to Restorative Nursing Program, dated 05/12/22, revealed Resident #72 was referred to wear a palm protector on the L hand for 6 hours or as tolerated. The document had the signatures of the therapist, the unit manager, and restorative certified nursing assistant (CNA). Review of the Nursing In-service Form dated 05/12/22 revealed instructions of restorative splinting program with palm protector L hand x 6 hrs or as tolerated, 5 x wk (week) to maintain skin integrity, for Resident #72. An observation was made on 05/25/22 at 9:04 a.m. of Resident #72 without a palm protector on. During an interview on 05/25/22 at 9:27 a.m. with Staff U, CNA, she stated sometimes [Resident #72] goes to therapy, or the therapists come and get her from activities or from her room. She stated therapy was the one who puts on her palm guard. During an interview on 05/25/22 at 11:46 a.m. with Staff V, CNA, she confirmed she was the restorative aide and she was aware of Resident #72's palm protector. She confirmed she signed the referral about a week ago but did not put the palm protector on until today. She stated, it fell through the cracks and that's why she has not put it on until today. She stated she did not receive education on putting on the palm protector from therapy. Staff V revealed she could not put Resident #72's palm guard until the DON puts the order into the system. During an interview on 05/25/22 at 1:40 p.m. with the DON, she stated she checks all therapy referrals during the daily morning meetings. She stated if the referral is accepted, she will put in the standing order for restorative. The DON revealed she will try to put in the orders at the end of each week. The DON confirmed she was the only one who puts in the therapy orders. She stated the expectations are for restorative to wait until the order is put in before placing a splint or palm protector onto the residents. The expectation was for therapy to conduct education with restorative on how to place a splint or palm guard onto the resident. The DON revealed the reason why the order was not placed into Resident #72's chart until the 24th (5/24/22) was because she was behind. The DON revealed she was not aware of the order until therapy came and told her about Resident #72's palm protector yesterday. The DON confirmed her signature on the Referral To Restorative Nursing Program dated 05/12/22. Review of the facility's policy titled, Resident Mobility and Range of Motion, revealed in the Policy statement .2. Residents with limited range of motion (ROM) will receive treatment and services to increase and/or prevent further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 8 of 24 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 05/26/2022 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure one (#115) out of five residents sampled for unnecessary medications received medications according to physician orders regarding a duplication of insulin orders and administration of anti-hypertensive medication outside of parameters. Residents Affected - Few Findings included: Review of the admission Record revealed Resident #115 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified type 2 Diabetes Mellitus with diabetic neuropathy, atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm, and hypertensive heart disease with heart failure. A review of Resident #115's May 2022 Medication Administration Record (MAR) identified the following orders: - Admelog SoloStar 100 unit/milliliter (u/mL) Solution pen-injector. Inject as per sliding scale subcutaneously before meals and at bedtime for Diabetes Mellitus. The order started on 4/16/22 and was discontinued on 5/24/22. - Humalog KwikPen 100 u/mL Solution pen-injector. Inject as per sliding scale subcutaneously before meals and at bedtime for diabetes. The order started on 5/21/22. - Norvasc 2.5 milligram (mg) - Give one tablet by mouth one time a day for hypertension (HTN). Hold if systolic blood pressure (SBP) less than 140. The order started on 4/15/22. A review of Resident #115's May MAR indicated the resident was administered 4 units of the fast-acting insulin Admelog for a blood glucose level of 222 on 5/21 scheduled at 8:00 p.m. and 2 units of Admelog for a blood glucose level of 164 at 10:00 a.m. on 5/23/22. A continued review of the MAR identified the resident was administered the fast-acting insulin Humalog at 8:00 p.m. on 5/21 for a blood glucose level of 224 and 2 units on 5/23 at 10:00 a.m. for a blood glucose level of 164. The review of the resident's MAR identified the resident received 2 doses of different fast-acting insulins on 5/21 at 8:00 p.m. and at 10:00 a.m. on 5/23/22. On 5/24/22 at 5:25 p.m. a review of Resident #115's May MAR was conducted with the Director of Nursing (DON) and the Regional Director of Nursing (RDON). The RDON stated good nursing practice would be for nursing to clarify the orders for both fast-acting insulins, Admelog and Humalog. She stated they [the facility] would clarify the orders right now. On 5/25/22 at 12:52 p.m. Staff M, Station 1 Unit Manager, stated that usually when pharmacy recommends changing Admelog to Humalog they send a discontinue