Health inspection·September 5, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and Medication Administration Records (MAR) for July 2025 and August 2025 documented the resident was receiving the following medications: Donepezil HCL (hydrochloric acid) 10mg (milligrams) tab (tablet) 1 tab PO (by mouth) HS (at night) for dementia; Meclizine HCL 12.5mg tab 1 tab PO TID (three times a day) for dizziness and Memantine HCL 10mg tab 1 tab PO daily for Alzheimer's disease.Review of the Elopement Risk Assessment/Evaluation dated 7/21/2025 documented: The resident was at high risk for elopement and wandering. Keep one copy of patient's/resident's photograph in the medical record and another at the security gate; Place a PINK armband on the resident.On 9/04/25 at 3:10 PM the Risk Manager stated, On 08/04/2025 in the afternoon between 4:30 PM we were called by the staff that they couldn't find the patient, and he was not in the wheelchair. We let the staff activate Code Pink. When she realized he was not in his wheelchair, she called the nurse and told the nurse to check in the patient's room because he is not down here in the wheelchair. The nurse proceeded to check the room, and he was not there. Once they came down to the patio and realized he was not there, Code Pink was activated. After 30 minutes he was not found, the police department was called and notified. I went to the security guard and asked if he saw anything. There was a transport van leaving the facility and a visitor that had come early. He opened the gate for the van and the visitor. He said he did not see the resident. At the same time, there was a car at the gate trying to enter and he was taking care of that. I told the security that they can only open one gate at a time from now on. The police department called back the Social Worker to let us know that the resident was found at 4:46 PM and [local emergency] was called to send the resident to [local hospital] for further evaluation.On 9/04/2025 at 3:34 PM, Staff A, Certified Nursing Assistant (CNA) Activities Assistant stated, On that day we played bingo, normally we transport the residents from downstairs but on that day his family came to visit and brought him down on their own. We finished the bingo and escort the residents to the elevators one by one back to their room. When I came back down, I saw his wheelchair was empty; the second time I saw the wheelchair empty and told my co-worker. I called the nurse and told him he was missing. I took the wheelchair upstairs and the nurse said let's go downstairs on the patio to look for him. We went back downstairs, and he was not there. We then called Code Pink. Three staff members were in the bingo, two help with transporting the residents back upstairs and one staff member stays downstairs with the remaining residents. The staff member that stayed downstairs did not see the resident leave from his wheelchair.Interview on 9/04/2025 at 4:05 PM, Staff B, Security Officer stated, I work 6:00 AM to 2:00 PM and I'm working over today to help them. I was not here when the resident left the facility. We have a book here for residents who may try to elope. The book has a picture of the resident and information about the resident. The resident [Resident #1] picture was in here before, but it has since been removed since he is no longer here.Interview on 9/05/2025 at 8:26 AM, Staff C, Licensed Practical Nurse (LPN) for the 3:00 PM to 11:00 PM shift via telephone stated, I work 3:00 to 11:00 PM shift. I came in at 3:00 PM, I went downstairs and saw him in bingo in the auditorium. Then the shift started; I got a call from Activities asking if the patient was in his room. I checked the bathroom. We started looking for him and called Code Pink. [NAME] staff was looking for him. Social Services called the police, and [local emergency] was called. We got a call saying the patient was found and taken to [local hospital].On 9/05/2025 at 8:36 AM, Staff D, CNA for the 3:00 PM to 11:00 PM shift stated, I work 3:00 PM to 11:00 PM shift. That day I came and I did rounds. When I went inside the room, I didn't see the patient. I had a report that said the patient was at bingo in the auditorium. I went downstairs to the auditorium, and he was in the bingo sitting in a wheelchair. I went back upstairs. That was the last that I saw of him. I was in the building when they called Code Pink. Everyone started looking for the patient. He had a wristband on his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 2 of 12 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street North 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few arm.On 9/05/2025 at 8:47 AM, Staff E, CNA Activities Assistant stated, Before each assistant would rotate and take the residents back up to the floor. The new policy is one would stay in the auditorium and the other two would take them back to their rooms. I work 8:30 AM to 5:30 PM shift. From what I can recall, the