Health inspection·October 2, 2024

F 0550 enough chairs. We only have one folding chair. Level of Harm - Minimal harm or potential for actual harm Review of facility policy and procedure titled, Resident Rights, undated, revealed: Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; . t. privacy and confidentiality . Residents Affected - Few On 09/23/24 at 12:00 p.m. Resident #3 was observed being taken to the resident's room for the lunch meal. Staff J, CNA was observed feeding Resident #3 while standing next to him. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 2 of 44 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 10/02/2024 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 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to honor a resident's right to receive a written notification for a room change before the change was made for one (#51) of one resident sampled. Findings included: On 09/23/24 at 10:15 a.m. Resident #51 was observed in her room. The resident said, I don't know why they moved me. I was on the other side. Resident #51 stated she was not given an opportunity to see the new room and she did not receive an explanation as to why the move was necessary. The resident stated she lived in her previous room since her admission to the facility last year. Review of the admission Record for Resident #51 showed she was originally admitted to the facility on [DATE]. The record showed Resident #51 was her own person and she also had a substitute decision maker. Review of a Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of 11 (moderately impaired). Review of Resident #51 census showed the resident was moved from room [A] to room [B] on 09/19/24. Review of the Electronic Medical Record (EMR) for Resident #51 showed there was no documentation regarding the move or the reason for the room change. On 09/24/24 at 3:49 p.m. an interview was conducted with the Social Services Director (SSD). She stated the process for a room change was for the nursing staff to figure out who was going to move and why. She said, We do a form. We let the resident know and then the POA [Power of Attorney], Responsible Party or Guardian if applicable. The SSD stated Resident #51's room change should be documented. Review of the room change binder revealed there was no documentation. The SSD stated she did not move Resident #51 and did not know why she had moved. On 09/24/24 at 3:55 p.m. an interview was conducted with the Director of Nursing (DON). He stated he moved Resident #51. He stated he did not tell her why she was moved, because he did not know at the time. He stated he had not spoken to the resident since the move; that happened a week prior. He said, The resident does not know why. I'm waiting for the Health Department to let me know. I probably should have told her that. I should have told her. The DON stated he did not document the room change. Review of a facility policy titled, Room Change, dated 09/01/22, showed when feasible the facility will make room to room transfers when requested by the resident or as may become necessary to meet the resident's medical and nursing needs. The procedure showed: 3. Unless medically necessary or for the safety and well-being of the resident, a resident will be provided advance notice of the room transfer. Such notice will include the decision to make the room transfer. 4. Prior to the room transfer, the resident, his or her roommate (if any) and the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 3 of 44 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 10/02/2024 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 0559 representative (if applicable) will be provided with information concerning the decision to make the room transfer. Level of Harm - Minimal harm or potential for actual harm 6. Complete the room change notification form and retain in the medical record. Residents Affected - Few 7. Document room to room transfers in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 4 of 44 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 10/02/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility did not ensure a clean, safe, sanitary, and homelike environment for five resident rooms (#113, #123, #214, #222 and #223), nine resident bathrooms (#122, #213, #214, #215, #216, #218, #219, #221, and #223), one shower room (West Wing), one housekeeping closet (West Wing) and two halls located on the [NAME] Wing during four of four days observed (09/23/24, 09/24/24 and 10/01/24 and 10/2/24). Findings included: An observation made on 9/23/2024 at 9:52 a.m. in the hallway outside of Resident room [ROOM NUMBER] revealed a petrified worm about one inch from the wall on the floor. The worm remained there until after 9/24/2024 at 5:00 p.m. An observation was made on 9/23/2024 at 10:08 a.m. of Resident room [ROOM NUMBER]'s bathroom that revealed the floor near the window having brown streaks in various locations. The bathroom sink counter was protruding from the particle board, creating a space and uncleanable surface. The counter had brownish stains surrounding the sink bowl all the way to the wall edge. Underneath the sink, the floor had an accumulation of dirt and debris, including a petrified lizard and worm. The floor next to the toilet had brown colored marks in various locations. The toilet seat had brown colored buildup of dirt. An observation was made on 9/24/2024 at 12:21 p.m. of Resident room [ROOM NUMBER]'s bathroom revealing the side of the toilet bowl had a blackish color, rough patch appearing as a small hole, the toilet bowl had brownish color around the top rim of the bowl and a brown ring where the water level resides. The connection point for the grab bars next to the toilet was cracked and had a buildup of debris, some flaking off. In addition, an observation of the remote control on the resident's bed in room [ROOM NUMBER] revealed it had wires exposed. An observation was made on 9/23/2024 at 10:13 a.m. of Resident room [ROOM NUMBER] and the bathroom. The observation revealed the wall beneath the window had a space between the drywall and cove base, and the resident room floor had brown/black colored stains on the floor. The toilet had a brown/yellow buildup of debris where the seat connects to the bowl. Inside the toilet bowl was a brown ring, and marks throughout the bowl. The toilet tank had a plastic shelf partially covering the toilet tank water. The cove base under the toilet paper holder was separated from the floor. At the base of the toilet and the floor was brown/yellow debris build up. The grab bars had brown stains covering them. The connection point of the grab bars to the toilet bowl had a whitish buildup and a raised metal piece. A petrified worm was next to the toilet opposite the toilet paper roll. An observation was made on 9/23/2024 at 10:18 a.m. in the bathroom of Resident room [ROOM NUMBER]. The toilet had a brown/yellow buildup of debris where the seat connects to the bowl. Inside the toilet bowl was a brown ring coming down from the rim, and marks throughout the bowl. The toilet bowl had a brown substance running down the front of the bowl to the floor. The floor surrounding the base of the toilet was brown/yellow in color. Significant debris was built up on the base of the toilet. The base of the toilet near the back had a brownish substance running to the floor. Dirt and debris were surrounding the bathroom walls. [NAME] colored marks were observed on the door frame going into the resident room, and the light switch and wall to the entrance of the other resident's room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 5 of 44 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 10/02/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (shared bathroom). No toilet paper was observed in the dispenser, and a roll was on top of the dispenser (open) with brown stains on the paper and a roll in the manufacturer paper. An observation was made on 9/23/2024 at 10:28 a.m. in the bathroom of Resident room [ROOM NUMBER]. The toilet seat was cracking and had a brownish color surrounding. Inside the toilet bowl was a brown ring, and marks throughout the bowl. Dirt and debris was built up surrounding the bathroom floor and wall. The emergency call cord next to the toilet had a black cloth tied in a knot and the cloth was observed to have small blotches of a brownish substance on it. An observation was made on 9/23/2024 at 10:30 a.m. of the bathroom of Resident room [ROOM NUMBER]. The wall next to the toilet had a brownish color running down a few tiles. The base of the toilet and bowl had various smudges of yellow/brown color and build up of debris surrounding the toilet. An observation was made on 9/23/2024 at 10:45 a.m. of the bathroom of Resident room [ROOM NUMBER]. The toilet bowl base had a significant build up of a brownish substance. The toilet paper dispenser was empty, and two open rolls, sat atop of the dispenser. An observation was made on 9/24/2024 at 12:34 p.m. in Resident room [ROOM NUMBER] of the remote for the bed with wires exposed. An observation was made on 9/23/2024 at 10:51 a.m. of Resident room [ROOM NUMBER]'s bathroom. The toilet bowl and floor were soiled with a brown/black/yellow substance. An observation of the room revealed the bed remote had exposed wires. An observation was made on 9/23/2024 at 10:04 a.m. of the [NAME] Wing Unit walls. The two hallways with Resident Rooms #211 to #229 had numerous locations with a beige substance splattered on the walls. Debris was in the cutout of the fire extinguisher near Resident room [ROOM NUMBER]. An observation was made on 9/23/2024 at 10:34 a.m. of the [NAME] Wing Unit's housekeeping closet. The door was unlocked, and the housekeeping carts were located inside. The housekeeping carts were unlocked and had chemicals stored in them. On the back wall of the closet a chemical dispensing machine was on the wall. An observation was made on 9/23/2024 at 11:58 a.m. of the [NAME] Wing Unit's shower room. The shower stall had black bio growth along the floor, walls and drain. The shower chair had a pink bio growth surrounding the connection points of all four of the chair legs. The seat of the shower chair had hair and brown substance on the left side. The shower bed had a white buildup on the straps. During an interview on 10/1/2024 at 1:48 p.m. the Maintenance Director (MD) stated he was also in charge of housekeeping and laundry. The MD toured the [NAME] Wing Unit hallways and specified rooms above. The MD stated, This is horrible. The MD continued to state a plan was in place to strip and wax the floors. The MD confirmed the issues being pointed out are not with stripping and waxing. The MD stated this just needs to be cleaned. The MD confirmed the above findings and stated, This should not be this way, we will need to get cleaning this. During an interview on 10/2/2024 at 11:55 a.m. the Nursing Home Administrator (NHA) confirmed the findings above. A review of the facility policy titled, Complete Room Procedure, undated, revealed: . 3) Scrub (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 6 of 44 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 10/02/2024 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bathroom floor (if ceramic tile) A) soak bathroom floor with mop water B) scrub floor with swivel scrub brush C) wet mop bathroom floor . *** Remember to detail clean all walls, doors, furniture*** . A review of the facility policy titled, 10 Step Cleaning Process, undated, revealed: . Step 4 Sanitize all horizontal surfaces * use germicide properly. Germicide kills harmful microorganisms.* Let surfaces air dry.