Health inspection·March 29, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety He says he knows where he is going, but cannot tell us how to get where he is going. He keeps repeating himself. He cannot provide an address. His orientation is the same as previous. The PA reported this is chronic for this patient. The Advanced Registered Nurse Practitioner (ARNP) did not feel the patient was safe to be discharged from the hospital. He was escorted back inside. The ARNP discussed the patient with case management (CM), and the patient was admitted to work on getting patient capacity and possible long-term placement. Differential Diagnosis included AMS, dementia, Alzheimer's, and homelessness. Residents Affected - Few A review of Resident #3's hospital case management notes revealed: 02/02/2024 at 9:18 AM - the patient was residing in a group home since August 2023 and now required a locked facility. 02/02/2024 at 2:01 PM resident has been accepted for transport to current skilled nursing facility. Review of Resident #3's Hospital to Nursing Home Medical Certification Transfer Form (Form 5000-3008), dated 02/02/2024, showed the resident required a surrogate for medical decision making and a primary diagnosis of AMS. The transfer form showed a patient risk alert for elopement and documented the patient was alert and disoriented but could follow simple instructions. Review of Resident #3's initial nursing evaluation collection tool, dated 02/02/2024 at 10:30 PM revealed a diagnosis of AMS, poor cognitive recall, orientation to person and place only. The resident was refusing care and had permanent medical needs with no plans to discharge from the facility anticipated. Review of a Nurse's Note dated 02/02/2024 at 11:30 PM showed Resident #3 refused to enter the facility initially and was eventually transported into the facility by wheelchair. The resident was alert and confused. Review of Resident #3's initial admission Wander Data Collection Tool, dated 02/02/2024 showed a score of 7 (3 or more Yes answers - Definite Risk for elopement.). The score of 7 was from the following Yes responses: 1. Has the resident wandered before, at home or in previous living settings? 2. Does the wandering place the resident at significant risk of getting to a potentially dangerous place? 3. Is the resident cognitively impaired with poor decision-making skills? 4. Is the resident a new admission and not accepting the new living arrangement? 5. Does the resident ambulate independently with or without an assistive device? 6. Does the resident talk about his desire to go home, talked about going on a trip, or packed up his belongings to leave? 7. Does the resident's former profession reflect the current behavior of wandering? (Documented past profession of truck driver). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 2 of 10 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 105350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698 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 0600 The sections of the wander data collection tool to list Resident #3's interventions and summary of findings was not completed for the initial admission on [DATE]. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #3's Baseline Care Plan dated 02/02/24 at 11:30 p.m. revealed checkmarks were made for: Residents Affected - Few No safety issues. Elopement risk - Intervention(s): ____________ The space to document elopement intervention(s) was blank. A review of Resident #3's Brief Interview for Mental Status (BIMS), dated 2/4/24, revealed seven of seven cognitive function indicators had a score of zero. The BIMS summary score section was blank; however, the total score of zero indicated severe cognitive impairment. The Staff Assessment for Mental Status, dated 2/4/2024 showed Resident #3 had short-term and long-term memory problems. The resident's Memory/Recall Ability revealed the resident did not know the current season, staff names and faces, or that he was in a nursing home. Resident #3 knew the location of his room. A review of Resident #3's Progress Note-MD [Medical Doctor] History & Physical dated 2/5/24, by the resident's physician (who is the facility's Medical Director) confirmed the resident's recent history of dementia, homelessness, and past alcohol use with recent admission to the nursing home after the hospital determined discharge to be unsafe without supervision. The physician described Resident #3 as pleasantly confused, oriented to self and not sure of the date, current location, or how he arrived to the facility. The resident alluded to having things to do and referred to people/situations that don't appear grounded in reality. Resident stated, I've got to go take these things somewhere, states he knows where but doesn't share the location. Resident wants to know how much longer he will be here. Per report has intermittently been kicking and sleeping under secure unit door. Assessment/Plan revealed diagnoses of dementia in other diseases classified elsewhere, unspecified severity with anxiety. Reported behavioral disturbances intermittent anxiety/agitation and exit seeking. Begin Hydralazine 