family member brought him down to bingo that ended around 4:00 PM and we were transporting them back to their floors. and noticed one of the residents was missing. I immediately started searching for him. I went outside, went past the gate and did not see him. By that time [Staff A], CNA Activities Assistant had called the nurse to let her know he was missing. They called the police, and the police found him. The DON went to the hospital to identify the patient.On 9/05/2025 at 8:55 AM, Staff F, Activity Recreational Assistant via telephone stated, I work 8:30 AM to 5:00 PM shift. I remember on August 4th we were having bingo. I was transporting a patient back to their room and we saw a patient wheelchair and the patient was missing. I called my co-worker [Staff A], Activities Assistant to ask if she had seen the resident. [Staff A], Activities Assistant and we notified the nurse if he was in the room, and she said no. We began to search, and we didn't find the patient we announced Code Pink.We were still searching for the resident, and the police was called. I didn't know he was at risk for elopement. A procedure was put in place after the incident to take residents who are at risk for elopement back upstairs first then take the remaining residents. On 9/05/2025 at 9:03 AM, Staff G, Security Officer via telephone stated, I work 2:00 PM to 10:00 PM. I have been working here for more than three months. My responsibilities are to secure anything coming in or out of the building, make sure that not anybody is allowed to come in and out, I must watch them. We used to have both gates opened at the same time. New procedure is to make sure one gate is opened at a time. On that day I had medical emergency working and the van was waiting to go out and there was another person trying to come into the building. I was looking at the ID for the person trying to come into the building and did not see anyone walking out of the gate. I only saw the person walking out when they showed me the video.On 9/05/2025 at 9:16 AM, Staff H, Receptionist via telephone stated, I work 3:00 PM to 8:00 PM. I have been working here for two years. On that day I came and checked my books for the patient. They called me to page the Code Pink, and they told me to look and I didn't see anything. I did not see him at the door. Any patient I see, I would check my book and call the nurse to come and get them. My responsibilities are to answer the phones and assist family members coming into the building.On 9/05/2025 at 9:38 AM, the Registered Nurse, Assistant Director of Nursing (ADON) stated, I work 8:00 AM to 4:00 PM. On 8/4 that day the daughter took the patient downstairs to the patio. She left him with activities. We didn't really know if he was in activities. After the activities lady said she couldn't find the patient and announced code pink. We were looking for the patient in the stairs, around the building, everywhere. After we couldn't find him, the social worker called the police. We continued looking for the patient, called the Administrator and the Risk Manager. They found out the police found the patient and took him to [local hospital]. Pink band was on the patient. If the patient takes it off, we put it around the ankle. His was on the ankle.On 9/05/2025 at 11:44 AM, the Registered Nurse, Director of Nursing (DON) stated, I got a call from [], the ADON, that there was an elopement and I told him that I would be there. As I was driving to the facility, I was searching for him. I took one of my nursing assistants and was informed he was at [hospital]. I went to the hospital to confirm he was there. I confirmed that he was there and spoke with the ER (Emergency Room) nurse and resident. He appeared to be stable, alert and responsive. I notified the daughter that I saw her father. She wanted me to take him back to the facility, but I told her no and she must speak with the hospital. I came back to the facility and met with the team and started in-servicing staff on elopement. The staff said they did everything, they called the code (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 3 of 12 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street North 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete and did a search. Our new procedure: In-service the security at the gate, that when one gate opens, the other one is closed. Discussed more about elopement. There should always be someone there when the patients are down for activities. Ensured that the assignments for the nurses and the CNAs document who are at risk for elopement.On 9/05/2025 at 11:52 AM, the Administrator stated, I am two minutes from my house and get a call from the ADON that one of the residents was missing and they couldn't find him. Code pink was called, and I turned around and came back. The Engineering Director and I looked at the video footage. We saw the resident and how he was able to leave. He was in communication with one of