* Don't forget door knobs and telephones. Step 5 Spot Clean all vertical surfaces * use germicide or all-purpose cleaners * don't forget to clean around waste receptacles and light switches. * Chemicals need time to work effectively. Step 6 Clean The restroom * pre spray shower to give chemical time to work. * Do not use toilet bowl brush outside of toilet bowl. Don't forget to fill the dispensers . Step 9 Damp Mop/Microfiber Mop the floor * change the germicidal solution in your mop bucket every three rooms. * Don't forget the restroom floor . On 09/23/2024 at 10:42 a.m. a tour was conducted of Resident room [ROOM NUMBER] with concerns noted in the bathroom. An observation was made of the inside of the toilet with brown stains. The toilet base was observed with brown matter on the surface. The walls and floors were observed with brown stains. The floor under the sink and the walls under the sink were observed with black and brown substances. The resident stated the brown substances were fecal matter. She stated she had asked them to clean it. On 09/23/2024 at 10:44 a.m. a tour of Resident room [ROOM NUMBER] revealed concerns related to dirt, dust and small dead insects on the window seal. The ceiling above the resident's bed was observed with cobwebs, dust and small debris. The air conditioning unit was observed with black matter on the inside of the vents. On 09/23/2024 at 1:47 p.m. an observation of Resident room [ROOM NUMBER] revealed a side table and bedside table with non-cleanable surfaces. The surfaces were observed with disintegrated particle board surfaces. This same observation was made on 09/24/2024, 10/01/2024 and 10/02/2024. On 09/24/2024 at 1:10 p.m. an observation of Resident room [ROOM NUMBER] revealed previously identified concerns in the bathroom. The toilet, floors and walls were observed with brown substances on the surfaces. On 10/01/2024 at 11:32 a.m. Resident Rooms #122 and #123 were observed with the same previously noted concerns. On 10/01/24 at 2:05 p.m. an interview was conducted with the NHA. She stated the resident rooms should be cleaned daily. She stated she was aware they need to replace some furnishings in the resident rooms. The NHA stated all non-cleanable surfaces should be replaced. (Photographic Evidence was Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 7 of 44 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 10/02/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure wound care was provided per physician orders for one resident (#13) of two residents reviewed for wound care treatment. Residents Affected - Few Findings included: An observation on 09/23/24 at 10:09 a.m. revealed a red substance that resembled blood stains on Resident #13's pillow as Resident #13 laid in bed asleep. An observation and interview on 09/23/24 at 11:15 a.m. revealed the red substance that resembled blood stains on Resident #13's pillow as Resident #13 sat in the bed awake. Resident #13 stated the red stains on the pillow were blood and probably from her wound on her shoulder. Resident #13 pulled the arm sleeve up on her shirt and presented her right shoulder area. Resident #13's top right shoulder revealed a red, raw and bloody wound that was open to the air. Review of the admission Record showed Resident #13 was admitted to the facility on [DATE] with diagnoses that included chronic viral hepatitis C, anoxic brain damage, seizures, anxiety disorder, obsessive compulsive disorder and bipolar disorder. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed in Section C- Cognitive Patterns Resident #13 had a Brief Interview for Mental Status (BIMS) score of 08 (moderate cognitive impairment). Section E- Behavior showed Resident #13 exhibited no behaviors during the 7 day look back time period. Section M- Skin Conditions showed Resident #13 had no pressure ulcers and no venous or arterial ulcer. Review of the Order Summary as of 9/24/24 included the following orders: - Apply moisturizer to right shoulder for radiation skin care. at bedtime for right shoulder okay to cover with hydrocolloid dressing and at bedtime for right shoulder okay to cover with hydrocolloid dressing, dated 09/16/24. - Apply moisturizer to right shoulder for radiation skin care. two times a day for right shoulder okay to cover with hydrocolloid dressing and at bedtime for right shoulder okay to cover with hydrocolloid dressing, dated 09/16/24. Review of the September 2024 Treatment Administration Record (TAR) showed the facility missed four wound care treatments during the 15 days reviewed for wound treatment opportunities. The treatment showed, Apply moisturizer to right shoulder for radiation skin care.- two times a day for right shoulder okay to cover with hydrocolloid dressing, with a start date of 09/16/24. Dates of missed treatment opportunities included: - 09/19/24 both wound treatments scheduled for 8:00 a.m. and 5:00 p.m., were not administered. - 09/20/24 wound treatment scheduled for 8:00 a.m., was not administered. - 09/23/24 wound treatment scheduled for 5:00 p.m., was not administered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 8 of 44 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 10/02/2024 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 0684 Review of the current care plan showed no care area noted for Resident #13's right shoulder wound. Level of Harm - Minimal harm or potential for actual harm Review of a Physician Wound Note, dated 09/17/24, showed: Wound Evaluation and Management Summary. Additional Wound Detail: has started radiation tx [treatment] and requested to discontinue silver sulfadiazine. Dressing Treatment Plan: Primary Dressing(s) Hydrocolloid sheet (satin) apply once daily for 30 days. Dressing Treatment Plan: Note: Add Hydrocolloid Sheet (Satin) Once Daily 30. Discontinue Silver Sulfadiazine. Residents Affected - Few An observation on 09/24/24 at 12:53 p.m. revealed the blood stains on the pillow and visible from the hallway when looking into Resident #13's room. (Photographic Evidence Obtained) During an interview on 09/24/24 at 12:40 p.m. Staff B, Registered Nurse (RN) stated there was no wound care nurse in the facility, but the facility had a wound care doctor who came to the facility once a week. Staff B, RN stated when the wound doctor was not in the facility it would be the nurse's responsibility to continue to provide treatment per the physician's order and provide any wound treatments. During an interview on 09/24/24 at 1:10 p.m. Staff C, Licensed Practical Nurse (LPN) stated she was familiar with Resident #13's wound and care. Staff C, LPN stated Resident #13 did have some skin cancer on her right shoulder that Resident #13 liked to pick at. Staff C, LPN stated currently there was lotion ordered to put on Resident #13's shoulder and staff can try to bandage the wound, however Resident #13 would pick it off. During an interview on 09/24/24 at 2:12 p.m. the Nursing Home Administrator (NHA) confirmed there were missing documented treatments on Resident #13's September 2024 TAR for the wound treatment. The NHA stated the blanks on the TAR would be considered missed treatments. The NHA stated had the treatment been completed and Resident #13 had a behavior of picking the bandage off, she would have expected to have seen that behavior noted on the behavior modification record, or in a nurse's progress note. She stated she could not find any behaviors in Resident #13's medical record. The NHA stated she did not see any focus, goals or intervention on Resident #13's care plan in the electronic medical record about the right shoulder wound. During an interview on 09/24/24 at 2:34 p.m. the Director of Nursing (DON) stated even Resident #13's September 2024 TAR showed wound treatments were not provided by the missing blanks on the TAR. The DON confirmed no wound treatments were documented as being provided for the dates of 09/19/24, morning of 09/20/24 and afternoon on 09/23/24. During an interview on 09/24/24 at 2:35 p.m. Staff D, LPN/Unit Manager (UM) stated nurses are supposed to provide wound treatment and document the care provided in the medical record. Staff D, LPN/UM confirmed the September 2024 TAR was missing treatments for Resident #13's shoulder wound. During an interview on 09/24/24 at 3:10 p.m. Staff F, Attending Physician (AP) stated he was Resident #13's primary attending physician. Staff F, AP stated he did expect the nurses to follow the physician orders for Resident #13's wound care. Review of a half written care plan page provided by the NHA, dated 01/15/23, showed Resident #13 was at risk of skin breakdown related to excoriation of the right shoulder. The goal showed Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 9 of 44 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 10/02/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #13 would be free of skin breakdown through next review. Interventions included : Check and inspect skin with care and report any and all findings. If skin altercation is noted, notify the physician immediately and obtain an order for topical creams/ointments to be applied to skin and if treatment is ineffective, notify physician immediately and obtain further orders. The target date was 04/16/23. During an interview on 09/24/24 at 4:00 p.m. the NHA stated the written care plan provided came from a care plan book that was located at the nurses' station. During an interview on 09/24/24 at 4:11 p.m. the DON stated there were no other accurate or current care plans in the facility, but the one in the electronic medical record. The DON stated the care plans in the book at the nurses' stations are old. The DON reiterated and stated, All current care plans are in the electronic medical record . An additional review of the September 2024 TAR showed the facility missed another wound care treatment .The treatment showed, Apply moisturizer to right shoulder for radiation skin care.- two times a day for right shoulder okay to cover with hydrocolloid dressing, with a start date of 09/16/24. Dates of the additional missed treatment opportunity included: 09/28/24 wound treatment During an interview on 10/01/24 at 2:17 p.m. Staff E Wound Physician (WP) stated he recommended and ordered Resident #13's right shoulder wound to be covered. Staff E, WP stated that he ordered the hydrocolloid dressing because it was stickier like a bandage and harder to fall off or pick off. Staff E, WP stated that since Resident #13's oncologist office was also recommending Resident #13's shoulder wound be covered. Review of the facility's policy Skin and Wound, effective date 08/01/2023, showed, Policy: To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decreased worsening prevention of injury. Procedure: Provide treatment per physician order with documentation in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 10 of 44 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 10/02/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm 2. On 09/24/24 at 12:31 p.m. Resident #39 was observed lying in bed with oxygen tubing in place via a nasal cannula. The tubing was connected to the oxygen concentrator sitting next to the bed, with a piece of tape wrapped around the tube and with the date of 9/16/2024 (Monday). (Photographic Evidence Obtained) Residents Affected - Few An interview was conducted with Staff C, Licensed Practical Nurse (LPN) on 09/24/24 at 2:00 p.m. Staff C, LPN stated the tubing is changed on the night shift, and she was not sure of the process. Staff C, LPN confirmed Resident #39 was on continuous oxygen and the date on the tape was 9/16/2024. Review of Resident #39's physician order summary revealed an order, dated 8/6/24, for oxygen tubing and oxygen bag to be changed every Thursday on night shift. Review of the facility policy and procedures titled, Oxygen, with a revision date of 08/2023 revealed: Policy: The facility will ensure oxygen is administered safely and per physician order Procedure: . 5. Oxygen tubing is to be changed weekly and/or as needed when soiled or the tubing becomes compromised . Based on observations interviews and record review, the facility did not ensure respiratory equipment was stored appropriately for two (#34 and #39) of two sampled residents. Findings included: 1. On 09/23/24 at 2:01 p.m. an observation was made of Resident #34's oxygen tubing placed on her bedside table and on the floor. The tubing was not stored in a sanitary manner. In an immediate interview the resident stated she used oxygen as needed. She said, I feel like I need it. Review of the admission Record for Resident #34's revealed an admission date of 08/23/24 with a primary diagnosis to include morbid (severe) obesity due to excess calories. Review of September 2024 physician orders for Resident #34 showed the resident had the following orders: - Oxygen at 2 Liters per nasal cannula as needed for SOB (Shortness of Breath), 9/2/24. - Oxygen tubing and humidifier change every night shift on Wednesday, 8/28/24. - BiPAP (Bilevel Positive Airway Pressure) oxygen tubing change (if indicated) every shift, 8/27/24. - BiPAP: Empty and Rinse Humidifier Change every night shift, 8/27/24. - BiPAP: Fill Humidifier Chamber with sterile or distilled water every night shift, 8/27/24. During a tour on 09/24/24 at 12:15 p.m. Resident #34's BiPAP machine was observed on the nightstand. The BiPAP tubing was set on top of the nightstand. It was not in a bag. The resident was not in the room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 11 of 44 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 10/02/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Review of a care plan for Resident #34, initiated on 08/30/24, showed the resident had oxygen therapy related to obesity. The interventions showed for residents who should be ambulatory, provide extension tubing or portable oxygen apparatus. Give medications as ordered by physician. Monitor/document side effects and effectiveness. Monitor for signs/symptoms of respiratory distress and report to the MD (Medical Director). Residents Affected - Few On 09/24/24 at 12:38 p.m. an interview was conducted with Staff B, Registered Nurse (RN). She stated resident's respiratory equipment should not be on the floor. Staff B stated the tubing, and cannula should be stored in a bag when not in use. On 09/24/24 at 12:45 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated the nurse administering the oxygen should bag the tubing after each use. He stated it should be replaced weekly for PRN (as needed) users. The DON stated the resident's CPAP mask and tubing should be stored in a bag when not in use. On 09/24/24 at 12:57 p.m. an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated they did not have a policy regarding storage of respiratory equipment. (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 12 of 44 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 10/02/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility did not ensure accurate