25 mg by mouth every six hours as needed (PRN) for agitation. A review of a Nurse's Note dated 2/6/23 [sic] at 10:00 AM showed Resident #3 was alert with confusion. Constantly looking for exit door to go back to Daytona. A review of the February 2024 Medication Administration Record (MAR) revealed the resident was administered Hydralazine 25 mg for anxiety on 2/6/24. This medication was not administered again, and the order was discontinued on 2/14/24. Review of a Psychiatric Evaluation and assessment for medical decision-making capacity, dated 2/8/24 by the psychiatric Advanced Registered Nurse Practitioner (ARNP), showed Resident #3 was alert, oriented to self only. The staff said resident was exit seeking upon arrival to the facility but was redirectable. The patient is not able to recognize his medical condition and the probable consequences of lack of treatment, nor the treatment options. The patient is not able to engage in a rational process of manipulating relevant information. Patient is unable to discuss the risk and benefits of his choices, and the alternative to treatment. In my opinion, this patient lacks the capacity to make decisions related to his need for health care, or long-term placement. Due to cognitive impairment, the patient is unable to understand the nature, extent or probable consequences of not receiving medical care. In addition, the patient is unable to make a rational evaluation of the burdens, risks, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 3 of 10 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 105350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and benefits of treatment. In my opinion, the patient can benefit from a guardian or POA [Power of Attorney]. The mental status exam noted the resident's insight and judgment were impaired due to dementia. Review of Resident #3's admission Minimum Data Set (MDS) assessment dated [DATE] showed a BIMS score of 0 (severe cognitive impairment), the resident exhibited inattention and disorganized thinking behavior that fluctuates (comes and goes, changes in severity). The resident had physical and verbal behavioral symptoms toward others for 1 to 3 days of the 6-day observation period. This behavior significantly interfered with the resident's participation in activities or social interactions. The resident rejected care for 1 to 3 days of the 6-day observation period. The resident wandered daily, and the wandering placed the resident at significant risk of getting to a potentially dangerous place. The resident was independent with all Activities of Daily Living (ADL's) except for needing supervision to shower/bathe. The resident had an active diagnosis of dementia. Review of Resident #3's care plan initiated on 2/20/24 revealed exit seeking behavior related to dementia and behaviors. Resident #3 was documented on the care plan as an elopement risk with goals to always keep the resident safe and to decrease exit seeking by 50% through the next review date (target date 5/20/2024). Resident #3's interventions included: redirect resident away from exits, encourage attendance at group activities, place resident's picture and information in elopement book, ensure all staff aware of exit seeking behavior, and other: secure unit. The bottom of the care plan noted the resident was cognitively impaired. Review of Resident #3's care plan initiated on 2/20/24 showed Resident #3's problems included few relationships, self-isolation, anger at self or others, impaired concentration and difficulty making decisions related to a mood disorder. The goal for this care plan was try to engage Resident #3 in activities (target date 5/20/2024). The interventions included: look for opportunities to help the resident see there are choices that can be used to control life, listen with patience, and compassion, and acknowledge sadness, irritability, or withdrawal. The bottom of this care plan noted the resident was cognitively impaired. Review of Resident #3's care plan initiated on 2/20/24 showed the resident had behavior issues related to being socially inappropriate, physically abusive, verbally abusive, wandering, sexually inappropriate, resistive to care, hoarding, and a propensity for taking things that belonged to others. The goal for this care plan was to not harm self or others and to redirect and encourage activity involvement (target date 5/20/2024). The interventions included: administer and monitor the effectiveness and or side effects of medications as ordered, intervene to protect the rights and safety of others, approach in calm manner, provide psych consult and psychological counseling. The bottom of this care plan noted the resident was cognitively impaired. Review of Resident #3's care plan initiated on 2/20/24 showed Resident #3 required long term care in a secured unit with a risk/challenge of unsafe discharge. The goal documented Resident #3 was not safe to transition to a lesser level of care and would remain in the secured unit until the next review date of 5/20/2024. The interventions included assess the needs of resident/caretaker during stay, anticipate needs and services, involve