order but this recommendation did not indicate to discontinue the Admelog. The staff member reviewed and identified the resident received 2 units of Admelog and 2 units of Humalog on 5/23/22. The DON stated, on 5/25/22 at 1:29 p.m., the physician identified that Resident #115 was not supposed to receive 2 different insulins per sliding scale. She stated when the pharmacy sent the medication interchange, they did not send a discontinue order for the other insulin. She stated the facility did an in-service the night before regarding all pharmacy orders are to be clarified and confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 9 of 24 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 05/26/2022 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with the physician. She stated staff were to review the medication list and confirm there are no duplicates. She indicated the facility did not receive The Automatic Therapeutic Interchange until 5/25/22 at 3:19 p.m. The Automatic Interchange identified on 5/19/22 the facility was to discontinue Insulin Lispro Kwikpen (Admelog) and to start Humalog Kwikpen per sliding scale. The interchange was not signed by the nurse. A review of Resident #115's April 2022 MAR identified the resident was administered 2.5 milligrams of Norvasc (amlodipine) on 4/15 ( blood pressure 128/77), 4/16 (132/71), 4/17 (129/79), 4/18 (135/89), 4/20 (137/77), 4/23 (120/76), 4/25 (137/78), 4/26 (129/89), 4/27 (135/76), 4/28 (132/67), and 4/29/22 (131/66). The MAR indicated the anti-hypertensive was to be held if the systolic blood pressure was less than 140. The April MAR identified Resident #115 received Norvasc 11 times out of 15 opportunities outside of the parameters set by the physician. The May 2022 MAR for Resident #115 indicated the medication Norvasc was to be held for a SBP less than 140. The MAR identified the resident had been administered the medication on the following despite a systolic blood pressure that was less than 140: 5/4 (127/77), 5/5 and 5/6 (111/75), 5/7 (120/68), 5/9 - 5/11 (136/78), 5/12 (130/70), 5/14 (138/68), 5/15 (124/65), 5/16 (132/74), 5/20 - 5/21 (136/72), 5/22 (131/87), 5/23 (126/78), 5/24 (128/73), and 5/25/22 (128/68). The MAR indicated the resident received Norvasc 17 out of 25 opportunities despite the parameters set by the physician. On 5/26/22 at 11:32 a.m., the DON reviewed the May MAR and stated staff should have been holding Norvasc for a systolic blood pressure of less than 140 as ordered then notify the physician. She confirmed that a checkmark on the MAR did indicate the medication was administered and a review of the progress notes indicated staff did not document the medication was held. The policy titled, Administering Medications, revised April 2019, indicated Medications are administered in a safe and timely manner, and as prescribed. The Interpretation and Implementation identified that Medications are administered in accordance with prescriber orders, including required time frame, and If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 10 of 24 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 05/26/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews the facility failed to ensure one (#115) out of five residents sampled for the administration of unnecessary medications was monitored for behaviors and side effects related to the use of psychotropic medications. Findings included: Review of the admission Record revealed Resident #115 was admitted on [DATE]. The admission Record included diagnoses not limited to generalized anxiety disorder and primary insomnia. The April 2022 Medication Administration Record (MAR) indicated Resident #115 received the psychotropic medication Buspirone twice daily and Alprazolam three times a day for anxiety, both of which began on 4/15/22. A review of the April MAR and Treatment Administration Record (TAR) did not indicate staff were monitoring the resident for exhibited behaviors or side effects related to the administration of the psychotropic medications. The May 2022 MAR and TAR identified Resident #115 was administered 30 milligrams (mg) of Buspirone twice daily and 0.25 mg of Alprazolam three times daily for anxiety. The psychotropic medications were started on 4/15/22. A review of the May MAR and TAR identified staff were not documenting the monitoring of behaviors or possible side effects related to the administration of the psychotropic medications. The care plan for Resident #115 identified the following: - Used anti-anxiety medications related to anxiety disorder and instructed staff to monitor for side effects and effectiveness every shift, with a target date of 5/6/22. - Used psychotropic medications related to behavior management, disease process bipolar disorder (d/o), with a target date of 7/22/22. The interventions identified staff were to monitor for side effects and effectiveness every shift and to monitor/document/report as needed any adverse reactions of psychotropic medications. - Exhibits the following behaviors: mood disorders, resists care, verbally aggression, diagnosis (dx) bipolar d/o, requested room change then refused the room offered. The interventions instructed staff to monitor and document behaviors and potential causes. The Director of Nursing (DON) stated, on 5/26/22 at 11:40 a.m., staff should be monitoring behaviors for psychotropic medications every shift. She reviewed Resident #115's May MAR and TAR and confirmed that neither the behaviors and/or side effects were being documented for Resident #115. The policy, Behavioral Assessment, Intervention, and Monitoring, revised December 2016, indicated The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. The policy identified that The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: onset, duration, intensity, and frequency of behavioral symptoms. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 11 of 24 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 05/26/2022 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 0758 When medications are prescribed for behavioral symptoms, documentation will include: Level of Harm - Minimal harm or potential for actual harm a. Rational for use; b. Potential underlying causes of the behavior; Residents Affected - Few c. Other approaches and interventions tried prior to the use of antipsychotic medications. d. Potential risks and benefits of medications as discusses with the resident and/or family; e. Specific target behaviors and expected outcomes; f. Dosage; g. Duration; h. Monitoring for efficacy and adverse consequences; and i. Plans (if applicable) for gradual dose reduction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 12 of 24 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 05/26/2022 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Forty medication administration opportunities were observed and five errors were identified for four residents (#42, #268, #17, and #49) of seven residents observed. These errors constituted a 12.5% medication error rate. Residents Affected - Few Findings included: 1. On 5/24/22 at 4:29 p.m., an observation of medication administration with Staff P, Licensed Practical Nurse (LPN), was conducted with Resident #42. The staff member dispensed the following medications: - Humalog Kwikpen 4 units - Humulin N 37 units - Carvedilol 6.25 milligram (mg) tablet - Acetaminophen 325 mg - 2 tablets. Staff P, LPN primed the Humalog pen appropriately then primed the Humulin N insulin pen while holding the pen with the needle pointing downwards. Staff P injected the Humulin and she was taking the pen away the insulin squirted in an arc out of the tip. Staff P identified that had never happened before. According to the manufacturer (https://uspl.lilly.com/humulinn/humulinn.html#ppi), users should prime the pen prior to each injection. The manufacturer instructions identified that by priming the pen it removes the air that collects during the normal use and ensures the pen was working correctly. The method for priming was to turn the dose knob to 2 units, hold the pen with the needle pointing upwards, tap the cartridge to collect air bubbles at the top, and while continuing to hold the pen upwards press the dose knob until it stops, and hold for 5 slow seconds. 2. On 5/24/22 at 5:03 p.m., an observation of medication administration with Staff Q, Registered Nurse (RN), was conducted with Resident #268. The staff member dispensed the following medications: - Oxycodone/Acetaminophen 10/325 mg tablet - Fluticasone/Salmeterol 100/50 microgram (mcg) inhalation - Gabapentin 300 mg capsule - Lamotrigine 25 mg - 2 tablets - Topiramate 200 mg tablet - Insulin Lispro (Humalog) 12 units. Staff Q dialed the Humalog pen to 12 units and injected the insulin into the resident's left upper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 13 of 24 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 05/26/2022 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few arm without priming the pen. Staff Q stated, on 5/24/22 at 5:21 p.m., that kind of pen (Humalog) did not have to be primed after priming it for the first time. A review of the manufacturer instructions for Humalog (https://uspl.lilly.com/humalog/humalog.html#ug1) revealed priming of the insulin pen should be done prior to each injection. The literature indicated priming the insulin pen is meant to remove the air from the needle and cartridge that may collect during normal use and ensures the pen was working correctly. The priming to the pen was done by turning the dose knob to 2 units and while holding the pen with the needle up, tap the cartridge gently to collect air bubbles at the top, while holding the pen upwards, push the dose knob until it stops and hold the dose knob for 5 slow seconds. 