accountability and storage of controlled medications in two (East Cart 1, East Cart 2) out of three medication carts inspected. Residents Affected - Some Findings included: On 10/01/2024 at 2:15 p.m. an observation was made of narcotic count discrepancies during medication storage observation, with Staff H, LPN. A count of the controlled medication drawer in the East Wing Carts 1 and 2 revealed the following: - One small loose light-yellow pill in the narcotic box of the medication cart (Photographic Evidence Obtained), - A card containing 26, Clonazepam 1.0 milligram (mg) tablets. The controlled substance record documented 27 remaining on the card. - A card containing 29 Clonazepam 0.5 mg tablets. The controlled substance record documented 30 remaining on the card. - A card containing 21 Oxycodone HCL 5 mg tablets. The controlled substance record documented 23 remaining on the card. - A card containing 26 Tramadol 50 mg tablets. The controlled substance record documented 27 remaining on the card. - A card containing 16 Hydrocodone/APAP 5-325 mg tablets. The controlled record documented 17 remaining on the card. - A card containing 30 Tramadol 50 mg tablets. Review of the electronic medical record showed the resident was discharged on 9/21/2024. On 10/01/2024 at 2:40 p.m. during an interview conducted with Staff H, LPN stated she was busy and just did not get around to signing the medications out and stated, It was a hectic morning. Staff H, LPN stated medication should be signed out when the medication is administered. Staff H, LPN stated discharged narcotics should have been removed from the narcotic medication box, but the DON (Director of Nursing) oversaw disposing of all narcotic returns. On 10/01/2024 at 3:30 p.m. an interview was conducted with the DON. The DON stated narcotic medication should be documented immediately after the medication is administered. The DON stated he oversees the disposal of narcotics when the nurses inform him of a return and he was unaware of a narcotic medication card from a discharged resident in the medication cart. A review of the facility policy titled, Controlled Substance, effective 9/07/2023, revealed under the section titled Policy showed the facility shall comply with all law, regulations, and other requirements related to handling, storage, and documentation of Scheduled 11 and other controlled substances. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 13 of 44 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 10/02/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility policy titled, Medication Storage, effective 12/08/2023, revealed under section Policy showed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The policy revealed under the section titled Procedures . Number 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes. ) Containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 14 of 44 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 10/02/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observed, and ten errors were identified for four residents (#4, #67, #11, #2) out of five residents observed. These errors constituted a 28.57% medication error rate. Residents Affected - Some Findings included: 1. On 10/01/24 at 8:24 a.m. an observation was made of Staff H, Licensed Practical Nurse (LPN). Staff H dispensed the following medications for Resident #4: -Baclofen 10 milligram (mg) tablet -Calcium 600 mg with Vitamin D3 tablet -Clonazepam 0.5 mg tablet -Colace 100 mg tablet -Iron (ferrous sulfate) 325 mg tablet -Valproic Acid 250 mg/5 milliliters (mL) -Levetiracetam 100 mg/10 mL -Risperidone 3 mg tablet -Vitamin C 500 mg tablet -Simethicone 80 mg tablet. Staff H, LPN confirmed dispensing 8 tablets, 5 mL of Valproic Acid and 10 mL of Levetiracetam. The observation revealed 5 mL of Levetiracetam was dispensed. Upon entering the resident room, Resident #4 was alert and asked Staff H if she could take the tablets by mouth and the liquid medication through her gastric tube (G-tube). The staff member administered the oral tablets and assisted resident with water cup. Staff H then washed her hands, gathered G-tube supplies and administered 15 mL of water to G-tube by gravity to flush. The staff member administered 5 mL of Valproic Acid through the G-tube by gravity, flushed with 10 mL of water by gravity, administered 5 mL of Levetiracetam by gravity followed by a flush of 20 mL of water by gravity. Staff H clamped the G-tube, washed hands and exited the room. Review of the Resident #4's October 2024 Medication Administration Record (MAR) revealed the following orders related to the observed administration of medications: - Ferrous Sulfate Oral Solution 220 (44 Fe) [44 Iron] MG/5ML (Ferrous Sulfate) Give 5 ml via PEG-Tube [Percutaneous Enterogastric tube] one time a day for anemia, 0900 (9:00 a.m.), - Calcium Oral Tablet (Calcium) Give 500 mg via PEG-Tube two times a day for supplement, 0900 and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 15 of 44 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 10/02/2024 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 0759 2100 (9:00 p.m.), Level of Harm - Minimal harm or potential for actual harm - levETIRAcetam Oral Solution 100 MG/ML (Levetiracetam) Give 10 ml via G-Tube two times a day for Seizure Disorder, 0100 (1:00 a.m.) and 0900. Residents Affected - Some 2. On 10/01/24 at 8:55 a.m. an observation was made of Staff I, Registered Nurse (RN). Staff I dispensed the following medications for Resident #67: -Vitamin B complex with vitamin B12 tablet -Aspirin 81 milligram (mg) tablet -Lasix 20 mg tablet -Carvedilol 12.5 mg tablet -Lisinopril 40 mg tablet -Tylenol 500 mg 2 tablets. Staff I, RN confirmed dispensing seven tablets. Upon entering the resident room, Resident #67 was alert. Staff I took a manual blood pressure prior to administering the oral tablets. Review of the Resident #67's October 2024 MAR revealed the following order related to the observed administration of medications: - Thiamine HCl [hydrochloride] Oral Tablet 100 MG (Thiamine HCl) Give 1 tablet by mouth one time a day for supplement, 0900. 3. On 10/01/24 at 9:05 a.m. an observation was made of Staff I, RN. The staff member dispensed the following medications for Resident #11: -Aspirin 81 mg enteric coated tablet -Tamsulosin 0.4 mg capsule -Hydroxyzine 25 mg tablet -Trihexyphenidyl 2 mg tablet -Metoprolol Succinate 50 mg tablet - Potassium Chloride Extended Release 20 milliequivalents (MEQ) tablet -Duloxetine 60 mg Delayed Release capsule -Plavix 75 mg tablet -Folic Acid 1 mg tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 16 of 44 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 10/02/2024 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 0759 -Donepezil 5 mg tablet Level of Harm - Minimal harm or potential for actual harm -Aripiprazole 5 mg tablet - Amlodipine 5mg tablet Residents Affected - Some -Pioglitazone 30 mg tablet -Glipizide 10 mg tablet. Staff I, RN confirmed dispensing 2 capsules and 12 tablets. Staff I placed all the tablets in a medication bag to be crushed. Staff I, RN stated, I crush all of these first, then open the capsules and put them on top. After the medications were crushed into a powder, the staff member took a medication cup, added a spoonful of vanilla pudding and poured the medication powder on top. The capsules were opened and added to the medication cup with the pudding and other medications. Another spoonful of vanilla pudding was added to the medication cup and stirred together mixing the crushed medications into the pudding. Upon entering the resident room, Resident #11 was alert and sitting in the bed. Staff I set the medication cup with the pudding medication mixture on the bedside table. After the vital signs were taken, Staff I assisted Resident #11 by spoon feeding him the medication mixture. Review of Resident # 11's October 2024 MAR revealed the following orders related to the observed administration of medications: - Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet by mouth one time a day for CAD [coronary artery disease], - Metoprolol Succinate ER [extended release] Tablet Extended Release 24 Hour 50 MG Give 1 tablet by mouth one time a day for HTN [hypertension], - Potassium Chloride ER Tablet Extended Release 20 MEQ Give 1 tablet by mouth one time a day for Hypokalemia, - DULoxetine HCl Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day for Depression, - Pioglitazone HCl Tablet 45 MG Give 1 tablet by mouth one time a day for diabetes mellitus. 4. On 10/1/24 at 11:17 a.m. an observation was made of Staff H, LPN, obtaining a blood glucose level, preparing medication, and injecting Resident #2's insulin. Staff H assisted the resident back to the room, washed hands, donned gloves, cleaned the resident's right middle finger with an alcohol pad, and lanced the finger unsuccessfully. Staff H cleaned the resident's right pinky finger, lanced the finger, and obtained a blood glucose level of 285. On 10/1/24 at 11:25 a.m. Staff H, LPN removed Resident #2's Novolog Flexpen from the medication cart, placed an insulin needle on the pen, dialed 3 units on the dosage selector and returned to the resident's room. The staff member cleansed the resident's right lower abdominal quadrant with an alcohol pad, the dosage selector of 3 units was verified prior to the injection of insulin. The staff member verified the dosage selector had returned to zero. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 17 of 44 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 10/02/2024 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/1/24 at 11:28 a.m. Staff H, LPN stated she did not prime the insulin pen prior to administration. Staff H stated she is only supposed to prime the insulin pen the first time the pen is used. Review of the manufacturer information for Novolog Flexpen, located at https://www.novo-pi.com/novolog.pdf revealed the instructions to use the air shot or prime the needle before each injection. Small amounts of air may collect during normal use. To avoid injecting air and ensure proper dosing, perform an air shot. -Turn the dose selector to 2 units -Hold flexpen with needle pointing up. -Tap cartridge gently a couple times to make any air bubbles collect to the top of the cartridge. -Keep the needle pointing upwards and press the push-button all the way in. The dose selector then returns to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. If you do not see a drop of insulin after six times, do not use the Novolog Flexpen. On 10/2/24 at 8:29 a.m. an interview with the Director of Nursing (DON) was conducted. The DON stated the nurses are supposed to prime the Novolog flex pens prior to each use. He stated they are supposed to point the tip upward, dial 2 units and push it out, then dial select the appropriate dose. On 10/2/24 at 12:00 p.m. an interview with the Medical Director was conducted. The Medical Director stated extended-release medications should not be crushed. It would be contraindicated to crush Metoprolol Succinate extended release. On 10/2/24 at 12:20 p.m. an interview with the Pharmacist was conducted. He stated extended-release medications should not be crushed. Metoprolol Succinate should not be crushed. Potassium Chloride ER cannot be crushed because it has microbeads in it, this medication can be dissolved in water and administered separately. Duloxetine can be opened and sprinkled in apple juice or applesauce and administered separately; it is not appropriate to open the capsule and mix with other medications in pudding. A review of the policy titled, Medication Administration Policy-General, dated 08/07/23, revealed the following: 3. Dose Preparation: 3.7 Verify that the medication name and doe are correct when compared to the medication order on the medication administration record. 3.10 Crush oral medications only in accordance with Pharmacy guidelines. 4. Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in the facility's medication administration schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 18 of 44 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 10/02/2024 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 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. Based on observation, interview and record review the facility did not ensure medications were stored appropriately in one (East) out of two medication storage rooms, in one treatment cart (Reflection Hallway), and three (East 1 Cart, East 2 Cart and [NAME] Cart) out of 5 medication carts. Findings included: On 9/23/2024 at 10:10 a.m. an observation was made of the Reflection hallway common room. A large wall unit used for storage had one cabinet unlocked with a resident's prescribed medication present. On 9/23/2024 at 10:15 a.m. an interview was conducted with Staff D, Licensed Practical Nurse/ Unit Manager (LPN/UM). Staff D, LPN/UM stated the cabinet was for wound care and should be locked. Staff D, LPN/UM could not state why the prescribed medication was in the cabinet. On 9/23/2024 at 1:47 p.m. an observation was made of a Personal Protective Equipment (PPE) storage bin located outside Resident Rooms #112 and #113 and revealed a box of 144 packets of Hydrocortisone Acetate 1% Cream. The box was opened with multiple individual packets stored in the box. On 10/01/2024 at 9:50 a.m. an observation and interview were conducted with the Director of Nursing (DON) in the medication storage room on the East Wing nurses' station. The DON obtained keys from Staff H, Licensed Practical Nurse (LPN) to enter the medication room. Upon entrance into the medication room, outside the refrigerator door was an unlocked brace lock. Inside the refrigerator, the secured narcotic box was unlocked. In the narcotic box was the emergency medication kit for the facility assembled by the pharmacist. The DON stated both locks should be locked and proceeded to attempt to lock the narcotic box with the numerous keys on the keychain. The DON stated he does not have a set of keys for the locks and stated the keys must be on the other set of keys Staff H, LPN was carrying. The DON stated Staff H, LPN was the only nurse to have the keys to the locked narcotic box. When Staff H, LPN provided the second set of keys to the DON she stated she was unaware she had the only set of keys to unlock the narcotic box in the refrigerator for the whole facility. The DON stated she works only four times a month for the facility. The DON went through several keys to close the narcotic box and the refrigerator door. The DON stated only nursing staff and maintenance have access to the medication room. A continued observation of the East Wing medication storage room revealed a milk crate box on the ground with numerous pharmaceutical medication dispense cards and a plastic bag full of personal medications of a resident. The DON stated the box contained discontinued medications for return to the pharmacy. The DON stated the pharmacy picks up medications daily. An electronic record review of a sample of the medication cards had two residents discharged on 9/21/2024 and 9/24/2024. On 10/02/2024 at 2:15 p.m. an observation of the East Cart 2 medication cart and interview were conducted with Staff H, LPN. The observation revealed two insulin pens not labeled. An observation was made of a loose pill in the locked narcotic box of East Cart 2. Staff H, LPN stated the insulin pens should be labeled and the loose pill should be destroyed. An observation was made of the East Cart 2's surface and revealed a liquid and white powdered substance while Staff H, LPN was administrating medication. On 10/01/2024 at 2:50 p.m. an observation and interview were conducted with Staff I, Registered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 19 of 44 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 10/02/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nurse (RN) in the [NAME] Wing. An observation was made of a loose blue and white pill in the [NAME] Cart's top drawer. An observation was made of six loose orange pills in a medicine cup. Staff I, RN stated the loose orange pills and the blue and white pill are not supposed to be in drawer loose. On 10/02/2024 at 1:55 p.m. an observation of East Cart 2 revealed it was unlocked with no nurse at the cart. A nurse was observed down the hallway at East Cart 1. Observations were made of numerous staff and residents walking multiple times in front of the unattended cart. The observation continued for ten minutes. The Nursing Home Administer closed the cart and stated the cart should be always locked. A review of the facility's policy and procedure titled, Medication Storage, effective date of 12/08/2023, showed the following policy statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The policy revealed under the section titled, Procedures the following: 1.Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. 2.The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . 7. Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 20 of 44 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 10/02/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure meal preferences were honored for one (#8) of eight residents sampled for dining in one hall (100) of two halls. Findings included: Review of the admission Record revealed Resident #8 was admitted to the facility on [DATE] with a primary diagnosis of amyotrophic lateral sclerosis. Review of the September 2024 physician orders for Resident #8 revealed the resident received a regular diet, pureed texture, nectar/mild thick consistency. Review of a Quarterly Minimum Data Set (MDS) assessment, with the ARD (assessment reference date) target date of 8/15/24, for Resident #8 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident was cognitively intact. Review of a meal ticket for Resident #8 showed a list of dislikes to include green beans. Review of a care plan for Resident #8, initiated on 05/02/19, showed the resident had potential for inadequate nutritional and hydration status. Interventions included to provide and serve diet as ordered. RD (Registered Dietician) to evaluate and make diet changes per facility policy. On 09/23/24 at 12:00 p.m. an observation was made of Staff A, Certified Nursing Assistant (CNA) assisting Resident #8 with her lunch. The meal ticket on the tray showed the resident did not like green beans. An observation was made of a green pureed vegetable on the resident's plate. Staff A, CNA stated the vegetable served for lunch was green beans. An immediate interview was conducted with Resident #8. She shook her head left to right when asked if she liked green beans. She stated she did not like green beans. Staff A, CNA who was present during this interaction proceeded to assist the resident with the meal. A follow -up interview was conducted on 09/23/24 at 12:20 p.m. with Resident #8. She stated she did not eat the green beans and the sausage. She stated the sausage was spicy. She confirmed she was not offered an alternate. Review of a document titled [Name of Facility] 2024 Menu, showed on September 23rd, the lunch menu included green beans and Italian sausage. On 09/23/24 at 12:23 p.m. an interview was conducted with Staff A, CNA. She stated the resident ate potatoes only. She said, I did not ask her if she needed anything. I did not see her dislike list. On 09/24/24 at 2:10 p.m. an interview was conducted with Staff A, CNA. She said, I heard her [Resident #8] say to you she did not like the green beans. I saw her meal ticket afterwards. I saw it was listed she did not like green beans. I should have offered her something else. Staff A stated she could have asked for a double portion of mashed potatoes or an alternate choice of vegetables. On 09/24/24 at 1:37 p.m. an interview was conducted with the Certified Dietary Manager (CDM). She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 21 of 44 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 10/02/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she checked resident trays prior to the meals going out. She stated they had a process to go through all of the meal tickets to see who does not like the menu items. She stated the aide circled the item if the resident was allergic to it or highlighted the disliked item; so they did not miss it. The CDM reviewed Resident #8's meal ticket and said, I can tell we missed it. She does not like veggies. She should not have been served green beans. It should be circled. It was missed. It was overlooked. The CDM stated upon admission she updated resident's meal preferences and any other time upon further meal change requests. On 09/24/24 at 2:28 p.m. an interview was conducted with the Director of Nursing (DON). He stated the resident should have been offered an alternate meal if she did not like what was served. On 09/24/24 at 2:41 p.m. an interview was conducted with the Nursing Home Administrator (NHA). She stated the expectation would be for a resident to be offered an alternate meal if they disliked an item. She said, The dietary staff should not have served her green beans if it is on her dislike list. The NHA stated meal preferences should be honored. Review of a facility policy titled, Nutrition Policy, dated 09/01/24, showed the RD (Registered Dietician) or other clinically nutrition professional will be responsible for ensuring the plan of care of each resident is in concert with the residents (sic) expressed wishes for care and services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 22 of 44 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 10/02/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, facility failed to ensure hospice services were being provided in accordance with accepted professional standards and principles due to a lack of communication and documentation in the medical record for one (#27) of two residents reviewed. Findings included: Review of Resident #27's admission Record revealed a re-admission date of 12/27/2021 with the diagnosis of early onset Alzheimer's disease and other co-morbidities. Review of Resident #27's physician order summary revealed an order for Hospice with the diagnosis of advanced dementia, dated 7/22/2024. Review of Resident #27's Minimum Data Set (MDS), dated [DATE], revealed hospice care being given while resident resided at the facility in Section O - Special Treatments, Procedures, and Programs. Review of Resident #27's progress notes in the facility chart revealed no documentation of hospice services. Review of Resident #27's care plan did not reveal a hospice care plan. An interview was conducted with Staff I, Registered Nurse (RN) on 10/1/2024 at 2:47 p.m. Staff I, RN stated Resident #27 has an order for hospice care. Staff I, RN stated only communicating with hospice if the resident were to have a change of condition. Staff I, RN stated a phone call would then occur. An interview was conducted with the Social Service Director (SSD) on 10/1/2024 at 10:11 a.m. The SSD stated the DON handled communication with hospice. An interview was conducted with the DON on 10/1/2024 at 3:00 p.m. The DON stated the hospice nurse was here yesterday, but did not check out with me as I have requested for them to do. The hospice nurse does not leave any notes, or binder. The DON stated, I do not know what she did, this is a consistent problem. Review of the facility policy and procedure titled, Hospice Services, dated 9/7/2023, revealed: Policy: The center will honor the residents wish to elect Hospice services as part of end-of-life care Procedure: 1. The physician will order a Hospice evaluation as indicated; for example, by resident or family request. If Hospice becomes involved in the care of the resident. a. The facility and Hospice, with input from the resident and family, will establish a coordinated plan of care which reflects and supports the Hospice philosophy. b. The plan of care will include directives for managing pain and other symptoms and will be revised and updated as the residence status changes. c. The facility and Hospice will identify this specific services that will be provided by the entity and this information will be communicated with the resident and family, and in the plan of care. d. The Hospice provider retains overall responsibility for directing and coordinating the plan of care related to terminal illness and related conditions. e. Medications and medical supplies needed for palliative care will be provided by the Hospice provider. f. The Hospice and facility will communicate with each (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 23 of 44 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 10/02/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few other and with their resident and family when any changes are indicated or made to the plan of care. 3. The Hospice provider is to be invited to the resident's care plan meetings. 4. Hospice services are provided, and plan of care is to be part of the facility medical record. Review of the agreement titled, Agreement Between Hospice and Nursing Facility for Hospice Care for Facility Residents, dated 6/27/20 (year of effective date blank), revealed: 2. 7 Communication of Coordination of Hospice Care. .Hospice and Facility have agreed to participate in a system of communication as described in the Hospice's Policies and Procedures to: (b) ensure that the care and services are provided in accordance with the Hospice Plan of Care; (d) provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provide directly or under arrangement; and (e) provide for an ongoing sharing of information with other non-Hospice healthcare providers furnishing services unrelated to the Terminal Illness and related conditions. 2.8 Coordination of Hospice Care. For Hospice Patients residing in a Facility, Hospice shall further coordinate services by: (a) Designating a specific member of each IDG (interdisciplinary group) that will be responsible for a Hospice Patient. The designated IDG member is responsible for: (i) overall coordination of Hospice Care for the Hospice Patient with the Facility representatives; and (ii) communicating with Facility representatives and other health care providers participating in the provision of care for the terminal illness, related conditions and other conditions to ensure quality of care. 3.10 Facility Representative's Duties . (a) Coordinate care to the Hospice Patient provided by both the Facility and Hospice staff, (b) Collaborate with Hospice Nurse Coordinator and coordinate Facility staff participation in the Hospice care planning process, (c) Communicate with Hospice Nurse Coordinator and other healthcare providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 24 of 44 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 10/02/2024 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 0849 of care for the patient and family . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 25 of 44 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 10/02/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee developed and implemented action plans to correct deficient practices identified during a recertification and complaint survey conducted on 9/23/24 to 9/24/24 and 10/1/24 to 10/2/24 and a Federal Monitoring Health Comparative Survey conducted on 11/12/24 to 11/15/24 related to 1.) failing to provide a safe, clean, and homelike environment in twelve resident rooms and bathrooms (#100, #210, #213, #202, #221, #216, #223, #211, #203, #206, #111, and #220) out of sixteen observed, in one shower room (East shower room) out of two facility shower rooms observed, for one resident (#1) of 26 sampled residents related to unserviceable bedding, and did not ensure housekeeping carts were kept locked on one (West Wing) of two wings of the facility (F584), 2.) failing to ensure one resident (#24) of three residents receiving continuous oxygen therapy had equipment changed per facility policy (F695), 3.) failing to implement a system for accurate reconciling and accounting of controlled substances for one resident (#26) of three residents sampled for the administration of narcotic medications (F755), 4.) failing to ensure drugs and biologicals were appropriately stored and labeled in three of three medication carts reviewed (F761), and 6.) failing to ensure four residents (#8, #20, #3, and #21) of four sampled residents were accurately screened for mental health services prior to admission and the Pre-admission Screening and Resident Review (PASRR) for the resident was updated to include mental health diagnoses (F645) during the revisit survey conducted 1/2/25 to 1/3/25 and 1/16/25. Findings included: Review of the policy titles Quality Assurance Performance Improvement program (QAPI), effective 8/1/23, revealed the following: The center and organization has a comprehensive, data-driven quality assurance performance improvement program that focuses on indicators of the outcomes of care and quality of life. The center's QAPI program is on-going comprehensive review of care and services provided to residents. May include but limited to: a. Medical care b. Clinical care c. Rehabilitation d. Pharmacy services e. Dining services f. Social service g. Community life services h. Hospitality services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 26 of 44 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 10/02/2024 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 0867 i. Environmental services Level of Harm - Minimal harm or potential for actual harm j. Admissions k. Business office Residents Affected - Few l. Medical records The Leadership portion of the policy revealed: The Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to: a) Implementation, b) Identify priorities, c) Ensure adequate resources, d) Ensures performance indicators, resident and staff input and other information is used to prioritize problems and opportunities, e) Ensures corrective actions are implemented to address identified problems in systems, f) Evaluates the effectiveness of actions, (and) g) Establishes expectations for safety, quality, rights, and choice and respect. The center will collect and monitor data from different departments reflecting its performance. The center will establish performance indicators for data collected. The center will ensure systems and actions are in place to improve performance. During an interview with the Director of Nursing (DON) on 1/3/25 at 3:30 p.m. the DON reviewed the Plan of Correction completed on 11/16/24. The DON reported facility audits and observations were completed regarding identified citations found during the recertification survey. The DON reported she could not submit all the Level II PASRR assessments at one time because the vendor did not have the staff to do them all. An interview was conducted on 1/3/25 at 5:30 p.m. with the Nursing Home Administrator (NHA). The NHA reported a QAPI meeting was held on 11/26/24 regarding both the recertification and Federal surveys. The QA meeting included management staff, other than Maintenance, and determined the root cause was the age of the building. The facility started deep cleaning, general repairs, replacement of mirrors, and weekly projects. 1. On 1/2/25 at 9:18 a.m., the following observations were made in resident room [ROOM NUMBER]: - Dried brown liquid substances on the wall next to the back of the resident's bed. - The windowsill had a dried black substance along with small debris in the corner where the sill meets the window frame. On 1/2/25 at 9:24 a.m., the following observations were made in the East Shower Room: - The top of the toilet rim and toilet seat were dirty with brown flecks, dark yellow colored liquid, and hair. The floor around the toilet base was stained black and the caulking was dirty. On the floor in front of the toilet there were darkened and dried brown/black colored stains. - A spot of a black dried substance was on the floor near the shower drain along with hair. The area of the shower drain was stained dark brown and there was hair on top of the drain. - On the inside front of the shower room entrance door was a dried dark brown substance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 27 of 44 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 10/02/2024 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 0867 On 1/2/25 at 10:58 a.m., an observation of room [ROOM NUMBER] showed the window frame was caked with dirt and small debris. Level of Harm - Minimal harm or potential for actual harm On 1/2/25 at 11:21 a.m., the following observations were made in resident room [ROOM NUMBER]: Residents Affected - Few - The paint on the windowsill was scratched revealing the wood underneath in several areas. - The air conditioner vent slats had a dried brown/black colored substance on all of the slats. - The wall next to the resident's closet had brown colored substance that dripped down the wall and had dried. - The resident's bed table was warped and peeled, showing the particle board inside. - The small three drawer dresser in the resident's room where the television was sitting on was warped and peeled, showing the particle board inside. - Lying in the corner of the resident's room next to the television was a clear plastic fast-food drink container, with a lid and straw laying on the floor. There was also a small amount of black and brown debris on the floor. - The mirror above the sink in the bathroom was desilvering and the sink was starting to separate from the top of the vanity. The sink drain was stained with a dark yellow substance. - In the corner under the sink in the bathroom there was a dark colored live pest and a white pill on the floor. The wall, the baseboard, and the floor under the sink was dirty and stained with a black substance. On 1/2/25 at 11:30 a.m., the following observations were made in resident room [ROOM NUMBER]: - Ripped and dirty walls and floor on the inside right of the entrance to the resident's room. - The air conditioner inside of the resident's room had a dried brownish black substance on the inside of the unit along with debris. - The connection point for the grab bars attached to the toilet was corroded and peeling. The toilet seat was yellowing around the inside rim and there was brown colored buildup inside of the toilet where the water flows when flushed. The baseboard behind the toilet was dirty and the caulking was stained with a dark yellowish substance. - The sides and front of the mirror above the sink was desilvering and the faucet was dripping. On 1/2/25 at 12:28 p.m., the following observations were made in resident room [ROOM NUMBER]: - The air conditioner vent inside of the resident's room had a dried brownish black substance behind the vent slats. -The floor around the sink, which was located inside of the resident's room, was dirty and stained with a yellow colored substance. The baseboard on the wall next to the sink was also dirty and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 28 of 44 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 10/02/2024 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 0867 stained. Level of Harm - Minimal harm or potential for actual harm - The mirror above the sink in the resident's room was desilvering on the bottom, and the top of the sink was stained with a rusty brown substance on the right side (facing the sink) of the faucet. Residents Affected - Few - The bathroom floor, walls, and baseboard were stained with a brownish black substance. The bottom of the toilet base was also dirty and stained. On 1/2/25 at 12:43 p.m., the following observations were made in resident room [ROOM NUMBER]: - The windowsill had trash sitting on it, including a cup with a brown liquid substance in it and a balled-up napkin. The paint around the window frame was peeling. - The air conditioner slats were dirty with a brown/black colored substance, and behind the slats on the inside bottom of the unit there were black spots. - The mirror in the bathroom was desilvering on the bottom and sides. - The toilet paper dispenser was empty and there were two open toilet paper rolls sitting on top of the commode. Also on top of the commode was a bottle of body cleanser which was not labeled for a resident. - There was a brown colored buildup inside of the toilet where the water flows when flushed. The toilet seat was up, which revealed dark yellow stains and hair where the seat attached to the toilet bowl. The underside of the toilet seat had flecks of a dried brown substance. - The floor around the toilet and behind the toilet was dirty and stained with a black substance. The wall and baseboards were also stained with a similar appearing black substance. On 1/2/25 at 1:00 p.m., an observation was made of dried and crushed food on the floor of resident room [ROOM NUMBER]. In the corner of the room, the resident had a three drawer dresser, which was warped with exposed particle board. The resident's bedside tabletop was warped, exposing the particle board. On 1/2/25 at 9:58 a.m., an observation was conducted in room [ROOM NUMBER]. The observation revealed the edges of the stand holding the rooms television was without veneer and a cleanable surface. On 1/2/25 at 11:44 a.m., an observation was conducted with Staff E, Certified Nursing Assistant (CNA) in room [ROOM NUMBER]. The observation showed a bedside dresser in room [ROOM NUMBER] with the unveneered top bubbling up. The staff member confirmed the top was not cleanable and demonstrated how the top flaked. A continued observation was conducted with the staff member with showed the base of sink in the room [ROOM NUMBER] was discolored with a black/yellowish-brown staining. The observation with Staff E, CNA also showed an unveneered dresser top in room [ROOM NUMBER] with the side of drawer split. On 1/2/25 at 4:04 p.m., an observation of room [ROOM NUMBER] showed the door to the bathroom was splintered with unattached pieces of veneer. The observation also showed a dresser next to the bed with the plastic edging broken and unattached. An observation of the bathroom revealed a toilet raiser was discolored with rust coloring and flaking surface, the toilet base was stained with a grey (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 29 of 44 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 10/02/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few splattering and built up dirt, the wall behind toilet was splattered with an unknown substance, the tiles between the toilet and wall were stained with a brown substance, and there was a buildup of dirt in corner next to toilet. On 1/3/25 at 9:29 a.m., an observation showed Resident #1 was lying curled up on the unmade bed. At the head of bed, above the resident's head was a pillow ripped with observed white stuffing. Staff F, Licensed Practical Nurse (LPN) confirmed the observation of the pillow, stating he would change it out. Staff G, CNA, reported noticing the pillow before breakfast. On 1/3/25 at 9:37 a.m., an observation was made of the bathroom shared by rooms [ROOM NUMBERS]. The tiles around toilet were stained and discolored with brown colored substance splattered. On 1/3/25 at 10:46 a.m., an observation was made of the windows outside of rooms 205-210 in the Reflections unit (six rooms) and rooms 211-215 on the [NAME] unit (five rooms). The observation showed the Reflections activity room windows were discolored with a green substance and five window screens were discolored and torn. Review of the facility's Department Managers Daily Room Rounds form showed managers were to document if walls were in good repair, furniture was in good repair, bathrooms were clean and free from odors, and if rooms were clean and free from odors. On 1/2/25 3:20 p.m., upon exiting the facility's [NAME] wing, a housekeeping cart was observed blocking a door and the housekeeping cart was unlocked. A facility tour and interview were conducted on 1/3/25 at 4:51 p.m. with the facility's Maintenance Director. He stated he is also the facility's Housekeeping Supervisor. He was notified of all identified environmental concerns and stated all new bedside dressers have been ordered, but he was unable to provide a receipt of order. The trash in window sill of room [ROOM NUMBER] was still present during the tour with the Maintenance Director and he stated the rooms are cleaned daily and deep cleaned weekly. Review of the Director of Maintenance job description showed under the section Purpose of Your Job Position, The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the maintenance department in accordance with current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner. The Duties and Responsibilities of the description showed the following: - Plan, develop, organize, implement, evaluate, and direct the maintenance department, its programs and activities. - Develop and maintain written maintenance policies and procedures. - Develop and maintain written job descriptions for each level of maintenance personnel in accordance with pertinent laws and regulations. - Assist the maintenance staff in the development and use of departmental policies, procedures, equipment, supplies, etcetera. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 30 of 44 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 10/02/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm - Review the departments policies, procedure manuals, job descriptions, etcetera, at least annually for revisions and make recommendations to the administrator. - Interpret the departments policies and procedures to employees, residence, visitors, government agencies, etcetera. Residents Affected - Few - Assume the administrative authority, responsibility, and accountability of directing the maintenance department. 2. On 1/2/25 at 4:10 p.m., Resident #24 was observed lying in bed while wearing a nasal cannula attached to an oxygen concentrator. The tubing was dated 12/21/24. A plastic bag was observed hanging from the concentrator with oxygen tubing coiled up inside dated 12/27/24. An observation and interview was conducted on 1/2/25 at 4:12 p.m. with Staff H, CNA of the tubing Resident #24 was wearing. The staff member confirmed the nasal cannula the resident was wearing in the nares was dated 12/21/24, which was 12 days prior to the observation. Review of Resident #24's admission Record showed the resident was admitted on [DATE] with a readmission on [DATE]. The record included diagnoses not limited to unspecified chronic obstructive pulmonary disease (COPD), chronic systolic (congestive) heart failure, and senile degeneration of brain not elsewhere classified. Review of Resident #24's Medication Administration Record (MAR) revealed staff documentation every day and night shift of the residents oxygen saturation levels at 3 liters per minute (lpm). Review of the facility policy titled Oxygen, revised 8/2023, revealed under Policy, the facility will ensure oxygen is administered safely and physician order. The policy included the following Procedure: 2. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/ or nasal cannula. 3. Check the tubing connected to the oxygen cylinder or concentrator to ensure that it is free of kinks. 5. Oxygen tubing is to be changed weekly and/ or as needed when soiled or the tubing becomes compromised. 6. Oxygen tubing is to be bagged/dated and changed weekly. Review of the facility's Department Managers Daily Room Rounds form showed managers were to ensure O2 (oxygen) tubing dated - not more than 7 days (and) tubing off the floor. 3. Review of Resident #26's admission Record revealed the resident was admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to other idiopathic peripheral autonomic neuropathy, unspecified paraplegia, unspecified low back pain, and chronic pain syndrome. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 31 of 44 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 10/02/2024 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 0867 Review of Resident #26's December and January MAR revealed the following Oxycodone orders: Level of Harm - Minimal harm or potential for actual harm - Oxycodone Hydrochloride (HCl) Oral Tablet 10 milligrams (mg) - Give 1 tablet by mouth every 6 hours as needed for severe pain 5-10 mg, per dose. This order started on 11/1/24 and discontinued on 1/3/25 at 6:00 p.m. Residents Affected - Few - Oxycodone HCl Oral Tablet 5 mg - Give 1 tablet by mouth every 6 hours as needed for moderate pain 5-10 mg per dose. This order started on 11/1/24 and was discontinued on 1/3/25 at 6:00 p.m. - Oxycodone HCl Oral Tablet 5 mg - Give 2 tablet(s) by mouth one time only for pain for 1 day. Ok to give oxycodone 5 mg 2 tablets x1 while 10 mg script is being refilled. This order started on 12/18/24 at 10:00 a.m. and was discontinued on 12/19/24. A review of Resident #26's January MAR and the Medication Monitoring/Control Record showed 26 Oxycodone 10 mg tablets had been received on 12/31/24. The review revealed the following discrepancy related to the administration of the resident's Oxycodone 10 mg tablets: - On 1/2/25 at 11:35 p.m., the Medication Monitoring/Control Record showed staff had administered one 10 mg tablet of Oxycodone. A review of the resident's MAR showed the resident received one 10 mg tablet at 6:49 p.m. and did not reflect another dose had been administered at 11:35 p.m. (less than 5 hours after the prior dose). A review of Resident #26's December and January MAR and the Medication Monitoring/Control Record for the resident's Oxycodone 5 mg tablets revealed the following discrepancies: - On 12/16/24 at 3:57 p.m., the Monitoring/Control Record showed the resident had been administered two 5 mg tablets of Oxycodone. The December MARs documentation for the resident's 5 mg of Oxycodone did not show the resident had received any doses on 12/16/24. The review of the resident's December administration of 10 mg of Oxycodone revealed the resident had received 10 mg's on 12/16/24 at 9:37 a.m. and at 5:58 p.m. - On 12/28/24 at 9:00 a.m., the Monitoring/Control Record of the resident's Oxycodone 5 mg tablets revealed one tablet had been administered. Review of the resident's MAR did not show the resident had received any doses of 5 mg on 12/28/24. - On 12/29/24 at 8:35 a.m., the resident's MAR showed the resident had received one 5 mg tablet of Oxycodone. The Monitoring/Control Record for the resident's 5 mg tablets did not show the resident had received any doses on 12/29/24. - On 1/1/25 at 3:58 p.m., the Monitoring/Control Record showed one 5 mg tablet of Oxycodone was documented as wasted. The record did not reveal a second nurse had witnessed the wasting of the controlled substance and the Record of Waste and Spoilage section of the record was blank. - On 1/2/25 at 11:31 p.m., the MAR showed the resident had received one 5 mg tablet of Oxycodone. Review of the Monitoring/Control Record did not show the resident had received any 5 mg doses of Oxycodone on that date. An interview was conducted on 1/3/25 at 5:26 p.m. with Staff M, Registered Nurse (RN). The staff member reported speaking with the physician about clarifying Resident #26's Oxycodone medication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 32 of 44 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 10/02/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few orders. Staff M, RN reported the resident received 5 mg and 10 mg doses of Oxycodone and did not want staff to administer both doses within the 6 hours. During an interview on 1/3/25 at 5:30 p.m., the DON reviewed Resident #26's Monitoring/Control Record and MARs. The DON reported understanding the findings and staff were not paying attention to the doses of Oxycodone. Review of the policy titled Controlled Substance, effective 9/7/23, revealed under Policy, the facility shall comply with all law, regulations, and other requirements related to handling, storage, and documentation of schedule 11 and other substances located in the facility. The policy also revealed the following under Procedure: 4. An individual controlled substance record is to be made for each resident who will be receiving a controlled substance. Do not enter more than one (1) medication per page. The record should contain (but not limited to): a. Name of the resident b. Name and strength of the medication c. Quantity received d. Number/amount of medication administered e. Number on hand f. Name of physician g. Name of issuing pharmacy h. Time of administration i. Method of administration j. Signature of person receiving medication; and k. Signature of the licensed nurse administering medication 10. The Director of Nursing is to investigate any discrepancies in narcotics reconciliation to determine the cause and identify parties responsible and report findings to the administrator. 4. On 1/2/25 at 11:16 a.m., an observation was conducted with Staff B, LPN of a medication cart on the East Wing. The observation revealed one opened insulin aspart FlexPen, which was not dated when it was opened. A yellow sticker was attached to the pen with an area available for staff to document the open date, the expiration date, and initials, which were all blank. The observation showed an unopened insulin glargine (Lantus) pen. The blue sticker attached to the pen informed users to Refrigerate until opened and the pharmacy label revealed the insulin was dispensed on 12/31/24. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 33 of 44 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 10/02/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few observation showed one oval pink colored pill and two round white colored pills, one with imprint visible and one without visible imprint, were laying on the bottom of the drawer without packaging. On 1/2/25 at 11:31 a.m., an observation was conducted with Staff C, LPN/Unit Manager (UM), of the [NAME] Hall medication cart. The staff member was seen standing with the medication cart open. The observation revealed an opened Novolin R insulin FlexPen labeled with an open date of 11/24/24, expiration 12/20/24, and initials. The white sticker attached to the pen documented Date opened 11/24/24 Discard after 28 days. The findings were confirmed by Staff A, Registered Nurse (RN), who came to the cart during the observation. On 1/2/25 at 11:33 a.m., an observation was conducted with Staff D, LPN of the Reflections medication cart. The observation revealed an opened Lantus insulin pen with no open date, labeled to Discard after 28 days , one white oval pill and one blue/white capsule was laying on the bottom of the drawer without packaging, and a container of disinfectant wipes were stored in the same compartment as oral medications. The findings were confirmed by the staff member. On 1/2/25 at 11:56 a.m., a continued observation was conducted with Staff A, RN of the [NAME] Hall medication cart. A white oval pill was observed laying loosely in the bottom of the drawer without packaging. The staff member confirmed the findings. Review of the policy titled Medication Storage, effective date 12/8/23, revealed: The facility shall store all drugs and biologicals in a safe, secure, in orderly manner. The Procedure included the following: 1. Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy has authorized to transfer medications between containers. 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 6. Antiseptics, disinfectants, and germicide used in any aspect of resident care must have legible, distinctive labels that identify the contents in the directions for use and shall be stored separately from regular medications. 