resident in discharge planning process, provide written and verbal instructions at the resident's level of understanding, assess for community resources that may be needed, and document all discharge teaching. The bottom of this care plan noted the resident was cognitively impaired. Review of Nurse's Notes revealed: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 4 of 10 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 105350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698 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 0600 2/21/24 at 11:00 a.m. Resident #3 was alert with confusion. Level of Harm - Immediate jeopardy to resident health or safety 2/27/24 At approximately 6 PM Resident sitting in [NAME] hall dining room after dinner. Reports sitting on edge of chair and slipped off landing on floor. Denies any pain/discomfort, able to stand by himself, and denies hitting head. Resident able to move all extremities with no limitations. Physician Assistant made aware of episode with no new orders. Call placed to family member and phone number has been disconnected. Residents Affected - Few A review of an ARNP Progress Note dated 2/28/24 revealed resident was seen for a follow up visit due to fall without injury on 2/27/24. The resident was alert with confusion, resided in the secure unit and was ambulatory without assistance. Continue watchful monitoring for changes, decreased mobility, and pain. Review of Resident #3's physician's orders revealed a telephone order dated 2/29/24 to change Hydroxyzine to 25 mg every 6 hours as needed for 14 days. Review of Resident #3's Treatment Record dated 2/29/24, time not legible showed Hydroxyzine 25mg was administered once. No additional notes were present in the medical record to indicate why the medication was administered on 2/29/24 or if it was effective. A review of a Physician Progress Note dated 3/4/24 revealed resident was seen for capacity to manage benefits. Resident oriented to self only, unsure of date, location, or circumstances. Pleasantly confused. The physician documented given degree of dementia/loss of insight, do not feel he has capacity to manage own benefits . Review of Resident #3's Nurse's Medication Notes and PRN documentation, dated 3/6/24 at 9:00 a.m. showed Hydroxyzine 25 mg was administered for increased anxiety. No additional information was present in the medical record related to the signs and symptoms of the anxiety and if the medication was effective. Review of a document, signed by Resident #3's physician dated 3/6/24 at 6PM, revealed the resident has a diagnosis of moderate dementia with behavioral disturbance, and the resident could not determine for himself whether examination was necessary; and there was substantial likelihood that without care or treatment the individual would cause serious bodily harm to self and others in the near future as evidenced by combative behavior with staff and law enforcement officer. The resident refused to return to the facility and the secure unit. The sources providing this evidence included the physician, Director of Nursing (DON) and the Nursing Home Administrator (NHA). No additional notes could be found in the medical record pertaining to an event prompting this involuntary transfer to the hospital for evaluation on 3/6/24 at 6:00 PM. A review of the facility's March 2024 Event Log used to document resident related incidents revealed no entry related to Resident #3. A tour of the facility on 03/27/2024 beginning at 9:00 a.m. revealed the secured unit where Resident #3 resided was located within the facility's [NAME] wing. The secured unit consisted of 10 resident rooms with two locked exit doors leading directly to the exterior of the facility with no patio or fencing. One of the two exit doors was located inside of the dining room used by the secure unit. This exit door had the ability to release after pushing on the bar and an alarm would sound to notify staff. A staff member was present in the unit with the assignment of door monitor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 5 of 10 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 105350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698 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 0600 A review of the resident census on 3/6/2024 revealed 15 residents were living on the secured unit. Level of Harm - Immediate jeopardy to resident health or safety A review of the 3/6/2024 Daily Staffing Assignment Sheet revealed the [NAME] wing had 2 licensed nurses and 3 Certified Nursing Assistants (CNA's) working on the 3:00 PM - 11:00 PM shift. The total resident census on 3/6/2024 for the [NAME] wing was 41 with 15 of the 41 residents residing on the secured unit. Residents Affected - Few A telephone interview was conducted on 3/27/24 at 11:24 a.m. with the facility's Speech Therapist (ST). She said while leaving a local grocery store on 3/6/24 at approximately 5:30 PM she saw Resident #3 on the grassy area near the store's parking lot. She immediately called her manager, the Director of Rehabilitation (DOR) to see if the resident had been discharged from the facility. She