3. On 5/25/22 at 9:24 a.m. an observation was conducted with Staff D, LPN with Resident #17. The staff member dispensed the following medications: - Keflex 500 mg capsule - Multi-Vitamin with mineral tablet - Sodium Chloride 1 gram (gm) tablet - Vitamin C 500 mg tablet - Prezcobix 800 mg/150 mg tablet - Tivicay 50 mg tablet Staff D administered oral medications and then obtained a blood glucose level of 193. During the observation the breakfast meal cart was observed being removed from the hallway. Staff D removed a Flexpen of Novolog from the medication administration refrigerator. The administration of the resident's Novolog continued at 10:08 a.m. on 5/25/22. Staff D primed the Novolog Flexpen with 2 units, then injected 2 units per sliding scale into the resident's left upper extremity. A review of the May 2022 Medication Administration Record (MAR) for Resident #17 indicated an order: - Novolog FlexPen 100 unit/milliliter (mL) pen injector per sliding scale subcutaneously before meals and at bedtime for Diabetes Mellitus (DM). The MAR identified the scheduled time for administration of the Novolog for the resident was at 6:00 a.m., 10:00 a.m., 4:00 p.m., and 8 p.m. According to the Meal Times and Tray Delivery Schedule provided by the facility, the delivery of the lunch meal cart to Resident #17's hall was scheduled to be delivered for 12:40 p.m. (2 hours and 40 minutes after the scheduled administration of Novolog). The manufacturer website, https://www.mynovoinsulin.com/insulin-products/novolog/home.html, indicated NovoLog® is a rapid-acting insulin that helps lower mealtime blood sugar spikes in adults and children with diabetes. It has been proven to help control high blood sugar in people with diabetes when taken with a long-acting insulin. NovoLog® starts acting fast. Eat a meal within 5 to 10 minutes after taking it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 14 of 24 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 05/26/2022 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The policy titled, Insulin Administration, revised September 2014, identified The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. The policy did not include instructions on the administration of insulin via an insulin pen. 4. On 5/25/22 at 9:48 a.m., an observation was conducted with Staff D, LPN with Resident #49. The staff member dispensed the following medications: - Ibuprofen 800 mg as needed tablet - Magnesium oxide 400 mg tablet - Aspirin 81 mg chewable tablet - Buspirone 10 mg tablet - Furosemide 20 mg - 3 tablets - Famotidine 20 mg tablet - Gabapentin 600 mg tablet - Pantoprazole 40 mg tablet - Carvedilol 3.125 mg tablet - Oxcarbazepine 300 mg tablet - Spironolactone 25 mg tablet. Staff D identified the resident's Calcium was not available in the prescribed dosage and Staff C, RN/Unit Manager offered to obtain the resident's Potassium and Lisinopril from the Emergency Drug Kit (EDK). The medication administration for Resident #49 continued at 11:27 a.m. on 5/25/22 with Staff D dispensing the following: - Lisinopril 2.5 mg - 2 tablets - Potassium Chloride granules 20 milliequivalent (meq) tablets - Calcium with Vitamin D 600-200 mg/unit (one time order obtained during administration) - Lactulose 10 g/15 milliliter (mL) - 15 mL - Fluticasone/Salmeterol 100 mcg/50 mcg one inhalation. Staff D confirmed she dispensed 15 mL of Lactulose and the observation identified the 30 mL medication cup was approximately half full. Staff D was observed, on 5/25/22 at 10:07 a.m., dispensing the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 15 of 24 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 05/26/2022 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 0759 oral medications, then Lactulose, then the resident was observed inhaling one puff of the activated inhalation powder. Staff D did not instruct Resident #49 to rinse mouth after use. Level of Harm - Minimal harm or potential for actual harm A review of the May 2022 MAR for Resident #49 identified the following: Residents Affected - Few - Lactulose 30 mL by mouth three times a day for constipation - Fluticasone/Salmeterol 100-50 dose Aerosol Powder. The physician order indicated the resident was to rinse mouth after use, do not swallow. According to https://www.mayoclinic.org/drugs-supplements/fluticasone-and-salmeterol-inhalation-route/proper-use/drg-20063110?p=1, the proper use of a Fluticasone/Salmeterol inhaler is to rinse mouth with water after each dose to possibly prevent hoarseness, throat irritation, and mouth infection but do not swallow the water after rinsing. The policy titled, Specific Medication Administration Procedures, dated April 2018, identified For steroid inhalers, provide resident with cup of water and instruct him/her to rinse mouth and spit water back into cup. An interview on 5/26/22 at 9:01 a.m. was conducted with the Consultant Pharmacist. The Consultant stated the optimal administration of (fast-acting) insulin was within an hour of the meal and the insulin pens are to be primed to ensure the dosage was accurate, per the manufacturer's recommendation. On 5/26/22 at 2:01 p.m., the Director of Nursing (DON) reported insulin pens should be primed before each injection and it did not matter what type of insulin or pen it was. She stated after Fluticasone/Salmetrol inhalation the mouth should be rinsed out. The DON stated the times for insulin administration were going to be changed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 16 of 24 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 05/26/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to 1. ensure one medication cart (400-hall) out of four medication carts and two out of