5. Review of Resident #8's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to unspecified recurrent major depressive disorder (onset 1/17/23), unspecified bipolar disorder (onset 2/4/20), unspecified mood (affective) disorder (onset 8/15/19), cognitive communication deficit (onset 7/24/17), unspecified severity vascular dementia with other behavioral disturbance (onset 1/17/23), and unspecified symptoms and signs involving cognitive functions and awareness (onset 9/25/18). A Mental Health Advanced Registered Nurse Practitioner (ARNP) note, dated 9/24/24, noted the reason for the visit was to Resident #8's follow up medication and behavior management and lab monitoring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 34 of 44 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 10/02/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The note included the resident's past medical history of Alzheimer's, Cognitive Communication Deficit, Psychosis, Dementia, Depression, Vascular dementia, and Schizophrenia. The note documented the resident was not taking any psych medications. Review of Resident #8's PASARR, dated 7/24/17, showed the resident had a diagnosis of Anxiety and was not currently or had not previously received services for Mental Illness (MI) due to documented history. The decision-making section did not reveal any other limitations and did not have a primary or secondary diagnosis of dementia or a related neurocognitive (including Alzheimer's Disease) disorder. The screening showed a Level II PASRR evaluation was not required. Review of Resident #8's Minimum Data Set, dated [DATE] revealed the diagnoses of dementia (non-Alzheimer's), depression other than bipolar, and manic depression (bipolar disease). Review of Resident #20's admission Record showed the resident's initial admission of 6/19/24 with admitting diagnoses including anxiety disorder. Review of Resident #20's PASRR, dated 6/18/24, Section I - Part A revealed the qualifying diagnosis of anxiety disorder was not checked. Section IV revealed no diagnosis or suspicion of Mental Illness or Intellectual Disability indicated and a Level II PASRR evaluation was not required. Review of Resident #3's admission Record showed the resident was admitted to the facility on [DATE] with admitting diagnoses including dementia, bipolar disorder, mood affective disorder, psychosis, anxiety disorder, and schizoaffective disorder bipolar type. Review of Resident #3's PASRR, dated 4/26/24, Section I - Part A revealed the qualifying diagnoses of bipolar disorder, anxiety disorder, schizoaffective disorder were not checked, and the qualifying diagnosis of mood affective disorder was not specified next to the other space. Section IV revealed no diagnosis or suspicion of Mental Illness or Intellectual Disability indicated and a Level II PASRR evaluation was not required. Review of Resident #21's admission Record showed an initial admission date 6/13/24 with admitting diagnoses including anxiety disorder, depression, alcohol abuse, and dementia. Review of Resident #21's PASRR, dated 6/13/24, Section I - Part A revealed the qualifying diagnoses of anxiety disorder, depression, and substance abuse were not checked. Section II revealed the resident had a primary diagnosis of dementia. Section IV revealed no diagnosis or suspicion of Mental Illness or Intellectual Disability indicated and a Level II PASRR evaluation was not required. Review of a Psychiatric Progress Note for Resident #21, dated 11/22/24, the resident had additional diagnoses of adjustment disorder, mood disorder and other depressive episodes. An updated PASRR for Resident #21 with the addition of these diagnoses was not completed by the facility. Review of the policy titled Preadmission Screening and Resident Review (PASRR), effective 11/8/21, revealed The center well I'm sure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. The procedure revealed the following: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 35 of 44 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 10/02/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the residents medical record. 4. If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services/designee to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. 5. Results of the screening evaluation will be placed in the appropriate section of the individual's medical records and any recommendations for services will be followed. 6. Recommendations will be incorporated in the individual resident's plan of care and approaches/interventions developed to meet the identified needs of the individual. 7. Social services/designee will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from previous years will be kept in the appropriate sections of the resident's records. Photographic Evidence Obtained FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 36 of 44 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 10/02/2024 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 0880 Provide and implement an infection prevention and control program. 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, interview the facility failed to ensure an effective infection prevention control program was maintained related to: 1. not reporting rashes to the local health department and not ensuring four residents (#62, #46, #12 and #22) received appropriate testing for a possible contagious epidermal condition out of four residents reviewed, 2. not ensuring a blood stained pillow case was changed for one resident (#13) of one resident reviewed with a bloodborne pathogen, and 3. not following the infection control practice of sanitizing equipment after use for one resident (#2) of five residents observed during medication administration. Residents Affected - Many Findings included: 1. An observation on 09/23/24 at 10:09 a.m. revealed a red substance that resembled blood stains on Resident #13's pillow as Resident #13 laid in bed asleep. An observation and interview on 09/23/24 at 11:15 a.m. revealed the red substance that resembled blood stains on Resident #13's pillow as Resident #13 sat in the bed awake. Resident #13 stated the red stains on the pillow were blood and probably from her wound on her shoulder. Resident #13 pulled the arm sleeve up on her shirt and presented her right shoulder area. Resident #13's top right shoulder revealed a red, raw and bloody wound that was open to the air. Review of the admission Record showed Resident #13 was admitted to the facility on [DATE] with diagnoses that included [bloodborne pathogen]. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed in Section C- Cognitive Patterns Resident #13 had a Brief Interview for Mental Status (BIMS) score of 08 (moderate cognitive impairment). Section E- Behavior showed Resident #13 exhibited no behaviors during the 7 day look back time period. Section M- Skin Conditions showed Resident #13 had no pressure ulcers and no venous or arterial ulcer. Review of the Order Summary as of 9/24/24 included the following orders: - Apply moisturizer to right shoulder for radiation skin care. at bedtime for right shoulder okay to cover with hydrocolloid dressing and at bedtime for right shoulder okay to cover with hydrocolloid dressing, dated 09/16/24. - Apply moisturizer to right shoulder for radiation skin care. two times a day for right shoulder okay to cover with hydrocolloid dressing and at bedtime for right shoulder okay to cover with hydrocolloid dressing, dated 09/16/24. Review of a Physician Wound Note, dated 09/17/24, showed: Wound Evaluation and Management Summary. Additional Wound Detail: has started radiation tx [treatment] and requested to discontinue silver sulfadiazine. Dressing Treatment Plan: Primary Dressing(s) Hydrocolloid sheet (satin) apply once daily for 30 days. Dressing Treatment Plan: Note: Add Hydrocolloid Sheet (Satin) Once Daily 30. Discontinue Silver Sulfadiazine. An observation on 09/24/24 at 9:27 a.m. revealed the blood stains on Resident #13's pillow as observed on 09/23/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 37 of 44 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 10/02/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many An observation on 09/24/24 at 12:53 p.m. revealed the blood stains on the pillow and visible from the hallway when looking into Resident #13's room. (Photographic Evidence Obtained) During an interview on 09/24/24 at 2:12 p.m. the Nursing Home Administrator (NHA) stated any blood smeared on a pillow case should be changed immediately and it was an infection control concern. During an observation on 09/24/24 at 2:20 p.m. with the NHA Resident #13's pillow remained stained with blood and asked staff to please change the pillow case immediately. During an interview on 09/24/24 at 2:34 p.m. the Director of Nursing (DON)/Infection Preventionist (IP) stated even if Resident #13 didn't have a bloodborne pathogen any blood on a pillow case for days at a time is an infection control concern for me. During an interview on 09/24/24 at 2:35 p.m. Staff D, Licensed Practical Nurse (LPN)/Unit Manager (UM) stated having blood spread around is definitely an infection control issue. The soiled linen should have been changed immediately. During an interview on 10/02/24 at 10:00 a.m. the DON/IP stated he was aware of four residents that developed rashes over the past couple weeks. The DON/IP stated he did not report the rashes to the local health department because they were just rashes and could not classify the rashes as scabies; because the residents were not tested for scabies. The DON/IP stated he was unaware, until today, the four residents were being treated with a medication to treat scabies. The DON/IP stated he confirmed with the Maintenance Director there was no change in detergents or water; so maybe it was just dermatitis. The DON/IP stated he does track and trend and used a color coded map to watch for infections, but he was not tracking the four residents with rashes on the color coded map. The DON/IP stated the only infection he was tracking and monitoring in the facility was a case of Candida Auris (C-Aureus). Review of the facility's policy titled, Infection Control Guidelines for All Nursing Procedures, revised date April 2013 showed: Purpose: To provide for general infection control while caring for residents. General Guidelines: 1. Standard Precautions will be used in the care of all residents in all situation regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucus membranes. Review of the facility's policy titled, Infection Control, undated showed: Policy: This facility's infection control policies are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission and infections. Policy Interpretation and Implementation: 2. The objective of the infection control policies and practices are to: a. Prevent, detect, investigate ad control infections in the facility. b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors and the general public .f. Provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment. Review of the facility's policy titled, Environmental Infection Control- Laundry and Linen, undated showed: Policy: Soiled linen shall be handled in a manner that prevents gross microbial contamination of the air and persons handling them. Procedures: Bagging and Handling Soiled Linen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 38 of 44 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 10/02/2024 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 0880 1. All soiled linen must be placed directly into a plastic bag Level of Harm - Minimal harm or potential for actual harm 2. Do not sort or pre-rinse soiled linens in resident care areas 3. Place any linen saturated with blood and body fluids into a plastic bag Residents Affected - Many 4. Handle soiled linen as little as possible to prevent agitation. 2. On 09/23/24 at 11:58 a.m. an observation was made of Resident #22 in the common room of the Reflection hallway. Resident #22 was self-propelling herself in the room with one sock missing and the other sock halfway off. Resident #22 had exposed skin on her feet. Both feet were with heavy red streaks with small scattered open areas and a small amount of blood noted. Another resident was ambulating in the common room without socks. An observation was made of a staff member searching for socks for the ambulating resident and another staff member approached Resident #22, who asked Resident #22 where her other sock was. This staff member stated to the resident she needed to put cream on her foot. Resident #22 agreed her feet were itchy. On 10/01/24 at 12:31 p.m. an observation was made in the Reflection hallway common room of Resident #22 scratching her legs while eating her meal and sitting to the left of another resident at her table. Staff L, Licensed Practical Nurse (LPN) stated Resident #22 received oral Ivermectin along with three other residents, and the nurse practitioner did not feel a skin scrapping was necessary; just treatment. On 10/02/24 at 9:00 a.m. an interview was conducted with Staff D, LPN/Unit Manager (UM). Staff D, LPN/UM stated rashes for the residents are most likely caused from the laundry detergent. On 10/02/24 at 9:09 a.m. an interview was conducted with Staff M, Certified Nursing Assistant (CNA) in Resident #22's room. Staff M, CNA stated Resident #22 and her roommate Resident #62 received the Ivermectin and she noticed some improvement in their rashes. A record review was conducted of Resident #22's weekly Skin Only Evaluation for the months of August 2024 to 9/25/24. The skin evaluations prior to 9/18/24 showed no current skin issues. A review of the Skin Only Evaluation, dated 9/18/2024, showed Resident #22 with a new rash located on the arms, legs, feet and hands. The rash continued to be documented during the Skin Only Evaluation dated 9/25/2024. A review of Resident #22's September physician orders showed an order for Ivermectin oral tablet 3 milligrams (mg) to give 4 tablets by mouth one time only for rash for one day dated 9/22/2024. A review of Resident #22's September and October Medication Administration Records showed an entry for Ivermectin 3 mg (milligrams) give 4 tablets by mouth one time only for rash as given on 9/25/24. An order for Ivermectin oral tablet 3 mg to give 4 tablets by mouth one time only for rash for one day with a start date of 10/06/24. A review of Resident #22's progress note, dated 9/23/24, showed the resident with ongoing scratching of chest and bilateral upper arms. The Assessment/Plan for rash and other nonspecific skin eruption included the following: Chronic rash per facility staff reports, comes and goes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 39 of 44 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 10/02/2024 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 0880 Patient as started on hydrocortisone 1% cream 9/12/24 until 9/28/24 Level of Harm - Minimal harm or