the visitors and he was telling him to stop following him. We got a call from the police saying that he was found. The facility communicated with the daughter and that he had been found. After communicating with the daughter, she said that she didn't want anything to be done at the hospital and wanted him to come back to the facility. We also communicated with the medical director. The daughter went to the hospital and brought him back to the facility. He was put on 1:1 and then transitioned to 30-minute rounding. The Risk Manager was in-servicing the staff about the elopement and had a long conversation with the guard at the gate. The next day formal in-services started, and we started a root cause and analysis. We looked at film and came up with solutions. We have a new process: One gate at time to be opened and the guards must put their eyes on who is leaving. When he left there was no one in the lobby to see him leave. Event ID: Facility ID: 105232 If continuation sheet Page 4 of 12 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street North 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews, the facility failed to provide a secure environment that with adequate supervision and an effective monitoring system; for one (Resident #1) out of three sampled residents that displayed exit seeking behaviors and intent of elopement; as evidenced by: 8/04/2025 at 4:24 PM Resident #1 who is impaired cognitively with diagnoses of Dementia and unsteady gait left the facility undetected by staff and was found at 4:46 PM on 8/04/25 by law enforcement 0.7 miles from the facility wandering in a neighborhood that has high traffic volume and cross streets this deficient practice increased the risk for the resident to be hit by an automobile that could have resulted in the likelihood of an adverse outcomes, sustained serious injury, serious harm or death. According to Accu weather.com on that day the temperature ranged between a high of 92 degrees and a low of 80 degrees Fahrenheit that could have caused Resident #1 to succumb to heat stroke. Refer to F600. The findings include: Record review of the facility's policy titled, Elopement/Code Pink revised May 2012 and reviewed August 2025 documented: Policy Statement: It is the policy of the Facility to provide a safe and secure environment for all residents. Purpose: 1) To assure the safety and security of all residents, 2) To establish policies and procedures in the event of a missing resident and 3) To train and maintain staff awareness of the importance of resident safety and security.Review of the facility's policy titled, Accident Hazards/Supervision/Devices revised February 2025 documented: Policy Statement: The resident environment will remain as free of accident hazards as is possible.Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes:1) Identifying hazards and risks, 2) Evaluating and analyzing hazards and risks, 3) Implementing interventions to reduce hazards and risks and 4) Monitoring effectiveness and modifying interventions.Review of the Demographic Face Sheet for Resident #1 documented the resident was initially admitted on [DATE] with a diagnosis of Dementia, Pneumonia, and unsteadiness on feet.Review of Resident's #1's Elopement care plan dated 7/21/2025 documented the resident is an elopement risk as evidenced by wandering with diagnosis of dementia; Goal: Resident will have no unauthorized departure from facility through next review date; Interventions: Place photograph on wander list; Redirect attention away from exit areas when wandering; Prompt and assist with meaningful activity attendance daily to keep occupied and Identify resident as an elopement risk and alert staff to monitor location on unit. Review of the facility's timeline of events documented the following: On 8/4/2025 a code pink was activated.Missing Resident #1 was playing Bingo around 3:00 PM in auditorium. Activity concluded at 4:00 PM. Patient was waiting to be transported to his room. Upon staff's arrival, staff found empty wheelchair. The surrounding areas by wheelchair was checked. Patient's room was also checked. Code Pink was called at 4:45 PM. Search throughout whole facility, patio, parking lot. Social Worker called 911 to file police report at 5:41 PM. [Local law enforcement] returned Social Worker's phone call to notify Social Worker that patient was in [residential neighborhood], police called [local emergency services] and the patient was transported to [local hospital] via ambulance. Social Worker notifiedall staff members. Nurse manager notified daughter. Daughter relieved patient was found safe and is medically stable. Resident Returned to facility 8/4/2025 at around 9:30 PM accompanied by the daughter.Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for July 2025 and August 2025 documented the resident was receiving the following medications: Donepezil HCL (hydrochloric acid) 10mg (milligrams) tab (tablet) 1 tab PO (bymouth) HS (at night) for dementia; Meclizine HCL 12.5mg tab 1 tab PO TID (three times a day) for dizziness and Memantine HCL 10mg tab 1 tab PO daily for Alzheimer's disease. Review of the Elopement Risk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 5 of 12 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street North 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 Assessment/Evaluation dated 7/21/2025 documented: The resident was at high risk for elopement and wandering. Keep one copy of patient's/resident's photograph in the medical record and another at the security gate; Place a PINK armband on the resident.On 9/04/25 at 3:10 PM the Risk Manager stated, On 8/04/2025 in the afternoon between 4:30 PM we were called by the staff that they couldn't find the patient, and he was not in the wheelchair. We let the staff activate Code Pink. When she realized he was not in his wheelchair, she called the nurse and told the nurse to check in the patient's room because he is not down here in the wheelchair. The nurse proceeded to check the room, and he was not there. Once they came down to the patio and realized he was not there, Code pink was activated. After 30 minutes he was not found, the police department was called and notified. I went to the security guard and asked if he saw anything. There was a transport van leaving the facility and a visitor that had come early. He opened the gate for the van and the visitor. He said he did not see the resident. At the same time, there was a car at the gate trying to enter and he was taking care of that. I told the security that they can only open one gate at a time from now on. The police department called back the Social worker to let us know that the resident was found at 4:46 PM and [ local emergency] was called to send the resident to [ local hospital] for further evaluation.On 9/04/2025 at 3:34 PM, Staff A, Certified Nursing Assistant (CNA) Activities Assistant stated, On that day we played bingo. Normally we transport the residents from downstairs but on that day his family came to visit and brought him down on their own. We finished the bingo. We escort the residents to the elevators one by one back to their room. When I came back down, I saw his wheelchair was empty. The second time I saw the wheelchair empty and told my co-worker. I called the nurse and told him he was missing. I took the wheelchair upstairs and the nurse said let's go downstairs on the patio to look for him. We went back downstairs, and he was not there. We then called Code Pink. Three staff members were in the bingo, two help with transporting the residents back upstairs and one staff member stays downstairs with the remaining residents. The staff member that stayed downstairs did not see the resident leave from his wheelchair.On 9/04/2025 at 4:05 PM, Staff B, Security Officer stated, I work 6:00 AM to 2:00 PM and I'm working over today to help them. I was not here when the resident left the facility. We have a book here for residents who may try to elope. The book has a picture of the resident and information about the resident. The resident [Resident #1] picture was in here before, but it has since been removed since he is no longer here.On 9/05/2025 at 8:26 AM, Staff C, Licensed Practical Nurse (LPN) for the 3:00 PM to 11:00 PM shift via telephone stated, I work 3:00 to 11:00 PM shift. I came in at 3:00 PM, I went downstairs and saw him in bingo in the auditorium. Then the shift started; I got a call from Activities asking if the patient was in his room. I checked the bathroom. We started looking for him and called Code Pink. [NAME] staff was looking for him. Social Services called the police, and [local emergency] was called. We got a call saying the patient was found and taken to [local hospital]. On 9/05/2025 at 8:36 AM, Staff D, CNA for the 3:00 PM to 11:00 PM shift stated, I work 3:00 PM to 11:00 PM shift. That day I came and I did rounds. When I went inside the room, I didn't see the patient. I had a report that said the patient was at bingo in the auditorium. I went downstairs to the auditorium, and he was in the bingo sitting in a wheelchair. I went back upstairs. That was the last that I saw of him. I was in the building when they called Code Pink. Everyone started looking for the patient. He had a wristband on his arm. On 9/05/2025 at 8:47 AM, Staff E, CNA Activities Assistant stated, Before each assistant would rotate and take the residents back up to the floor. The new policy is one would stay in the auditorium and the other two would take them back to their rooms. I work 8:30 AM to 5:30 PM shift. From what I can recall, the family member brought him down to bingo. Bingo ended around 4:00 PM and we were transporting them back to their floors. and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 6 of 12 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street North 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 noticed one of the residents