Oak Haven Rehab And Nursing Center

F-F761) and 2.) failing to maintain an effective infection control and prevention program to prevent the spread of infection by failing to ensure staff donned appropriate personal protective equipment (PPE) before entering the rooms of residents under transmission based precautions for one (Resident #3) of 2 residents under transmission based precautions (

F-F880) during

the revisit survey conducted on 09/11/2024.

Findings included:

1.)

An observation on 09/11/2024 at 0917 AM revealed 3 treatment carts unlocked and unsecured across from

the nurse's station. There were no staff near the carts, and the carts contained prescription medications for treatments. Photographic evidence was obtained.

An interview was conducted on 09/11/2024 at 01:45 PM with Staff C, Licensed Practical Nurse (LPN). The LPN confirmed the treatment carts should not be left unlocked. She also stated the nurse is assigned a treatment cart correlates with their medication cart and assignment.

An interview was conducted on 09/11/2024 at 02:02 PM the Director of Nursing, RN (DON). The DON stated

the nurse has the keys to the treatment cart and there was also an extra set for the wound care nurse. She also stated all the carts should be locked when not being used.

The facility policy titled Standards and Guidelines: Medication Storage and Labeling reveals under the section titled Procedure Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.

2.)

A review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE REDACTED] with a diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) infection.

A review of Resident #3's physician orders revealed an order dated 9/7/2024 for contact precautions for MRSA every shift until 9/19/2024 at 9:43 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 45 105302 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105302 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Haven Rehab and Nursing Center 919 Old Winter Haven Rd Auburndale, FL 33823

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 An observation was conducted on 9/11/2024 at 10:07 AM outside of Resident #3's room. A sign was posted to Resident #3's room door indicating Resident #3 was on contact precautions. The posted signage included Level of Harm - Minimal harm or directions for providers and staff to put on gloves before room entry, discard gloves before room exit, put on potential for actual harm gown before room entry, and discard gown before room exit. An caddy was observed outside of Resident #3's room containing isolation gowns and gloves. Staff A, Occupational Therapist Assistant (OTA) was Residents Affected - Few observed in Resident #3's room speaking to the resident at the bedside. Staff A, OTA was not observed wearing an isolation gown or gloves while inside of the resident's room. After Staff A, OTA exited Resident #3's room, an interview was conducted. Staff A, OTA stated she spoke to a nurse prior to entering Resident #3's room to find out why Resident #3 was on contact isolation precautions and was told she did not have to don PPE because the infection was in the resident's urine. Staff A, OTA also stated she did not touch the resident while she was inside of the resident's room. Staff A, OTA observed the signage posted to Resident #3's room door and stated she should have donned an isolation gown and gloves before entering Resident #3's room. Staff A, OTA stated she received in-service education from the facility a few weeks ago related to infection control and the proper procedures for donning and doffing PPE.

An observation was conducted on 9/11/2024 at 10:16 AM outside of Resident #3's room. Staff B, Registered Nurse (RN) and Unit Manager (UM) was observed pushing a cart with boxes of disposable gloves on it down

the unit hallway. Staff B, RN UM was also observed entering Resident #3's room. Staff B, RN UM did not don an isolation gown or gloves before entering the resident's room. After Staff B, RN UM exited the room an

interview was conducted. Staff B, RN UM stated she was conducting rounds on the unit and ensuring gloves inside of the resident rooms were stocked. Staff B, RN UM also stated Resident #3 was on contact isolation precautions and she did not don PPE before entering the room because she did not touch the resident. Staff B, RN UM observed the signage posted on Resident #3's room door and stated she should have donned an isolation gown and gloves before entering Resident #3's room. Staff B, RN UM stated she received in-service education from the facility about two weeks ago related to infection control and the proper procedures for donning and doffing PPE.

An interview was conducted on 9/11/2024 at 1:33 PM with the facility's Infection Preventionist (IP). The IP stated when a resident is on contact isolation precautions, all staff are to don an isolation gown and gloves prior to entering the resident's room. The IP also stated it does not matter if the staff member touches the resident or not while they are inside of the room, the staff don the appropriate PPE any time they enter the resident's room. The IP stated he conducted in-service education with the facility staff and discussed the difference between transmission based precautions and enhanced barrier precautions and the PPE required for each type of precautions used.