potential for actual harm Add oral Ivermectin one dose (4 tablets) now, repeat in 2 weeks Monitor for resolution of symptoms Residents Affected - Many Currently waiting for delivery of Ivermectin form pharmacy Order for Loratadine 10 mg daily to help with itching Consider hydralazine if Loratadine ineffective, caution, with potential sedation side effect, high fall risk. A record review of Resident #62's weekly Skin Only Evaluation for the months of August 2024 up to 8/29/24 showed no current skin issues. A review of the Skin Only Evaluation dated 9/05/24, showed Resident #62 with a new rash located all over the thighs and Triamcinolone cream was applied as ordered. On 9/19/24 the weekly Skin Only Evaluation showed a rash to arms, legs, back and abdomen and a skin note showed resident does have a treatment in place for her rash, skin is clean dry and intact. On 9/26/24, the weekly Skin Only Evaluation showed a skin issue but not specified and the skin note showed resident has itching and on Ivermectin for the scabies rash. A review of Resident #62's active physician orders as of 10/2/24 showed an order for Ivermectin oral tablet 3 mg to give 4 tablets by mouth one time only for rash for one day dated 9/22/24. An order for Ivermectin oral tablet 3 mg to give 4 tablets by mouth one time only for rash for one day with a start date of 10/06/24. A review of Resident #62's September Medication Administration Record showed an entry for Ivermectin 3 mg give 4 tablets by mouth one time only for rash as given on 9/25/24. A review of Resident #62's progress note, dated 9/22/24, showed the resident with ongoing, worsening rash with staff reports of itchy and scratching a lot. The Assessment/Plan for rash and other nonspecific skin eruption included the following: Ivermectin one dose now (4 tablets), followed by repeat dose in 2 weeks. Continue Loratadine 10 mg orally daily for 30 days. Continue with Triamcinolone cream 0.1% three times a day for 14 days. Keep area of rash clean and dry. Wash with mild soak and warm water, pat dry. A record review of Resident #46's weekly Skin Only Evaluation for the months of August 2024 up to 8/21/24 showed no current skin issues. A review of the Skin Only Evaluation, dated 8/28/2024, showed Resident #46 with a new rash on chest, back and abdomen and a skin note showed resident previous rash noted back abdomen and stomach and treatment in place for itching. On 9/11/24 the weekly Skin Only Evaluation showed a current skin issue of rash with a skin note of rash to bilateral arms, chest and back persists treatment orders in place. On 9/18 and 9/25/24 weekly Skin Only Assessment showed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 40 of 44 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 10/02/2024 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 0880 rash continued with current treatment in place with an added area of rash to thighs on 9/25/24. Level of Harm - Minimal harm or potential for actual harm A review of Resident #46's active physician orders as of 10/2/24 showed an order for Ivermectin oral tablet 3 mg to give 6 tablets by mouth one time only for itching for one day dated 9/24/2024. An order for Ivermectin oral tablet 3 mg to give 6 tablets by mouth one time only for itching for one day with a start date of 10/06/24. Residents Affected - Many A review of Resident #46's September Medication Administration Record showed an entry for Ivermectin 3 mg give 6 tablets by mouth one time only for itching as given on 9/25/24. A review of Resident #46's progress note, dated 9/25/24, showed resident still with intermittent itchiness secondary to recent rash. The Assessment/Plan for rash and other nonspecific skin eruption included the following: Received dose of Ivermectin. A record review of Resident #12's weekly Skin Only Evaluation for the months of August 2024 up to 9/26/24 showed no skin issue, but chronic leg skin tear to left shin. A review of Resident #12's active physician orders as of 10/2/24 showed an order for Ivermectin oral tablet 3 mg to give 6 tablets by mouth one time only for itching for one day dated 9/22/24. An order for Ivermectin oral tablet 3 mg to give 6 tablets by mouth one time only for rash for one day with a start date of 10/06/24. A review of Resident #12's September Medication Administration Record showed an entry for Ivermectin 3 mg give 6 tablets by mouth one time only for itching as given on 9/23/24. A review of Resident #12's progress note, dated 9/22/24, showed staff notes of resident with worsening rash to trunk and bilateral lower extremities and scratching a lot. The Assessment/Plan for rash and other nonspecific skin eruption included the following: Ivermectin times one doe now (weight based, 6 tablets, verified with pharmacist), repeat in 2 weeks. Triamcinolone cream twice a day for 14 days. Consider Hydroxyzine at bedtime for pruritus if symptoms do not improve and patient continues to scratch. On 10/02/24 at 9:48 a.m. an interview was conducted with the primary Advance Practice Registered Nurse (APRN) for Residents #62, #22, #46, and #12. The APRN stated she was aware of the skin conditions and ordered steroidal creams upon initial assessment. The APRN stated she was suspicious of the ongoing skin conditions and chose to prescribe Ivermectin orally. The APRN stated a skin scrapping had been considered but was not aware of a dermatologist the facility utilized. The APRN stated she did not have a conversation with the Director of Nursing, but stated she had multiple conversations with the nursing staff for these residents. The APRN stated she contacted her physician on the process for getting a dermatologist consult through their company. The APRN stated if a potential positive diagnosis of scabies was reported, the whole unit should be treated, but compliance may be an issue with applying lotion and bathing. On 10/02/24 at 11:34 a.m. an interview was conducted with the NHA. The NHA stated the facility has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 41 of 44 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 10/02/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many daily meetings related to resident clinical concerns in which all department heads attend. The NHA stated she was not aware of residents with orders for Ivermectin and cannot conclude scabies was the rationale behind the orders for the four residents in the Reflection hallway. The NHA stated scabies is not a reportable criterion for infection surveillance to the [State Agency]; therefore, the facility's infection control policy would be the process for the facility to follow. The NHA stated the orders for Ivermectin were put in last week. The NHA stated they will follow their process and have the residents sent out to be tested. The NHA stated the Director of Nursing/Infection Control Preventionist (DON/IP) should have been notified of the concern the moment it was discovered. A record review of the facility's Order Listing Report, dated 9/24/2024 at 1:42 p.m., showed: Resident #12 with an order for Ivermectin oral tablet 3 milligrams give 6 tablets by mouth one time only for rash for one day, order date 9/22/24. Resident #22 with an order for ivermectin oral tablet 3 milligrams give 4 tablets by mouth one time only for rash for one day, order date 9/22/24. On 10/02/24 at 12:00 p.m. a telephone interview was conducted with the Medical Director (MD) and primary physician for Residents #62, #22, #46 and #12. The MD stated he was aware of the residents' rashes and of the orders for Ivermectin. The MD stated the rational for the Ivermectin was empiric coverage but not clear on what the primary cause was. The MD stated Ivermectin would be the medication utilized for a potential diagnosis of scabies. The MD stated he noticed residents itching on his last visit to the facility; but could not state he witnessed definitive signs of scabies. The MD stated that to send a resident out for testing could take time and to treat empirically would make sense. The MD stated two weeks ago his suspicions were low for a potential diagnosis for scabies. On 10/02/24 at 12:20 p.m. a telephone interview was conducted with an epidemiologist at the [State Agency] for Pinellas County. The epidemiologist stated not only are scabies a reportable criterion to the [State Agency] but rashes of any nature in which two or more residents and/ or staff members are involved should be reported. The epidemiologist stated the [State Agency] will provide recommendations to assist the facility. The epidemiologist denied any phone calls were made to the [State Agency] from this facility regarding rashes and/ or potential scabies. A review of the facility's Surveillance For Infections undated policy showed the policy statement as: The Infection Control Nurse will conduct ongoing surveillance for Health Care Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and may require transmission -based precautions and other preventive interventions. 1. The purpose of surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and HAIs, to guide appropriate interventions, and prevent future infections. 2. The criteria for such infections are based on the current standard definitions of infections. 3. Infections that will be included in routine surveillance include those with a. evidence of transmissibility in a healthcare environment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 42 of 44 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 10/02/2024 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 0880 b. available processes and procedures that prevent or reduce the spread of infection. Level of Harm - Minimal harm or potential for actual harm c. clinically significant morbidity or mortality associated with infection and Residents Affected - Many d. pathogens associated with serious outbreaks for example invasive streptococcus Group A, acute viral hepatitis, norovirus, scabies, influenza . 5. Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the Infection Control Nurse/ DON as soon as possible. 6. If a communicable disease outbreak is suspected, this information will be communicated to the Infection Control Nurse/ DON immediately. 7. When infection or colonization with epidemiological important organisms is suspected, cultures may be sent, if appropriate to the lab for identification or confirmation period cultures will be further screened for sensitivity to antimicrobial medications to help determine treatment measures. 8. The Infection Control Nurse/DON will notify the physician of suspected infections. a. the Infection Control Nurse /DON will notify the physician to determine if laboratory tests are indicated and whether special precautions are warranted b. the Infection Control Nurse/DON will determine if the infection is reportable. c. The physician will determine the treatment plan for the resident. 9. If transmission- based precautions or other preventative measures are implemented to slow or stop the spread of infection, the Infection Control Nurse/ DON will collect data to help determine the effectiveness of such measures 10. when transmission of HAIs continues despite documented efforts to implement infection control and prevention measures; the appropriate state agency and /or a specialist in infection control will be consulted for further recommendations. Gathering Surveillance Data: 1. The infection control nurse is responsible for gathering and interpreting surveillance data. The QAPI committee may also be involved in the interpretation of data. 2. The surveillance should include a review of any or all of the following information to help identify possible indications indicators of infections: a. laboratory records b. skin care sheets c. infection control rounds or interviews (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 43 of 44 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 10/02/2024 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 0880 d. verbal reports from staff Level of Harm - Minimal harm or potential for actual harm e. infection documentation records f. temperature logs Residents Affected - Many g. pharmacy records h. antibiotic review . 3. On 10/01/24 at 11:28 a.m. Staff H, Licensed Practical Nurse (LPN), was observed placing the glucometer used for Resident #2 during medication administration into the medication cart without cleaning or sanitizing after its use. Staff H stated every resident is supposed to have their own glucometer and she normally cleans them with an alcohol wipe. On 10/01/24 at 11:30 a.m. an interview with the DON/IP was conducted. The DON/IP stated there are only supposed to be two glucometers on the cart. The residents don't have their own glucometer anymore. The glucometers are supposed to be cleaned with bleach wipes after each use. Review of the competency checklist titled, Skill Competency Assessment: Glucometer, revealed the following: 3. Inspect, clean and disinfect the glucometer utilizing a disinfectant wipe per manufacturer's recommended wet time. A review of user instruction manual of the manufacturer of the glucometer at www.arkrayusa.com revealed the following: Blood Glucose Testing: The meter should be cleaned and disinfected after use on each patient . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105350 If continuation sheet Page 44 of 44