was missing. I immediately started searching for him. I went outside, went past the gate and did not see him. By that time [Staff A], CNA Activities Assistant had called the nurse to let her know he was missing. They called the police, and the police found him. The DON went to the hospital to identify the patient.On 9/05/2025 at 8:55 AM, Staff F, Activity Recreational Assistant via telephone stated, I work 8:30 AM to 5:00 PM shift. I remember on August 4th we were having bingo. I was transporting a patient back to their room and we saw a patient wheelchair and the patient was missing. I called my coworker [Staff A], CNA Activities Assistant to ask if she had seen the resident. [Staff A], CNA Activities Assistant and we notified the nurse if he was in the room and she said no. We began to search, and we didn't find the patient we announced Code Pink. We were still searching for the resident, and the police was called. I didn't know he was at risk for elopement. A procedure was put in place after the incident to take residents who are at risk for elopement back upstairs first then take the remaining residents.On 9/05/2025 at 9:03 AM, Staff G, Security Officer via telephone stated, I work 2:00 PM to 10:00 PM. I have been working here for more than three months. My responsibilities are to secure anything coming in or out of the building, make sure that not anybody isallowed to come in and out, I must watch them. We used to have both gates opened at the same time. New procedure is to make sure one gate is opened at a time. On that day I had medical emergency working and the van was waiting to go out and there was another person trying to come into the building. I was looking at the ID for the person trying to come into the building and did not see anyone walking out of the gate. I only saw the person walking out when they showed me the video.On 9/05/2025 at 9:16 AM, Staff H, Receptionist via telephone stated, I work 3:00 PM to 8:00 PM. I have been working here for two years. On that day I came and checked my books for the patient. They called me to page the Code Pink, and they told me to look and I didn't see anything. I did not see him at the door. Any patient I see, I would check my book and call the nurse to come and get them. My responsibilities are to answer the phones and assist family members coming into the building. On 9/05/2025 at 9:38 AM, the Registered Nurse, Assistant Director of Nursing (ADON) stated, I work 8:00 AM to 4:00 PM. On 8/4 that day the daughter took the patient downstairs to the patio. She left him with activities. We didn't really know if he was inactivities. After the activities lady said she couldn't find the patient and announced code pink. We were looking for the patient in the stairs, around the building, everywhere. After we couldn't find him, the social worker called the police. We continued looking for the patient, called the Administrator and the Risk Manager. They found out the police found the patient and took him to [local hospital]. Pink band was on the patient. If the patient takes it off, we put it around the ankle. His was on the ankle.On 9/05/2025 at 11:44 AM, the Registered Nurse, Director of Nursing (DON) stated, I got a call from [], the ADON, that there was an elopement and I told him that I would be there. As I was driving to the facility, I was searching for him. I took one of my nursing assistants and was informed he was at [hospital]. I went to the hospital to confirm he was there. I confirmed that he was there and spoke with the ER (Emergency Room) nurse and resident. He appeared to be stable, alert and responsive. I notified the daughter. She wanted me to take him back to the facility, but I told her no and she must speak with the hospital. I came back to the facility and met with the team and started in-servicing staff on elopement. The staff said they did everything, they called the code and did a search. Our new procedure: In-service the security at the gate, that when one gate opens, the other one is closed. Discussed more about elopement. There should always be someone there when the patients are down for activities. Ensured that the assignments for the nurses and the CNAs document who are at risk for elopement.On 9/05/2025 at 11:52 AM, the Administrator stated, I am two minutes from my house and get a call from the ADON that one of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 7 of 12 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street North 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 FORM CMS-2567 (02/99) Previous Versions Obsolete the residents was missing and they couldn't find him. Code pink was called, and I turned around and came back. The Engineering Director and I looked at the video footage. We saw the resident and how he was able to leave. He was in communication with one of the visitors and he was telling him to stop following him. We got a call from the police saying that he was found. The