reported seeing the resident from a distance and did not see a shopping cart near him. She thought the resident was wearing a long sleeve shirt, pants, and footwear. The ST reported that the DOR said he was pulling into the parking lot and visualized Resident #3. Once she knew the DOR was present, she left the parking lot and did not make contact with the resident during the observation. An interview was conducted on 3/27/24 at 10:44 a.m. with the DOR. The DOR stated the ST called him on 3/6/2024 after 5:00 p.m. and said she saw Resident #3 in the local grocery store parking lot. He called the NHA to confirm the resident had not been discharged from the facility. The DOR reported he was on his way to the local grocery store that day and approached Resident #3 around 5:24 PM. The resident was pushing a grocery cart on the sidewalk and had a black grocery bag. The DOR was unsure of the bag's contents. The DOR said Resident #3 was pleasant and not combative and went into the DOR's vehicle willingly without incident. The DOR drove the resident back to the facility. While in the vehicle Resident #3 told the DOR he was out of the facility for about 3 hours and was thirsty. The DOR reported the resident was dressed appropriately for the weather. After returning to the facility, the DOR provided fluids to the resident shortly after returning to the facility and escorted the resident back to the secured unit with the Assistant Director of Nursing (ADON). The DOR said there were two routes the resident may have taken to get to the local grocery store and assumed the resident traveled down County Road because it was a straight shot from the facility. Observation of the route likely traveled by Resident #3 from the facility to the local grocery store located at 1491 Main Street in Dunedin, Florida revealed it was 0.8 miles and approximately an 18-minute walk from the facility. The resident likely walked: 1. East on San [NAME] Drive toward Scotswood Glen for 0.4 miles. This is a 2-lane road located in front of the facility. 2. Turn right onto [NAME]/County Road 1 for approximately 0.3 miles. This is a four-lane road with turning lanes at the intersection. 3. Continue on [NAME] Rd for 469 ft. to the intersection of Main Street. There are six lanes going east and west with 4 turning lanes at this intersection. There are two lanes going north and south with one turning lane at the intersection. The speed limit was 45 miles per hour and the resident would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 6 of 10 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 105350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698 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 0600 have had to cross this intersection. Level of Harm - Immediate jeopardy to resident health or safety 4. Residents Affected - Few 5. Turn left and travel 250 ft on Main Street Turn right 100 ft into parking lot 6. Turn left and walk for about 280 ft to reach the entrance to the local grocery store. Observation of this route and shopping plaza on 3/28/24 revealed this was a highly traveled area with busy traffic and uneven terrain and obstacles like curbs and parking bumpers. The temperature in Dunedin, FL on 3/6/24 at approximately 5:00 PM was 72 degrees with no rain. On 3/27/24 at 2:13 p.m. a follow-up interview was conducted with the DOR (in the company of the NHA, DON, and ADON). The DOR confirmed Resident #3 did not display any behaviors when they returned to the facility from the local grocery store. He gave Resident #3 snacks and was unsure what happened to cause Resident #3 to dash out the door, leaving the facility a second time through the secured unit dining room door. A telephone interview was conducted on 3/27/24 at 10:59 a.m. with Staff E, CNA. Staff E said she worked on 3/6/24 and was assigned to care for Resident #3 during the 3:00 PM -11:00 PM shift. Staff E had witnessed the resident trying to leave the facility and stating he wanted to go to Daytona prior to the 3/6/2024 event. He was usually redirected when offered snacks and fluids. Staff E recalled on the day of the elopement, Resident #3 was stating he wanted to go back to Daytona, and she told him to talk to the staff about it tomorrow. Staff E said she last saw the resident on 3/6/2024 at approximately 3:45 PM, but stated at about 3:45 PM she heard the secured unit dining room door alarm going off while she was providing care to another resident. Staff E said she poked her head out of the room of the resident she was caring for and saw Staff A, Registered Nurse (RN) in the hallway. Staff A told Staff E, she would take care of that. Staff E assumed Staff A, RN meant the alarm and would determine the cause of the alarm. She did not follow up with the RN following this and reported she was unaware Resident #3 was out of the building until he was returned around 5:20 PM that evening. Staff E stated he must have left through the dining room door. Staff E stated Resident #3 was aggressive, angry, and upset upon his return. She was not asked to provide the resident with any additional supervision or services. Approximately 5-10 minutes after he had