Inspection·July 7, 2023

F 0689 resident and family at appropriate time to discuss discharge plans and possible need for Home Health Agency services. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #1's Progress Notes included, but were not limited to the following: Residents Affected - Few Review of the Progress Notes dated 06/24/2023 at 5:45pm revealed, Resident alert, awake, aware, oriented, but missing on facility at this time, Certified Nursing Assistant (CNA) answer last time she saw resident on the patio but cannot find him now. Physician notified. Review of the Progress Notes dated 06/24/2023 at 6:50pm revealed, Resident search in the facility have been done, resident was missing, physician notified, skilled nurse to place call to 911 police. Review of the Progress Notes dated 06/24/2023 at 7:25pm revealed, Resident awake, alert, aware, oriented, self-responsible missing facility left by self-decision. Police officer presented on facility interview skilled nurse, Certified Nursing Assistant (CNA) and staffing related, request camera access; and releases case report card with number PD230624216928. Review of the Progress Notes dated 06/24/2023 at 9:31pm revealed, Skilled nurse placed phone call to both registered contacts, about resident awake, alert, aware, oriented, self-responsible; resident out of medication pass, resident left facility silent by his own decision, skilled nurse call police, physician notified aware. Contacts did not answer phone call from nurse then a voice message was released. Review of the Progress Notes dated 06/25/2023 at 6:02am revealed, Resident alert oriented self-responsible out of medication pass left facility by his own. Interview with Staff A, a Registered Nurse (RN) on 07/05/2023 at 10:27 AM. from the 3:00 PM to 11:00 PM shift, he reported, when he arrived at 3:00 PM, he did a tour with the previous shift nurse. All residents were in their rooms, including the resident who eloped. He stated, he did a round at approximately 4:00 pm to check on all the residents. Around 5:00 pm the evening CNA, was serving dinner and asked him where the resident was. He stated, the resident was in his room. He reported, staff were looking for the resident in the area near the facility. He reported, he contacted the Director of Nursing to inform her. He stated, he called the emergency contacts listed in resident #1's face sheet and no one answered. He stated, he left messages for the contacts. He reported, the resident was ambulatory, and used to walk slowly. He stated, the resident was a good resident, and he never exhibited aggressiveness or anxiety. He stated, he called the police, and the police completed a case report. Phone Interview with Staff B, a Certified Nurse Assistant (CNA) on 7/7/23 at 2:00 PM, She stated, I work the 3:00 PM-11:00 PM shift, and Saturday I worked a double shift from 7:00 AM-3:00 PM and 3:00 PM-11:00 PM, and on Saturday's I work double all the time. That day at around 2:30 PM, I saw him in the bed with his face covered up with his sheets, and at dinner time when I was going to give him his tray, I went and I noticed he was not there, I check in the bathroom, the patio and told the nurse and we kept searching, we went outside, other rooms, the patio again and he was not there. On my shifts, every thirty minutes I check on the residents. The dinner time is 5:00 o'clock. On that day, I notified the nurse, and the nurse told me to go to the room, check the patio, and all over. I was not the usual CNA on that room, but when I was, usually I said hi and that's it and he is independent, we don't have to ask anything else. He was independent, and I placed his tray, he would open it and said thank you. Yesterday during the 3:00-11:00 PM shift, we did get an in-service, they told us (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 2 of 7 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few that when a person is missing, the first thing to do is, you have to check to see where the patient is and notify the nurse and tell the code, the purple code. We must contact the Director of Nursing and the Administrator, and anyone above me. For the keypad they are going to install a keypad on the door, and we are going to have the code for opening and closing. Interview with the Director of Nursing on 07/07/2023 at 1:31 PM revealed, on June 24th at approximately 5:00 PM while serving dinner the Certified Nursing Assistant (CNA) identified that they could not locate the [resident # 1]. The last known location staff witnessed was the residents assigned room and the facility patio area. Staff searched for the individual throughout the facility and surrounding area. She stated, staff notified her and she notified the Administrator. She stated, all individuals (emergency contacts) on the resident #1's face sheet were called to determine if they had any information, none was found. She stated, local hospitals were called, his physician