facility communicated with the daughter and that he had been found. After communicating with the daughter, she said that she didn't want anything to be done at the hospital and wanted him to come back to the facility. We also communicated with the medical director. The daughter went to the hospital and brought him back to the facility. He was put on 1:1 and then transitioned to 30-minute rounding. The Risk Manager was in-servicing the staff about the elopement and had a long conversation with the guard at the gate. We have a new process: One gate at time to be opened and the guards must put their eyes on who is leaving. We reviewed the books for people at elopement risk, but we also added the wanders. When he left there was no one in the lobby to see him leave. Event ID: Facility ID: 105232 If continuation sheet Page 8 of 12 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street North 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility's administration failed to implement, provide and ensure an effective and efficient preventative measures were in place to prevent the neglect and elopement of one resident (Resident #1) out of three sampled residents who displayed exit seeking behaviors. As evidenced by inadequate safety measures that included failure to ensure residents were not able to leave the premise of the facility and failure by staff to implement assigned level of supervision for resident #1 who was a high risk for elopement. These deficient practices enabled resident #1 to exit the facility undetected at 4:24 PM through an electronic gate in the front of the facility on foot on 8/04/25 placing the resident at risk for harm and or injury. There were 191 residents residing in the facility at the time of the survey.The findings included:Record review of the facility's policy titled, Suspected Adult, Disabled Person or Elderly Abuse/Neglect/ Exploitation protocol implementation date was on 12/2000, the policy documented: The facility will provide a safe resident environment and protect all residents from abuse. Therefore, each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. Neglect means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A prompt thorough investigation will be conducted by the facility immediately.Record review of the facility's policy titled, Elopement/Code Pink revised May 2012 and reviewed August 2025 documented: Policy Statement: It is the policy of the Facility to provide a safe and secure environment for all residents. Purpose: 1) To assure the safety and security of all residents, 2) To establish policies and procedures in the event of a missing resident and 3) To train and maintain staff awareness of the importance of resident safety and security.Review of the Job Description for the Executive Director (Nursing Home Administrator) documented: The Administrator is responsible for developing, managing and supervising the overall functions of the facility in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents.Review of the Job Description for the Director of Nursing documented: The Director of Nursing is responsible for planning, organizing, developing and directing the day to day functions of the nursing department in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents.Review of the Job Description for the Activities Assistant documented: The Activities Assistant is responsible for instructing and leading various activity/recreation programs and transporting and assisting residents to and from activity/recreational programs.Review of the Job Description for the Risk Manager documented: The Risk Manager is responsible for coordinating programs for risk identification, risk analysis, risk control and risk reduction.Review of the Job Description for the Security Officer documented: The Security Officer is responsible to maintain safe and secure environment for customers and employees by patrolling, monitoring and guarding entrance points and gate of the facility.Review of the Job Description for the Receptionist documented: The Receptionist is responsible for answering the telephone, directs visitors and residents, maintains security by following safety procedures and oversees the front reception area.Based on observational tour of the facility's parameter increased risk factors included the fact that, the facility is located in an area that has high traffic volume and busy intersections. Both locations where the facility is located and the location where the resident was found later that day, are high traffic areas with busy two laned roads and four laned cross streets.According to Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 9 of 12 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street North 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Accu weather.com on that day of August 4, 2025, the temperature ranged between a high of 9 degrees and a low of 80 degrees Fahrenheit.Review of the Demographic Face Sheet for