two treatment carts (Station One carts) were locked while unattended, 2. opened insulin vials/pens (9) were dated to ensure the medication was discarded when expired, and 3. ensure one insulin vial (Lispro) was refrigerated when unopened. Findings included: 1. An observation was made, on [DATE] at 10:31 a.m. of two unlocked treatment carts parked across from Station One nursing station. (Photograph Evidence Obtained) The Director of Nursing (DON) was standing at the nursing station with her back to the carts. Staff M, Unit Manager (UM), confirmed the carts should have been locked and they (facility) were possibly doing treatments and did not lock the carts. On [DATE] at 11:12 a.m., an observation was made of an unlocked medication cart outside of room [ROOM NUMBER]. The observation indicated a person could move in between the cart and the doorway of the room. Staff R, Licensed Practical Nurse (LPN) came out of room [ROOM NUMBER] and confirmed the cart should not be left unlocked. 2. An observation was made on [DATE] at 7:52 a.m. of Station 1 Cart 2 medication cart. Staff S, LPN began the observation when an insulin pen was identified as opened and undated. The Staff S asked for the off going LPN (Staff T) to continue the observation. The review of the medication cart revealed the following and was confirmed by Staff T: - One opened, undated Novolog FlexPen. - One insulin Glargine opened and undated. - One insulin Lispro KwikPen opened and undated. Label indicated the pen should be discarded after 28 days. - One insulin Lispro KwikPen (Humalog) opened and undated. - One Humalog 75/25 insulin pen opened and undated. - One insulin Glargine Injection pen, opened and undated. - One insulin Lispro KwikPen (Humalog) opened and undated. - One insulin Lispro KwikPen (Humalog) opened and undated. - One vial of insulin Lispro unopened and undated. The pharmacy label indicated the vial was dispensed on [DATE]. - One vial of insulin Glargine opened and undated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 17 of 24 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 05/26/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm - One vial of Humulin R insulin indicated Do Not Use After 31 Days. The label did not indicate an opened date or specific expiration date. - One vial of insulin Lispro, unopened and undated. The labeled indicated the insulin should be discarded after 28 days. Residents Affected - Few - One 30 fluid ounce Pro-Stat liquid protein, approximately 1/4 full that was undated as to when the bottle was opened. The label identified to Discard 3 months after opening. The Consultant Pharmacist stated, on [DATE] at 9:15 a.m., that insulin (containers) should be dated as to when it was opened. The policy, Storage of Medications, revised [DATE], indicated Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. The policy, Insulin Administration, revised [DATE], instructed staff to Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening.) A review of the manufacturer instructions for Lispro (also known as Humalog), found at https://uspl.lilly.com/humalog/humalog.html#ug1, revealed: 16.2 Storage and Handling Dispense in the original sealed carton with the enclosed Instructions for Use. Do not use after the expiration date. Unopened HUMALOG should be stored in a refrigerator (36° to 46°F [2° to 8°C]), but not in the freezer. Do not use HUMALOG if it has been frozen. In-use HUMALOG vials, cartridges, and HUMALOG prefilled pens should be stored at room temperature, below 86°F (30°C) and must be used within 28 days or be discarded, even if they still contain HUMALOG. (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 18 of 24 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 05/26/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and policy reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen related to not labeling or dating foods, not maintaining refrigerator and freezer temperature logs, not implementing cleaning schedules and not utilizing sanitizing buckets for three days (5/23/22, 5/24/22 and 5/25/22) of four days observed. Findings included: On 05/23/2022 at 9:26 a.m., the initial kitchen tour was conducted with Staff J, [NAME] Manager. An observation of the walk-in cooler revealed no thermometer found inside the cooler. Also observed were food items not properly labeled and or dated to include: two opened containers of cottage cheese, white sliced cheese wrapped in clear plastic, an opened package of sliced turkey, a container of fruit (pale yellow in color and appeared to be diced) and a partially used pan of red gelatin with no date. Staff J, [NAME] Manager stated (red gelatin) was used as a dessert and was not sure exactly when, but it was for a supper meal. In addition, several food products were found with labels but no dates to include pound cake, chocolate pie, and whipped topping. Four packages of opened and partially used bread and rolls were located on the top shelf with no dates. On a cart were three trays with spilled liquid on them and lidded cups, approximately a total of 20-24 cups per tray which appeared to be filled with orange juice. The cups or trays