was called and stated that no medications if missed would cause him any acute problems. She stated, the local law enforcement was called; however, they stated that they would not investigate at this time since the Resident was alert and oriented to person, place, time, and situation and they gave a police case number. The nurse of the floor called emergency services and completed a report. She stated the Administrator contacted the Department of Children and Families (DCF) hotline on 06/24/2023 approximately 7:30 PM and the case was not accepted by DCF. The Agency for Healthcare Administration (AHCA) Immediate report was filed. The facility administration completed an immediate in-service education to all staff, education topics were on elopement, residents' rights, abuse/neglect, free of accidents hazards, elopement code policy, communication, and timely notification on late arrivals, call out notification immediately, and staff advocacy for residents' safety and welfare. Review of the residents medications revealed physician orders for Aspirin oral capsule 81mg (milligrams), Give 1 capsule by mouth one time a day for Moderate pain; Amlodipine Besylate Oral Tablet 5 MG (Amlodipine Besylate) Give 1 tablet by mouth one time a day to Treat high blood pressure; Mirtazapine Oral Tablet 15 MG (Mirtazapine) Give 1 tablet by mouth at bedtime to Treat depression, Rosuvastatin Calcium Oral Tablet 20 MG (Rosuvastatin Calcium) Give 1 tablet by mouth at bedtime to Treat high cholesterol; Metformin HCl (Hydrocholride) Oral Tablet 850 MG Give 1 tablet by mouth one time a day to Treat Type 2 diabetes; Aspirin EC (enteric coated) Tablet Delayed Release 81 mg (Aspirin) Give 1 tablet by mouth one time a day for Blood clots prevention. Multivitamin-Minerals Oral Tablet Give 1 tablet by mouth one time a day related to Anemia. Review of the Physical Therapy (PT) notes revealed, Resident #1 was receiving Physical Therapy 5 times a week for 8 weeks, starting on 6/14/2023 due to muscle weakness. The focus for the physical therapy was for therapuetic exercise, neuromuscular re-education, gait training, manual therapy, group therapy, physical therapy evaluation and therapuetic activities. The last physical therapy was on 6/23/2023. The physical therapy progress and Discharge summary dated [DATE] documents the resident had not met his goals and the resident had received 8 visits prior to discharge. Review of the Occupational Therapy (OT) notes revealed, Resident #1 was receiving Occupational Therapy starting 6/14/2023 due to muscle weakness 5 times a week for 8 weeks. The resident was receiving therapuetic exercises, neuromuscular re-education, therapuetic activities and community/work reintegration. The occupational therapy progress and Discharge summary dated [DATE] documents the resident had not met his goals and the resident had received 8 visits prior to discharge. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 3 of 7 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record Review of the facility's Policy and Procedures for Free of Accidents Hazards/Supervision/Devices dated 09/13/2022 revealed, Intent: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered, in accordance with the resident's preferences goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. Supervision/Adequate Supervision referred to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff and the frequency of supervision needed. This determination is based on the individual residents assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. The facility's Immediate Jeopardy Removal Plan was received on July 7, 2023 and was verified as completed through interview, observation and record review. It was determined the IJ had been removed on July 7, 2023. The following information was reviewed and verified as completed: 1) All staff will be re-educated on the elopement process and residents who wander or are exit-seeking, on an ongoing basis beginning on 7/6/2023. This includes initiating the missing person policy immediately upon identifying a resident is missing, as well as initiating the elopement policy once it is confirmed that a resident is missing. Upon identifying that a resident is missing, a Code Purple will be announced immediately which will prompt the staff to take action. No one will be allowed to begin working their shift until they have received the education. The first education sessions took place on the night of July 6-7 for the 3-11pm and 11-7am shifts. Record review of in-services education: Topic: Elopement Process and Importance of rounding every 2 hours. Dated 07/06/2023 time 11:05 PM Staff from 3:00 PM to 11:00 PM-11:00 PM to 7:00 AM Record review of in-services education: Topic Elopement Policies and Importance of rounding every 2 hours. Dated 07/07/2023 Time 7:05 AM Staff from 7:00 AM to 3:00 PM shift. 