An interview was conducted on 9/11/2024 at 2:22 PM with the DON. The DON stated facility staff should follow the instructions on the posted signage for a resident under transmission based precautions and donning the PPE is not optional when entering the resident's room. The DON also stated it does not matter what the staff member is doing inside of the room, all staff should be donning the appropriate PPE as ordered by the physician because the disease could be transmitted to other residents if PPE is not used.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 45 105302 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105302 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Haven Rehab and Nursing Center 919 Old Winter Haven Rd Auburndale, FL 33823

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 An interview was conducted on 9/11/2024 at 3:32 PM with the facility's Nursing Home Administrator (NHA) and DON. The NHA stated the facility's QAPI committee met following the previous survey to discuss the Level of Harm - Minimal harm or findings and began to develop a plan of correction. A facility wide audit was conducted to identify residents potential for actual harm who were potentially effected by the deficient practice and facility wide education was conducted to all of the related areas identified during the previous survey. Audits were put into place to ensure the facility's Residents Affected - Few education and processes had improved. The DON stated weekly audits of the medication carts were initiated and all nursing staff received education related to medication storage to ensure compliance. The DON also stated the audits mainly focused on the medication carts and not the treatment carts in the facility. The NHA stated four separate audits were put into place related to infection control, including sanitizing equipment, hand washing, PPE use, and glucometers. All types of transmission based precautions were reviewed as part of the education and explained to facility staff to ensure they understand.

A review of the facility policy titled Standards and Guidelines: Transmission Based Precautions, last revised

in February of 2024, revealed under the section titled Standard, all staff receive training on transmission based precautions upon hire and at least annually. The policy also revealed under the section titled Procedure: Initiation of Transmission-Based Precautions (Isolation), an order for isolation will be obtained for residents who are known or suspected to be infected with infectious agents that require additional controls to prevent transmission effectively. The policy revealed the following under the section titled Procedure: Contact Precautions:

- Intended to prevent transmission of infectious agents which are spread by direct of indirect contact with the resident or the resident's environment.

- Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment.

- Donning PPE upon room entry and discarding before exiting the room is done to contain pathogens.

A review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program, revised in February of 2020, revealed under the section titled Policy Statement, this facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of

the outcomes of care and quality of life for our residents. The policy also revealed under the section titled Policy Interpretation and Implementation the objectives of the QAPI program are to:

- Provide a means to measure current and potential indicators for outcomes of care and quality of life.

- Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators.

- Reinforce and build upon effective systems and processes related to the delivery of quality care and services.

- Establish systems through which to monitor and evaluate corrective actions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 45 105302 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105302 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Haven Rehab and Nursing Center 919 Old Winter Haven Rd Auburndale, FL 33823

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Photographic evidence obtained.

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 45 105302 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105302 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Haven Rehab and Nursing Center 919 Old Winter Haven Rd Auburndale, FL 33823

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34768 potential for actual harm Based on observations, record review and interviews, the facility failed to ensure hand hygiene was Residents Affected - Some performed during medication administration, the blood glucose monitoring machines were adequately disinfected, and blood pressure cuffs were cleaned between residents for 6 (#66, #86, #272, #67, #19, and #97) of 39 sampled residents; and the facility failed to ensure staff doffed Personal Protective Equipment (PPE) before entering/exiting two resident rooms (234 and 248) on droplet precautions.

Findings included:

On 07/16/2024 at 8:00 a.m. Resident #66 was observed during medication pass with Staff D, Registered Nurse (RN). Staff D, RN pushed the medication cart from the nurse's station to the resident's room. She was observed to not hand sanitize prior to medication pass. She entered the resident's room with a blood pressure machine. Staff D sat the blood pressure machine on the resident's bed and proceeded to take his blood pressure. The blood pressure was 117/68. Staff D exited the room with the blood pressure machine and sat it on the top of the mediation cart without cleaning it. Staff D proceeded to open the medication cart and started removing his medications. She had not hand sanitized. After administering the resident's medications, she exited the room and still had not performed hand sanitizing or cleaned the blood pressure machine.