Resident #1 documented the resident was initially admitted on [DATE] with a diagnosis of dementia, pneumonia, hypertension and unsteadiness on feet.Review of Resident's #1 Elopement care plan dated 7/21/25 documented the resident is an elopement risk as evidenced by wandering with diagnosis of dementia; Goal: Resident will have no unauthorized departure from facility through next review date; Interventions: Place photograph on wander list; Redirect attention away from exit areas when wandering; Prompt and assist with meaningful activity attendance daily to keep occupied and Identify resident as an elopement risk and alert staff to monitor location on unit. Review of the facility's timeline of events documented the following: On 8/4/2025 a code pink was activated. Missing Resident #1 was playing Bingo around 3:00 PM in auditorium. Activity concluded at 4:00 pm. Patient was waiting to be transported to his room. Upon staff's arrival, staff found empty wheelchair. Surrounding areas by wheelchair checked. Patient's room was also checked. Code Pink was called at 4:45 PM. Search throughout whole facility, patio, parking lot. Social Worker called 911 to file police report at 5:41 PM. [ ] local law enforcement returned Social Worker's phone call to notify Social Worker that patient was in [ ] residential neighborhood, police called [ ] local emergency services and the patient was transported to [ ] local hospital via ambulance. Social Worker notified all staff members. Nurse manager notified daughter. Daughter relieved patient was found safe and is medically stable. Resident Returned to facility 8/4/2025 at around 9:30 pm accompanied by the daughter.Review of the Elopement Risk Assessment/Evaluation dated 7/21/25 documented: The resident was at high risk for elopement and wandering. Keep one copy of patient's/resident's photograph in the medical record and another at the security gate; Place a PINK armband on the resident. On 9/04/25 at 3:10 PM the Risk Manager stated, On 8/04/2025 in the afternoon between 4:30 PM we were called by the staff that they couldn't find the patient, and he was not in the wheelchair. We let the staff activate Code Pink. When she realized he was not in his wheelchair, she called the nurse and told the nurse to check in the patient's room because he is not down here in the wheelchair. The nurse proceeded to check the room, and he was not there. Once they came down to the patio and realized he was not there, Code Pink was activated. After 30 minutes he was not found, the police department was called and notified. I went to the security guard and asked if he saw anything. There was a transport van leaving the facility and a visitor that had come early. He opened the gate for the van and the visitor. He said he did not see the resident. At the same time, there was a car at the gate trying to enter and he was taking care of that. I told the security that they can only open one gate at a time from now on. The police department called back the Social Worker to let us know that the resident was found at 4:46 PM and [local emergency] was called to send the resident to [local hospital] for further evaluation. On 9/05/2025 at 9:03 AM, Staff G, Security Officer via telephone stated, I work 2:00 PM to 10:00 PM. I have been working here for more than three months. My responsibilities are to secure anything coming in or out of the building, make sure that not anybody is allowed to come in and out, I must watch them. We used to have both gates opened at the same time. New procedure is to make sure one gate is opened at a time. On that day I had medical emergency working and the van was waiting to go out and there was another person trying to come into the building. I was looking at the ID for the person trying to come into the building and did not see anyone walking out of the gate. I only saw the person walking out when they showed me the video.On 9/05/2025 at 9:16 AM, Staff H, Receptionist via telephone stated, I work 3:00 PM to 8:00 PM. I have been working here for two years. On that day I came and checked my books for the patient. They called me to page the Code Pink, and they told me to look and I didn't see anything. I did not see (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105232 If continuation sheet Page 10 of 12 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street North 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 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete him at the door. Any patient I see, I would check my book and call the nurse to come and get them. My responsibilities are to answer the phones and assist family members coming into the building.On 9/05/2025 at 9:38 AM, the Registered Nurse, Assistant Director of Nursing (ADON) stated, I work 8:00 AM to 4:00 PM. On 8/4 that day the daughter took the patient downstairs to the patio. She left him with activities. We didn't really know if he was in activities. After the activities lady