were not labeled or dated. The floor of the walk-in was found to have a build-up of dirt and debris in the corners and running alongside of the wall and floor underneath the shelving unit. Staff J stated she was unsure of why there was no thermometer in the cooler or why staff were not labeling and dating products. Continuing with the tour an observation of the walk-in freezer revealed no thermometer was found inside. No dates of receipt were observed on cases of frozen parbaked rolls, mighty shakes, magic cups, pound cake, pie shells, and stuffed shells. Frozen meat products of roast beef and ground beef that were removed from the original box sitting on a metal, two tier cart was observed with no dates. In addition, an observation of the reach in refrigerator revealed no thermometer inside and three gallons of opened milk, not dated. The initial tour continued with Staff J and the observation of the dry storage room revealed no dates on several opened and or partially used food products, which included: a half-used bag of pasta, a bag of opened breadcrumbs, several packages of opened hot dog rolls. Additional observations during the tour revealed no sanitizing buckets being used and only one green bucket for cleaning was located under the cook's shelf with dirty water. Staff J, [NAME] Manager was not able to confirm if there was a policy or procedure related to the use of sanitizing buckets. In addition, a large industrial size circulating fan, located near the end of the tray line station was observed to have buildup of greasy dirt and debris covering the protective metal screen and the blades of the fan. At the time of the observation the fan was plugged in but not on. An observation was made of the four air vents located in the kitchen ceiling and dish room ceiling were noticeably wet with moisture and had signs of rust. During the tour, no cleaning schedules were observed posted or in binders anywhere in the kitchen to confirm kitchen cleaning was assigned and being completed daily. Staff J was not sure where they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 19 of 24 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 05/26/2022 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 0812 were located. Level of Harm - Minimal harm or potential for actual harm An observation of the kitchen on 5/23/2022 at 12:00 p.m. revealed the large circulating fan was turned on and pointed in the direction of the steamtable and tray line during meal service. The fan still had dirt and debris on the protective screen. Also observed were several light fixtures in the ceiling, located above the steam table and reach in freezer with clear visibility of dead bugs inside the base of the light covers. Residents Affected - Many A request was made at this time of Staff H, Regional Dietary Manager for documentation of recorded temperatures for the refrigerators and freezer and cleaning policies and schedules. This information was not provided to the survey team at the time of exit on 5/26/22. On 05/24/2022 at 4:43 p.m. an observation of the kitchen and interview with Staff H, Regional Dietary Manager revealed no sanitizing buckets in use. An observation inside the walk-in-cooler revealed on the shelf an open box containing portions of one ounce pre-package cream cheese and several 4-ounce cups of juice opened and leaking inside the box, along with an undated opened bag of whipped topping. An observation of the dry storage room revealed a clear plastic zip-closed bag of biscuits not labeled or dated, an opened box of jelly packets which contained several packets split open and a dark purplish-red dried substance was observed on the inside of the box. Staff H, at this time, stated he has not been in the facility in about seven months and was unaware of the issues. On 05/25/2022 at 10:00 a.m. an observation and interview with Staff H, Regional Dietary Manager, during an additional walk through of the kitchen revealed, three red sanitizing buckets not filled or being used. Also observed was a foam carton of food left over from breakfast and stored inside the microwave. Staff H stated it must be for an employee to have on break. Staff H, disposed of the container. The observation also showed dried food splatter inside of the microwave. Additional observations revealed five large boxes of juice base concentrate attached to the juice machine and undated. Further observations at this time of the walk-in cooler revealed a bucket of cottage cheese with a use by date of 5/23/2022, two open jugs of Italian salad dressing undated, and a roasting pan covered with plastic wrap with unknown food items that was not labeled or dated. On 05/25/2022 at 12:05 p.m. Staff H was provided with a second request for the missing documentation for staff cleaning schedules, and a policy for use of the sanitizing buckets. On 05/26/2022 at 10:56 a.m., an interview was conducted with Staff H, Regional Dietary Manager. Staff H stated he was unable to locate the cleaning policies or schedules. On 05/26/2022 at 11:45 p.m. Staff H, Regional Dietary Manager confirmed food items should be labeled, dated, and stored in sanitary conditions per