On 07/16/2024 at 8:15 a.m. Resident #86 was observed during medication pass with Staff H, Licensed Practical Nurse (LPN). Staff H was observed pushing the medication cart from the nurses' station and entered the resident's room with a blood pressure cuff, without hand sanitizing. Staff H took the resident's blood pressure. Staff H exited the room, applied gloves and cleaned the blood pressure cuff, removed his gloves, and did not hand sanitize. Staff H was observed touching his hair throughout the medication pass. Staff H entered the resident's room with gloves in place and took the box with the inhaler in it, into the resident's room. The resident was handed the inhaler to the resident and he took his medication. Staff put

the inhaler back into the box and brought it back out of the resident's room. Staff H removed his gloves at the medication cart, he did not hand sanitize. He opened the cart and replaced the boxed inhaler back into the medication cart. He still had not hand sanitized. Staff H left the medication cart, went to the nurses' station, then down the hallway to another nurse's medication cart and retrieved insulin syringes. While returning to his medication cart, he stopped in room [ROOM NUMBER] due to the call light being on. He progressed to his cart. On his return he still had not hand sanitized. Staff H opened the medication cart and retrieved a multiple dose bottle of insulin. Staff H applied gloves without hand sanitizing. He removed the alcohol wipe from the cart and cleaned the top of the vial. He withdrew 10 units of insulin. Staff H entered the resident's room with glove in place and injected the insulin in the right arm of the resident. He removed his gloves, disposed of the syringe and washed his hands.

On 07/16/2024 at 8:40 a.m. Resident #272 was observed during medication pass with Staff J, LPN. Staff J was observed applying gloves without hand sanitizing before entering the resident's room with her inhaler. Staff J exited the room and placed the inhaler on the medication cart without a barrier. Staff J removed her gloves and washed her hands.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 45 105302 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105302 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Haven Rehab and Nursing Center 919 Old Winter Haven Rd Auburndale, FL 33823

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 07/16/2024 at 8:45 a.m. Resident #67 was observed during medication pass with Staff J, LPN. Staff J was observed to not perform hand sanitizing prior to medication administration. Staff J took a blood pressure Level of Harm - Minimal harm or machine into the resident's room and the blood pressure was taken, 141/65. Staff J returned to the potential for actual harm medication cart and placed the used blood pressure cuff on the medication cart. Staff J did not clean the blood pressure cuff or hand sanitize. Staff J administered the medications to the resident. She returned to Residents Affected - Some the medication cart and did not hand sanitize. Staff J was observed taking the dirty blood pressure cuff back into room [ROOM NUMBER]B and taking the blood pressure of the roommate in the room. She returned to

the cart with the blood pressure cuff and laid it on the cart.

On 07/16/2024 at 8:50 a.m. Resident #97 was observed during medication pass with Staff K, RN. Staff K did not hand sanitize prior to medication administration. Staff K placed the used blood pressure cuff on the medication cart without cleaning it. Upon leaving the room, she had not hand sanitized. Hand sanitizing was not performed after passing the medications. Staff K was observed using the uncleaned blood pressure cuff

on Resident #12.

On 07/16/2024 at 10:50 a.m. Resident #19 was observed during blood glucometer monitor use and insulin injection by Staff H, LPN. Staff H was sitting at nurses' station, moved the medication cart to the resident's room. Staff H washed his hands. Staff H laid the blood glucose monitor, lancet, bottle of strips and plastic cup on top of medication cart as well as 2 alcohol wipes. Staff H applied gloves. Staff H took the blood glucose monitor, lancet, bottle of strips and laid them on the (dirty) overbed table. The table had not been cleaned and had personal items as well as food on it. Staff H placed a strip in the blood glucose monitor. He laid the blood glucose monitor back on the overbed table as well as the bottle of strips. He opened an alcohol wipe and wiped the left pointer finger. He used a lancet. wiped the finger again with alcohol and placed a drop of blood on the strip. The blood sugar level was 140. He laid the blood glucose monitor on overbed table. He then picked up the blood glucose monitor, bottle of strips and used lancet and exited room. He put

the used lancet and strip in the hazardous waste. He placed the dirty blood glucose monitor in the plastic cup and placed the bottle of strips on the cart. He took the blood glucose monitor out of the cup and wrapped a wipe from the Microdot Minute container and replaced into the same cup. 1/4 of the blood glucose monitor was not covered by the wrap. Staff H removed his gloves and hand washed. He had left the computer open to names and a paper with names on the medication cart while performing the blood glucose monitoring.