said she couldn't find the patient and announced code pink. We were looking for the patient in the stairs, around the building, everywhere. After we couldn't find him, the Social Worker called the police. We continued looking for the patient, called the Administrator and the Risk Manager. They found out the police found the patient and took him to [local hospital]. Pink band was on the patient. If the patient takes it off, we put it around the ankle. His was on the ankle. On 9/05/2025 at 11:52 AM, the Administrator stated, I am two minutes from my house and get a call from the ADON that one of the residents was missing and they couldn't find him. Code pink was called, and I turned around and came back. The Engineering Director and I looked at the video footage. We saw the resident and how he was able to leave. He was in communication with one of the visitors and he was telling him to stop following him. We got a call from the police saying that he was found. The facility communicated with the daughter and that he had been found. After communicating with the daughter, she said that she didn't want anything to be done at the hospital and wanted him to come back to the facility. We also communicated with the medical director. The daughter went to the hospital and brought him back to the facility. He was put on 1:1 and then transitioned to 30-minute rounding. The next day formal in-services started, and we started a root cause and analysis. We looked at film and came up with solutions. We have a new process: One gate at time to be opened and the guards must put their eyes on who is leaving. When he left there was no one in the lobby to see him leave. Event ID: Facility ID: 105232 If continuation sheet Page 11 of 12 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 105232 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Maria Nursing Center 1050 NE 125th Street North 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review and interviews, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to adequate supervision resulting in repeated deficient practice. The facility's history includes deficient practice for failing to supervise residents resulting in possible accidents. The facility was cited for Free of Accident Hazards, Supervision, Devices, Administration and Quality Assurance and Assessment on July 31, 2025. On 8/04/2025, the facility was negligent and failed to provide adequate supervision and effective services to prevent the elopement of one (Resident #1) out of three sampled residents with exit seeking behaviors, resulting in Resident #1 eloping from the facility at 4:24 PM, through an electronic gate in the front of the facility on foot undetected. These repeated deficient practices have the potential to affect any of the 191 residents residing in the facility.The findings included: Record review of the facility's Quality Assurance Performance Improvement (QAPI) Program Policy and Procedure (implemented December 2004) documented the following: Policy-This facility shall develop, implement and maintain an effective, comprehensive, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents; QAPI purpose is a type of quality management program which takes a systematic, interdisciplinary, comprehensive and data-driven approach to maintaining and improving safety and quality. Guidelines for Governance and Leadership: 1) The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan; 2) The QAA Committee shall be interdisciplinary and shall: b) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program; 3) b) Policies and procedures for feedback, data collection systems and monitoring, c) Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following: i.) Tracking and measuring performance, iii.) Identifying and prioritizing quality deficiencies, iv.) Systematically analyzing underlying causes of systemic quality deficiencies and v.) Developing and implementing corrective action or performance improvement activities.Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 6/17/25, 7/15/25 and 8/19/25 documented the facility had a QAA Committee meeting monthly. Attendees included: Executive Director, DON, Medical Director, Director of Social Services, Director of Activities, Dietitian, MDS Coordinator, Director of Case Management, Director of Housekeeping/Laundry Services, Risk Manager, Infection Control, Director of Health Information Management, Fiscal Services, Pharmacist, Data Analyst, Laboratories and Community Liaison.Interview with the Director of Nursing/QAA on 9/05/25 at 2:27 PM. She stated, The QAA Committee meet monthly and we meet on the third Tuesday of the month. The committee members consist of the Administrator, DON, Medical Director and Department Heads. The purpose of the QAA committee is to bring forth any concerns that we may have and that we may need to address patient concerns and quality of care. Event ID: Facility ID: 105232 If continuation sheet Page 12 of 12