regulation and policy. He stated the cleaning task should be completed after each shift and daily. Staff H, Regional Dietary Manager stated he will begin to in-service all employees regarding labeling and dating, taking, and recording of dish machine temperatures, implement daily weekly and monthly cleaning schedules, recording of temperatures for all refrigerators and freezers as well as cleaning and sanitizing of all equipment with regards to the proper use of the sanitizing buckets with documentation. A review of a policy titled, Food Receiving and Storage, with an effective date of 01/15/2021, showed the policy statement was to ensure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 20 of 24 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 05/26/2022 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 0812 1) Food Services staff will always maintain clean food storage areas. Level of Harm - Minimal harm or potential for actual harm 7) Dry foods that are stored in bins will be removed from original packaging, labeled, and dated, such foods will be rotated using a first-in-first out system, Residents Affected - Many 8) All foods in the refrigerator or freezer will be covered, labeled, and dated (use by date) 12) Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee. Photographic Evidence Obtained FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 21 of 24 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 05/26/2022 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, facility record review and staff interviews, the facility failed to ensure one courtyard, where residents frequent during the day to engage in smoking activities, was maintained and cleaned related to multiple used cigarette butts found on sidewalks, grass, dry landscaping and tabletops for three days (5/23/2022, 5/24/2022 and 5/25/2022) of four days observed. Findings included: During tours of the facility's outdoor courtyard on 5/23/2022 at 11:30 a.m. and 1:45 p.m.; 5/24/2022 at 9:08 a.m. and 11:10 a.m.; 5/25/2022 at 10:00 a.m. and 11:40 a.m.; and on 5/26/2022 at 7:55 a.m., the outside courtyard area where residents frequented daily either to get fresh air or to participate in group smoking activities, was observed with multiple used cigarette butts flicked and strewn on the various grassed and landscaped areas as well as on concrete walking surfaces and table tops. (Photographic Evidence Obtained) During various times of each of the days observed, there were approximately ten to fifteen residents who came out during scheduled smoking times (8:00 a.m., 11:00 a.m., 1:30 p.m.), to smoke and were supervised by staff. The above observations revealed many cigarette butts strewn near the cigarette butt disposal can and on the ground at and near the tables with ashtrays. On 5/23/2022 at 11:30 a.m. Staff A, Activities Aide and Staff B, Central Supply revealed they supervise the residents with smoking during the scheduled times and they pass out cigarettes, lighting devices, smoking aprons if needed, watch the residents smoke, and monitor for safety. Staff A and B confirmed there were various ash trays throughout the courtyard and residents should be using them when they are done smoking a cigarette. Neither Staff A or B would confirm if they saw residents flick or throw cigarette butts in the grass and landscaped areas but did confirm that residents should not be doing that. Staff A and Staff B also confirmed the many cigarette butts strewn throughout the courtyard and did not know who's responsibility it was to pick them up. On 5/26/2022 at 7:55 a.m. a tour was conducted with the Maintenance Director out in the facility courtyard. The Maintenance Director confirmed the many used cigarette butts strewn throughout the courtyard landscaping and grass areas and said he tries to get out and pick up the cigarette butts daily. He confirmed residents were not following rules by sticking or dropping used cigarette butts into the safety ashtray or cigarette butt can. He stated the staff monitoring for smoking should see when cigarette butts are thrown on the ground and should either tell residents they can't do that or report it to management. The Maintenance Director did confirm he picks up cigarette butts from the courtyard landscaped area often but did not have a set schedule for it. An interview with the Director of Nursing and the Regional Nursing Consultant on 5/26/2022 at 2:00 p.m. revealed the facility did not have a specific policy that included outside smoking rules when and where to dispose of cigarette butts. They both revealed staff should be trained and in-serviced to monitor residents during the entire smoking scheduled times and if they see residents flicking, throwing, or dropping cigarette butts in areas that are not designated; to include cigarette ash trays, they should educate the residents and or report it to management. A review of the policy titled, Smoking Policy - Residents, revised July 2017, revealed the policy statement as, The facility shall establish and maintain safe resident smoking practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 22 of 24 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 