returned to the building, he went out the same door again. He eloped twice that day. The second time he was in the road in front of the facility. They could not redirect him, the local law enforcement and paramedics were called. It was very bad. Staff E said the facility does not have enough staff and reported having 13 residents on the secured unit the day Resident #3 eloped twice. Staff E reported that a second CNA was assigned to care for the remaining 2 residents on the secured unit along with additional residents outside of the secured unit. Staff E reported the Licensed Nurse assigned to the secured unit worked a split assignment between the secured unit and additional residents residing on the [NAME] wing. Staff E, CNA said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 7 of 10 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 105350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few often times, she was the only staff member inside the unit at any given time due to the split assignments. Since the incidents on 3/6/2024 a door monitor has been assigned to watch the emergency exit doors in the secured unit. The staff monitoring the door was not offered breaks, and the nurses do not want to sit back in the secured unit to monitor the exit doors. No additional staff outside of the door monitor had been added since the elopement occurred. Staff E stated there have been times when one CNA is assigned to all residents in the secured unit. Staff E did not feel this amount of staffing met the needs/supervision levels needed for the residents living on the secured unit. On 3/27/24 at 11:20 AM an attempt to contact Staff A, RN was made via telephone. An automated message was received saying the phone line was disconnected. Another phone number for Staff A was called on 3/29/24 at 11:19 AM. A voicemail was left but no return call was received. A telephone interview was conducted on 3/27/24 at 12:07 PM with Staff I, Licensed Practical Nurse (LPN). Staff I said on 3/6/2024 she received a phone call from the DON to check Resident #3's room, when she checked the room, the resident was not there. Staff I, LPN said she was told the resident was found at a local grocery store. When Resident #3 returned to the facility he was fine and calm. Staff I, LPN said twenty minutes later, at approximately 6:00 p.m., she was outside on break and saw Resident #3, was outside the building again. He was walking by himself on the roadway at the back of the facility. Staff I, LPN said Resident #3 was carrying a drink and holding a black plastic bag with chicken. She said she called the ADON to notify her Resident #3 had eloped again. Staff I said she was unable to redirect the resident to return to the facility. Resident #3 became aggressive, combative and was walking in the middle of San [NAME] Drive and almost collided with a vehicle. Staff I, LPN, said three law enforcment officers and two Emergency Medical Service (EMS) vehicles responded to the scene for assistance. Staff I, LPN confirmed the staffing levels on the secured unit as one CNA having two residents on the secured unit close to the entrance, along with additional residents on the [NAME] Wing outside of the secured unit. The second CNA was assigned to the remainder of the residents in the secured unit. The nurse assigned to the secured unit was responsible for all residents on this unit along with additional residents outside of the unit residing on the [NAME] Wing front unit. On 3/27/24 at 2:41 p.m., a follow-up interview was conducted with Staff I, LPN. Staff I, LPN said Resident #3's 2nd elopement occurred during mealtime. Staff I, LPN said she was not sure how Resident #3 could get out of the facility a second time without supervision. Staff I, LPN reported the secured unit dining room door had been found open before. It was broken, not alarming, the door would beep randomly at times. Additionally, when the emergency doors alarm, the sound for each door was the same so you have to figure out which door was alarming. She said the facility leadership knew the secured unit dining room door was broken. Staff I said she had reported the door issues to the DON prior to the event (date unknown). On 3/28/24 at 9:01 AM, an interview was conducted with the ADON. The ADON said on 3/6/24 when the DOR returned Resident #3 to the facility from the local grocery store, the resident was walking and talking. The ADON and DOR escorted Resident #3 back to the secured unit without difficulty. The ADON said she did not assess Resident #3 and returned to her office for a short time before receiving a phone call from Staff I, LPN notifying her Resident #3 was outside of the facility behind the building. When the ADON observed Resident #3 was outside again, she went to the secured unit and observed the dining room door was open, and the alarm was sounding. Nurse A, RN was in the vicinity passing medications. The ADON said several staff members were with Resident #3 prior to her arriving on the scene including the DOR, Staff I, LPN and Staff E, CNA. Resident #3 walked on the grass and roadway to the front of the facility and crossed a two-lane road in