During an interview Staff H, LPN stated he wraps the blood glucose monitor and leaves it for 3 minutes.

During the interview he locked his cart and left and walked toward the nurses' station and then down the hallway out of view. The blood glucose monitor, and bottle of strips were left on the medication cart. He returned with insulin syringes in his hand. When he returned, he washed his hands. He replaced his gloves.

He removed the insulin from the medication cart, removed it from the baggie and box. He used an alcohol wipe and cleaned the top of the insulin bottle. He removed 4 units on insulin. He entered the resident room and injected the insulin into her left arm post use of alcohol. Staff H returned to the cart and threw away the syringe in the hazardous container and removed his gloves. Staff H washed his hands. During an interview following the observation, Staff H stated he wraps the blood glucose monitor and leaves it for 3 minutes. then removes the wipe and lets it dry. He stated the blood glucose monitor was to be cleaned after each use and placed in the cart. Staff H stated the blood pressure cuffs are to be cleaned with the Microdot wipes also,

after each resident. Staff H stated he lets the blood pressure cuff sit also. He stated he was supposed to hand sanitize between each resident, before and after medication pass, before and after glove changes. Staff H stated he washes his hands after gloves are removed and before gloves are put on. Staff H stated he washes his hands because the hand sanitizer breaks his hands out, so he just hand washes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 45 105302 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105302 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Haven Rehab and Nursing Center 919 Old Winter Haven Rd Auburndale, FL 33823

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 07/17/2024 at 5;32 p.m. the DON was apprised of the medication administration

observation. The DON stated the staff was supposed to clean the blood pressure cuffs between residents. Level of Harm - Minimal harm or She stated they are supposed to hand sanitize before and after med pass, with gloves changes. The potential for actual harm expectations were for medication boxes to not go into the resident's room, insulin was not to be left on the computer and out of a locked medication cart. The blood pressure cuffs, and blood glucose monitors need to Residents Affected - Some be cleaned between residents. The DON stated they needed to instruct the staff on infection control, which included hand sanitizing or hand washing.

Review of the facility's policy, Standards and Guidelines: Medication Administration, revised 01/2024 showed Standard: Medications are ordered and administered safely and as prescribed. Guideline: Medications will be administered safely and as prescribed by only licensed personnel. Procedure: 19. Staff follows established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.

Review of the facility's policy, Standards and Guidelines: Hand Hygiene Infection Control, revised 6/2023 showed Standard: This facility shall require facility personnel use accepted hand hygiene after each direct resident contact for which hand hygiene is indicated. Hand hygiene is a general term that applies to washing hands with water and either plain soap or thoroughly applying an alcohol-based hand rub (ABHR). Procedure: The facility acknowledges the CDC (Centers for Disease Control) guidelines to improve adherence to hand hygiene and healthcare settings. The hand hygiene guidelines are part of an overall CDC strategy to reduce infections in healthcare settings to promote resident safety. These guidelines state that hand washing is necessary when health care personnel hands are visibly soiled. When the hands are not visibly soiled, the CDC recommends the use of alcohol-based hand rubs by healthcare personnel for resident care to address the obstacles that health care professionals face when taking care of residents.

