Inspection·July 28, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the medical record was complete related to Activities of Daily Living (ADLs) for 3 of 3 sampled residents (#1, #2, #3)Findings included: 1. Resident #2 was admitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to Parkinson’s, dementia, anemia, and hypotension. Review of the Minimum Data Set (MDS) dated [DATE] showed Section GG, Functional Abilities dependent for toileting hygiene, showering and bathing, upper and lower body dressing. Review of the care plans showed the resident had an ADL self-care deficit related to chronic medical conditions. ADL needs and participation vary as of 07/18/2022. Interventions included but not limited to encourage and assist with all ADL tasks as indicated, as tolerated by resident, including locomotion/ambulation, bathing, bed mobility, transfers, toileting tasks, meals, personal/oral hygiene, etc. as of 07/18/2022. Review of the Activities of Daily Living for June 2025 showed bed mobility, behavior symptoms, bladder continence, bowel management, dressing, float heels while in bed, evening snack, locomotion off unit, locomotion on unit, oral care, personal hygiene, skin observation, toilet use, transferring, turning and positioning, walking in corridor, walk in room, amount eaten with fluids, eating, incontinence care every 2 hours and as needed was not documented as performed on the following dates: 07/03/25, 07/05/25, 07/07/25, 07/08/25, 07/10/25, 07/11/25, 07/16/25, 07/1925, 07/21/25, 07/2325, 07/24/25. During an interview on 07/28/2025 at 12:43 p.m. the Director of Nursing (DON) stated the ADLs for Resident #2 had not been documented as performed on the above dates. She stated she expected to see documentation of tasks performed. 2. Resident #3 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to diabetes, Alzheimer’s disease, hypertension and dementia. Review of the quarterly MDS dated [DATE] showed a BIMs score of “0” or resident is rarely, never understood. Section GG, Functional Abilities showed she was dependent for toileting hygiene, shower and bathing, upper and lower dressing, and personal hygiene. Review of the care plan showed Resident #2 has an ADL self-care deficit related to chronic medical conditions as of 04/15/2025. Interventions included but not limited to the resident may need dependent assistance of one or two for ADL care. This may fluctuate with weakness, fatigue, and weight (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 105302 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 (X3) DATE SURVEY COMPLETED A. Building 07/28/2025 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)