05/26/2022 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, facility record review and staff and resident interviews, the facility failed to ensure implementation of an effective pest control program for four of four days observed to include 5/23/2022, 5/24/2022, 5/25/2022 and 5/26/2022. It was determined there were wasp/hornet like flying insects and several wasp/hornet like nests and mud dauber (type of wasp) nests in the facility courtyard where residents frequent most of the day. Residents Affected - Few Findings included: During brief tours of the facility courtyard frequented by residents daily, on 5/23/2022 at 11:30 a.m., 5/24/2022 at 9:08 a.m. and 1:20 p.m., 5/25/2022 at 10:00 a.m. and on 5/26/2022 at 8:00 a.m., many wasp/hornet like nests were observed attached to the inside door wall light housings and stuck on various areas under roof overhangs. (Photographic Evidence Obtained) While residents were outside and spread throughout the courtyard, the outside doors leading into the facility's 200 and 400 unit television lounges, were observed with five flying wasp like/hornet like insects. Further observations revealed wasp/hornet like nests inside two of two door wall light housings. There were several wasp like/hornet like inside the light housing as well. Further observations revealed wasp/hornet like flying insects buzzing around residents, who were entering and exiting the doorway area. There were two observations of wasp/hornet like insects landing on the back of a resident occupied wheelchair and then flying away. Also, along all four outer walls in the courtyard, to include roof overhangs and over resident room windows, over ten mud dauber (type of wasp) nests with holes leading into the nests were observed. Some nests were verified with actual flying insects and some of these nests were vacated. (Photographic Evidence Obtained) On 5/23/2022 at 11:23 a.m. an interview with Staff A, Activities Aide and Staff B, Central Supply both confirmed residents come out to the courtyard during specified times and are supervised, especially during smoking times. Staff A and B confirmed various wasp/hornet like nests throughout the outdoor courtyard area, to include two mud dauber nests on the upper wall overhang, where they were both standing. A continued interview with Staff A and Staff B revealed they did not really think about the nests but have been seeing more and more wasp/hornet like insects flying around the entire courtyard and entrance/exit door areas at the 400 and 200 lounges. Neither Staff A or Staff B reported wasp/hornet like insects, or the nests to management or the maintenance department. Interviews with Residents #49, #108, #32, #97, #33, #318, who confirmed they frequent the courtyard several times a day, and every day; all confirmed they had seen hornets/wasps when coming out to the courtyard from the 400 unit lounge area. Some indicated they swat at the hornets/wasps but have never been stung. The residents interviewed could not remember if they have reported the nests or flying insects to staff but would want for them to be removed so they do not get stung. On 5/26/2022 at 7:55 a.m. a tour was conducted of the facility courtyard with the Maintenance Director. The Maintenance Director confirmed the wasp/hornet like nests inside both wall light housings near the entrance/exit doors on both the 400 and 200 halls. He also confirmed the mud dauber nests along various walls near and at the roof overhangs and throughout the entire courtyard. The Maintenance Director confirmed there was a pest control program but was not aware if the pest control company treats for wasps, hornets, or mud daubers. He revealed he has a wasp/hornet spray and treats wasp/hornet nests and knocks down the mud dauber nests that are built up on the facility walls and roof overhangs. He indicated he does not have a specific timeframe to look out for various nests in resident frequented area but looks often and also relies on staff to tell him when they identify nests. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 23 of 24 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 05/26/2022 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's pest control contract, which was prepared and revised as of 5/25/2021, revealed in Section B, the targeted pests included bees, wasps, yellow jackets, up to 10 feet on the structure and within 20 feet of the structure perimeter. It was indicated the pest control company was responsible for the treatment of wasps, hornets, bees, and yellow jackets. Review of the pest control visits for the dates of 5/24/2022, 5/6/2022, 4/15/2022 and 4/1/2022 did not indicate treatment for wasps, hornets, yellow jackets, or bees. On 5/26/2022 at 11:00 a.m. an interview with the Nursing Home Administrator, and the Maintenance Director confirmed they were not aware if the pest control company was to treat for hornets/wasps, bees; but the facility staff, to include the maintenance department, should have treated the courtyard for these flying insects on their own. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105302 If continuation sheet Page 24 of 24