Situations that require hand hygiene include, but are not limited to:

Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice)

Before and after performing any invasive procedure (e.g., finger stick blood sampling)

Before and after entering isolation precaution settings

Before and after medication administration

After removing gloves or aprons

Review of the facility's policy, Standards and Guidelines: Disinfecting, revised 01/2024 showed Guideline:

The facility will ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal regulations, and national guidelines. Procedure: 1. EPA-registered healthcare disinfectant wipes will be used in accordance with manufacturer's instructions. An EPA- approved intermediate level disinfectant wipe is required for surfaces soiled with body fluid. Disinfectant wipes are used to clean the following items: B. Non-critical (i.e. contact with intact skin only) resident care equipment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 45 105302 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105302 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Haven Rehab and Nursing Center 919 Old Winter Haven Rd Auburndale, FL 33823

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of the EvenCare Proview Blood Glucose Monitoring System User's Guide, dated 2018 showed on page 40, 6. Caring for the Meter: caring for the meter is easy. Single-use medical protective gloves should be Level of Harm - Minimal harm or worn during disinfection procedures and also by anyone performing blood glucose testing on another person. potential for actual harm Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients. Use gloves should be removed and hands washed before proceeding to the next patient. Residents Affected - Some Cleaning and Disinfecting Procedures for the Meter: the EVENCARE are ProView meter should be cleaned and disinfected between each patient.

Disinfection Instructions: the meter must be disinfected between patient uses by wiping it with a CaviWipe towelette or EPA-registered disinfecting wipe in between tests and be cleaned prior to disinfecting. The disinfection process reduces the risk of transmitting infectious diseases if it is performed properly.

Disinfection Instructions: step 1. Before disinfecting, clean the meter as described in Cleaning Your Meter process.

Step 2. Wash hands with soap and water, put on single-use medical protective gloves.

Step 3. Prepare the CaviWipe towelette or EPA-registered disinfecting wipe. Take out a wipe from the container and follow the instructions on the package. If needed squeeze the wipe slightly to remove the excess liquid.

Step 4. Wipe the glucose meter thoroughly including the front, back and sides and take care not to get any liquid in the test strip port or serial port. Do not wrap the meter in a wipe.

Step 5. If using the CaviWipe towelette, allow to remain wet for two minutes. For other EPA- registered disinfectant wipes allow the surface of the meter to remain wet for the contact time listed on the disinfecting wipes instructions for use. Dispose of wipe when finished.

Step 6. After disinfection, users should take off gloves and wash hands thoroughly with soap and water

before proceeding to the next patient

41015

An observation on 07/16/24 at 12:01 p.m., revealed Staff A, Licence Practical Nurse (LPN) exiting room [ROOM NUMBER] with the face shield still donned. The signage on the door stated Droplet Precautions. The Droplet Precautions sign showed, Remove face protection before room exit. Photographic evidence obtained.

During an interview on 07/16/24 at 12:03 p.m., Staff A, LPN stated Sorry that was my bad; the face shield should have been taken off before I left the room.

An observation on 07/16/24 at 12:13 p.m., revealed Staff B Certified Nursing Assistant (CNA) exiting room [ROOM NUMBER] with a blue surgical mask under the face shield still donned. The signage on the door stated Droplet Precautions. The Droplet Precautions sign showed, Remove face protection before room exit. Photographic evidence obtained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 45 105302 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105302 B. Wing 07/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Haven Rehab and Nursing Center 919 Old Winter Haven Rd Auburndale, FL 33823

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 07/16/24 at 12:13 p.m., Staff B, CNA stated , I forgot to take it off when I left the room.

Level of Harm - Minimal harm or During an interview on 07/17/24 at 5:46 p.m., the Director of Nursing (DON) stated, she would have potential for actual harm expected the staff to don a N95 mask prior to entering a droplet precaution room and also doff the face shield and mask prior to leaving the room. The DON stated staff are expected to follow the instructions on Residents Affected - Some the transmission based precaution signs.

A review of the facility's Policy Standards and Guidelines: Screening, Testing, Return to work, Personal Protective Equipment, Isolation, Reporting revised date 06/24/24 showed, PPE (Personal Protective Equipment)/Hand Hygiene 1. Covid Unit- If the facility has an active Covid unit, then facility staff and visitors

on the unit should wear full PPE including N95 mask and eye wear. 3. Transmission Based Precautions will be implemented and signage instructing the appropriate use of PPE's will be posted outside the resident's door.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 45 105302