Health inspection·October 13, 2025

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, interviews and record reviews the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, related to failure to ensure weekly skin checks were completed for two residents (#2 and #3) of three sampled residents. Findings included: Residents Affected - Some Resident #3 was admitted to the facility on [DATE] and discharged on 09/07/25. Review of the admission record showed diagnoses included but not limited to vascular dementia with other behavioral disturbance, stage III chronic kidney disease, diabetes, anxiety disorder, major depressive disorder, and cerebrovascular disease. Review of the physician orders for Resident #3 showed to perform weekly skin checks. Review of the skin evaluation dated 09/05/2025 showed - scratches on the bilateral arms. Multiple superficial scratches to bilateral arms. Dried blood present around the affected area. No active bleeding observed. Review of Resident #3's electronic medical record (EMR) revealed there were no other documented skin evaluations for the period August through September 2025. Review of the care plans showed there was no care plan for skin integrity or a focus addressing weekly skin checks. During an interview on 10/13/25 at 12:40 p.m. Staff A, Licensed Practical Nurse (LPN) stated she does not normally work in the resident's area. She stated the nurses are supposed to do weekly skin checks and document it under the assessment tab of the electronic medical record. She stated the Weekly Skin Only Evaluation Schedule was listed by room numbers, which was subdivided by the day of the week and the shift. Staff A stated the nurses were to see which room was due on their shift, and perform the weekly skin check. During an interview on 10/13/25 at 12:45 p.m. the acting Director of Nursing (DON) stated the nurses were to perform weekly skin checks. He stated the nurses were supposed to do them and document them in the assessment section in the electronic medical record. He reviewed Resident #3's electronic medical record and stated the resident did not have any weekly skin assessments performed. During an interview on 10/13/25 at 1:44 p.m. Staff B, Nurse Practitioner (NP) stated she sees her physician provider's residents only. She stated she was at the facility 5 days a week. Staff B stated they have 88 or 90 residents in the facility. She stated she does not see all of their residents weekly. She stated she tries to see the long-term care residents at least every 2 weeks and sometimes Page 1 of 3 105350 105350 10/13/2025 Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some only monthly. She stated she will see a resident more often for a specific concern. She stated she does not do a head-to-toe skin evaluation on every visit. She stated she will evaluate the residents if they have rash or something. She stated the nurse would tell her if there was an issue she needed to evaluate. She stated she did not evaluate the resident's skin on every visit. During an interview on 10/13/25 at 2:36 p.m. the DON stated all residents should have a skin integrity care plan. He reviewed Resident #3's care plans and stated she did not have a skin integrity care plan. He stated he did not see an intervention showing to perform weekly skin checks. 2. A review of Resident #2's admission record revealed an admission date of 10/2/25 with diagnoses to include osteomyelitis of vertebra, lumbar region, acute hepatitis b with delta-agent without hepatic coma, other psychoactive substance abuse, uncomplicated, and septic pulmonary embolism without acute cor pulmonale. A review of Resident #2's physician orders revealed there were no orders for skin assessments. A review of Resident #2's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for 10/2025 revealed there was no documentation of skin checks or assessments. A review of Resident #2's assessments revealed a skin evaluation dated 10/3/25. Review of Resident #2's EMR revealed there were no other documented skin evaluations/assessments. A review of Resident #2's care plan revealed a focus initiated on 10/03/2025, Impaired/Risk for impaired skin integrity AEB [as evidenced by]/Related to: Dry, fragile skin Date Initiated: 10/03/2025, with interventions to include, Weekly skin checks per protocol. A review of Resident #2's physician notes revealed the following: On 10/10/25, . Patient presents with increasing swelling of bilateral lower extremities and left upper arm. Swelling generally improves after lying down, but today it has remained the same. Patient is also being treated for thoracic osteomyelitis with intermittent daily fevers since admission, which improve with Tylenol. Blood cultures currently negative. Skin: Warm, Dry, IV [intravenous] Access, Pink, Normal for ethnicity, Other: multiple healing scabs, various stages, of extremities . On 10/13/25 at 1:50 p.m., an interview was conducted with Staff C, LPN. She said the east unit does not have a weekly skin assessment schedule for the residents. Staff C, LPN said they are supposed to. An observation of the east unit nurses station revealed no skin check sheet or schedule was observed for Resident #2. On 10/13/25 at 12:42 p.m., an interview was conducted with Staff A, LPN. She said the weekly skin only assessment schedule is supposed to be completed on every unit/hall. On 10/13/25 at 12:54 p.m., an interview was conducted with the DON. He confirmed the skin assessment was missing for Resident #2 on 10/10/25. He said it should have been completed. The DON said the provider saw Resident #2 and looked at his skin. He said the provider's note counted as a skin assessment. A review of the facility's policy titled, Skin and Wound, effective date 8/1/23 and a revision 105350 Page 2 of 3 105350 10/13/2025 Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698

F 0684 Level of Harm - Minimal harm or potential for actual harm date of 9/24/24, revealed the following, 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 decrease worsening of/prevention of pressure injury. Further review of the policy, under procedure, revealed the following, . License nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record. Residents Affected - Some 105350 Page 3 of 3