2) Licensed nursing staff will be re-educated on the Elopement Risk Evaluation Form used to identify residents at risk for elopement, on an ongoing basis, beginning on 7/6/23. For those residents identified as being at risk for elopement, proper interventions will be put in place, such as a wander alert bracelet. Record review of In-services education: Topic: Elopement Risk Evaluation Assessment: Will be completed on admission, and if there is a change in elopement status. Elopement binders will be updated with photo and demographics of all residents. Wander alert bracelet will be placed immediately on all elopement residents' records and all departments will be made aware. Date: 07/07/2023 Time 8:00 AM. Review of sign-in sheet completed. 3) Elopement drills will be conducted on each shift for seven days, 7/6/23-7/12/23. The first drill (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 4 of 7 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was conducted at 11:05 pm on July 6th for the 3-11pm and 11-7am shifts. Date: 7-7-23 and signed by all nurses.The facility's assessment document the facility has 23 nurses to include RN's and LPN's. The documentation was reviewed as completed. 4) Current residents have been re-evaluated for being at risk for elopement, as well as care plans and the need for wander alert bracelets. Dated 7/6/2023, 3PM-11 PM Shift and 11PM-7AM shift, Employee Sign In, Time: 11:05 PM. Signed by all the staff. The documentation was reviewed as completed. 5) Elopement Risk Binders will be created and reviewed for accuracy and posted at every department and at the exit. The binders were observed as completed. 6) Ad Hoc QAPI meetings were held on 6/25/23 and 7/6/23 to discuss missing residents and the elopement process. Sign-in Sheet with date: 6/25/23 @ 12:00 noon. Discussed Missing Resident and Next Step to Take Nursing Home Administrator participated via Telephone. Sign-in Sheet with date: 7/6/23 @ 7:15 PM. Discussed IJ Citation for Elopement/Failure to Supervise/Door and measures taken to remove the IJ. Nursing Home Administrator/Risk Manager Director of Nursing Owner, participated via telephone. 7) A repair company is scheduled to install a keypad security system on the front door on 7/7/23. Work should be completed by the end of the day. Until that time, a staff member has been always posted at the front door to ensure no resident exits without authorization. Staff members assigned to guard the front door have received education on not leaving their post unless they are relieved by another employee. Staff member observed at exit door on 7/7/23. General Contractor Invoice dated 7/6/2023, Estimate #3084 Description: 4 EXTERIOR [NAME] DOORS PARTS: MAGNET DYNA- LOCK DELAY EGRESS 3101C KEYPAD 212 INTERIOR KEYPAD 212 EXTERIOR (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 5 of 7 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 0689 POWER SUPPLY 12VDC-5AMP Level of Harm - Immediate jeopardy to resident health or safety Heavy Duty Door Closer Commercial Residents Affected - Few Labor: MATERIALS Install 8 new magnets lock Install 4 new keypad Install 4 new power supplies Config operation Customer signature on 7/6/23 8) Facility doors will be checked daily by Maintenance staff/ Designee to ensure proper functioning. The checks were reviewed and verified as started. 9) Clinical staff (nurses and CNAs) will be re-educated on the importance of rounding at least every 2 hours. First education session took place at 11:05 pm on July 6 for the 3-11pm and 11-7am shift. Employee sign in sheet 7/6/23 of in-service titled elopement process and importance of rounding every 2 hours. 14 signatures 7/7/23 Elopement Policies and rounding every 2 hours. 25 signatures. The documentation was reviewed as completed. 10) The facility's Missing Person and Elopement Policies have been updated as of 7/6/2023 to reflect the current federal guidelines. The policy and procedure was reviewed and updated on 7/6/2023. Based on the facility's assessment date 1/18/2023, the facility has 76 staff members working at the facility. Twenty-six facility staff members were interviewed to confirm the completion of the IJ Removal Plan. This included staff from the nursing department to include, RN's, LPN's and CNA's; the therapy department OT and PT, Social Services and Maintenance staff. Staff were interviewed from the 7AM-3PM, 3PM-11PM and the 11PM-7AM shifts. Staff were interviewed about the dates they received inservice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 6 of 7 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 105057 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pines Nursing Home 301 NE 141 Street Miami, FL 33161 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 0689 training, the information they were taught during the training, whether they participated in an elopement drill and what they were trained to do if an elopement occurs at the facility. Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105057 If continuation sheet Page 7 of 7