front of the facility. The ADON said in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 8 of 10 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 105350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few this intersection the resident and staff who were trying to intervene were almost hit by a white vehicle in the intersection. The physician was notified, and law enforcement was contacted to transport the resident to the hospital. An interview was conducted on 3/27/24 at 1:34 PM with Staff J, CNA. Staff J said on 3/6/24 she was in the main dining room and observed staff running and screaming. Staff J was not assigned to the secured unit and normally works on the East Wing. She asked a nurse, what's going on? She heard someone say, [Resident #3] got out. Staff J, CNA said she did not observe anything but heard the secured unit dining room emergency exit door was not secure and anybody could go in and come out. Staff J, CNA said there were not enough employees. An interview was conducted on 3/28/24 at 2:38 p.m. with Resident #3's physician, who is the facility's Medical Director. Resident #3's physician said on 3/6/24, he was notified by the NHA that Resident #3 almost got out and was having behaviors. The NHA said local law enforcement and EMS had been notified. The physician/Medical Director proceeded to document the event to have the resident transported involuntarily to the hospital. Resident #3's physician said, I do not recall knowing [Resident #3] eloped to a grocery store on that day. He was not aware of the situation with the DOR transporting Resident #3 back to the facility. A follow-up interview was conducted on 3/29/24 at 3:38 p.m. with Resident #3's physician/facility Medical Director. He said after a resident elopes from the facility, he expects the resident to be returned to the secure unit and continue the measures to prevent elopement. The Medical Director said he would definitely expect an assessment to be completed after an elopement and 72-hour hourly checks. The resident's care should be documented, physician notification, and possible pharmacy and psych teams ' involvement. On 3/27/24 at 9:37 AM, an interview and observation of the secured unit was conducted with Staff M, LPN. Staff M, LPN said all staff members are expected to respond to emergency door exit alarms. The keys for the emergency exit door alarms on the secured unit are now kept on the nurses ' key ring. The key must be used to deactivate the door exit alarms. Prior to this, a code was used to deactivate the door alarms. Staff M confirmed that the staffing on the secured unit had remained unchanged post the 3/6/24 elopement, apart from the door monitor. Staff M, LPN confirmed that the nurse was still assigned to both the secured unit and the [NAME] Wing Front unit. Staff M, LPN said the residents on the secured unit are like little toddlers and must be watched all the time. On 3/27/24 at approximately 9:39 AM, an interview was conducted with Staff L, CNA. Staff L was assigned to monitor the secured unit emergency exit doors. She said Resident #3 likes to talk a lot, walks around the unit saying he wants to go to Daytona, and attempts to get out of the door. On 3/27/24 at 11:45 AM, an interview was conducted with the Director of Nursing (DON). The DON said he completed an investigation of the event. The DON said on 3/6/24, unsure of the specific time, the NHA notified him Resident #3 was located at a local grocery store. The DON called staff at the facility and verified Resident #3 was missing from the facility. The DOR transported Resident #3 back to the facility from the grocery store, and Resident #3 refused to enter the facility. Resident #3 walked into the roadway in front of the facility. Local law enforcement officers were notified and transported to the hospital. The DON determined Staff A, RN heard the secured unit dining room emergency exit door alarm, closed the door, and deactivated the alarm. The DON said Staff A, RN did not check outside or notify facility leadership the alarm had been activated. The DON said when the emergency exit door alarms are activated the facility expects staff to respond to the alarm. Since the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 9 of 10 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 105350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few event, the DON said staff are expected to count all residents at the beginning of their shift. The facility's department leadership also counts residents twice daily, five times per week. The DON said new alarms were installed on the two exit doors in the secured unit after the elopement. The new alarms are louder than the previous alarms and a key is now needed to deactivate the alarm (prior to this only a code was needed to deactivate the alarm). The DON said the facility had not completed elopement drills in 2024 prior to Resident #3's elopement on 3/6/24. The DON was not aware that 2 separate elopement events occurred with Resident #3 on 3/6/24 at the time of this interview (21 days post event). An interview was cond[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 10 of 10