Inspection·October 3, 2024

F 0689 Get help from other staff members in the immediate vicinity, if necessary; and Level of Harm - Minimal harm or potential for actual harm c. Residents Affected - Few Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident is attempting to leave or has left the premises. d. The nurse will notify the MD and document accordingly in the medical record Triggers for the wandering occurrence will be identified and communicated with the care team. The care plan will be updated, and all notifications will be made to the care team, family members/legal representatives . 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the resident's legal representative (sponsor); d. Notify search teams/law enforcement that the resident has been located; Complete an elopement assessment and update care plan Document relevant information in the resident's medical record. Maintain resident's safety by providing direct supervision until Physician recommends discontinuing Report the incident according to state and federal regulations. Report the incident to the Quality Assurance/Risk/Safety Committee. Review of the facility incident logs dated 07/01/24 through 09/30/24 revealed the facility had no incidents of elopements. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 2 of 6 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 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 - Minimal harm or potential for actual harm Clinical record review conducted on 10/02/24 revealed Resident #1 was admitted to the facility on [DATE] with diagnoses to include Metabolic Encephalopathy, Dementia, and Alcohol Abuse. Review of the Hospital records documented, [AGE] year-old male presented in the emergency department under [NAME] Act. Patient [PT] was found driving on US 1 asking for directions with confusion. Patient noted with alcohol abuse. Pt admitted for Dementia with Psychosis. Hospital course patient was noted Residents Affected - Few to have urinary tract infection [UTI] and was placed on Cefepime. Infectious disease and neurology consults were obtained and therapists recommended Skilled Nursing Facility placement for strengthening and conditioning. Review of the Elopement assessment dated [DATE] documented the resident was assessed as low risk for elopement with a score of 20. Review of the Minimum Data Set (MDS), admission assessment, with reference date of 08/05/24 documented the resident BIMS (Brief Interview Mental Status) score as 03. A score of 3 indicates the resident is severely impaired for skills of daily decision making. Resident #1 exhibited wandering behavior, had one fall prior to admission and was receiving antipsychotic medications. Review of the Progress notes dated 08/05/24 documented Resident is alert and oriented with periods of confusion, resident is able to verbalized his needs, .resident is wandering back in forth down hallway needs re-direction, continue with skilled services, call light within reach. Review of the Progress notes dated 08/06/24 documented Resident is alert and oriented with periods of confusion .continue on antibiotic for metabolic toxic Encephalopathy . Resident is continue on wandering back and forth down the hallway . safety maintained. Review of the Progress notes dated 08/06/24 documented Resident has been having increase periods of confusion and exit seeking. Able to redirect however, still manages to head toward exits. Writer increased observation for this shift. Will continue to monitor. Review of the Progress notes dated 08/08/24, that has been stricken from the resident's record, documented, The leave of absence process was reviewed with the resident and/or their representative. The resident does have the ability to move about the facility independently with or without assisted devices like a walker or wheelchair. The resident does have cognitive impairment and has expressed a desire to leave the facility. The resident has exhibited exit seeking behavior including: The patient was found outside of the main entrance. The incident occurred when a visitor existing the building, and the resident followed him out through the door. A staff member promptly brought the resident back inside. The resident is at risk for elopement. The Resident does currently reside on a secure unit. Interventions include Increased staff observation, transfer to secured unit. The following people have been notified of this elopement evaluation: Resident Representative/Family Physician IDT/Care plan. Review of the Care Plan initiated on 08/08/24 documented the resident is an elopement risk / exit seeker related to Cognitive Status / Decline. The goal documented the resident will remain safe within the facility and will make no attempts to exit facility without being accompanied through next review. The interventions included: Distract resident from exit seeking by offering pleasant diversions, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 3 of 6 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 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 - Minimal harm or potential for actual harm structured activities, food, conversation, television, book, etc; Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate; Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes as indicated and Psychological services as ordered/indicated. Residents Affected - Few Review of the Progress Notes dated 08/21/24, Summary of Skilled Services, documented, Resident is alert with confusion, continue on isolation for COVID with no acute respiratory distress noted at this time, assisted with care, all medications given as ordered, tolerated well, denies pain, call light within reach, safety maintained and continue with skilled services. Review of the Progress Notes dated 08/23/24 documented the resident is alert and able to make all needs known, no distress or behavior noted on shift continue on 1:1 Certified Nursing Assistant for safety measures. Interview with the Nursing Home Administrator and the Director of Nursing, from the nursing facility located across the street, on 10/02/24 at approximately 4:00 PM confirmed a resident from Sea Breeze showed up to their door. He was asked if he wanted to visit someone and stated no, the resident was unable to verbalize why he was there and the staff recognized the resident, had an identification band and contacted Sea Breeze. The staff came in and escorted the resident back to their facility. Interview conducted with the Administrator (NHA) and the Director of Nursing (DON) on 10/03/24 at 9:20 AM confirmed the incident involving Resident #1 was not captured on the incident log but the facility completed an investigation. The NHA stated they deemed the event was not an elopement based on the fact the staff supervised him at all times. Review of the facility investigation conducted on 10/03/24 revealed on 08/22/24, Resident #1 exited the facility and ended up across the street at another nursing facility. The report documented, Resident stated that he wanted to be discharged . The discharge was held as he was COVID positive, and he decided to go LOA (leave of absence) without signing out. The resident deemed at elopement risk and exit seeker due to mentation and Metabolic Encephalopathy and was on antibiotic for UTI. Conclusion: It was an intentional LOA without signing out. The unit manager was watching him in the driveway and the resident was discharged to a lower level of care ALF [Assisted Living Facility]. Interview with the receptionist on duty on 08/22/24 was conducted on 10/03/24 at 9:25 AM. The receptionist stated she was doing receptionist duties, Resident #1 was sitting in the therapy room in his wheelchair, across from her desk. Approximately 20 minutes later, he was not there. The receptionist stated she did not see the resident go out the door, but it was a busy day, lots of visitors in and out and is possible that the resident went out with visitors. The receptionist denied being involved in the investigation, confirmed she gave a statement but did not receive any feedback or education after the event. The receptionist also denied the facility having a book or list to identify residents that may be at risk for elopement. Interview with Assistant Director of Nursing (ADON) on 10/03/24 at 9:46 AM revealed her recollection of the incident. The unit manager called her to inform her that the resident was outside, and she was following him on her vehicle. The manager then went outside, went across the street and was able (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 4 of 6 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 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 - Minimal harm or potential for actual harm Residents Affected - Few to convince the resident to return to the facility. The manager was asked why the staff was not aware of his elopement risk to escort the resident back into the facility, and who notify the responsible party or family members of the events and stated she did, but was not able to locate documentation. Interview with the NHA conducted on 10/03/24 at 9:51 AM revealed the facility has surveillance video, it keeps for 30 days, and was asked if the video was reviewed to identify how the resident was able to leave the facility. The NHA stated she reviewed the video, she did not keep a copy and furthermore stated the time line provided on the investigation file was based on staff interviews estimation of time, not from the surveillance video. The NHA was not able to confirmed that Resident #1 exited the building through the main door, that is locked, and the receptionist has to give access in and out of the building, unless you entered the code. Interview with the Unit Manager conducted on 10/03/24 at 9:53 AM revealed she was in her truck making a phone call and saw Resident #1 coming out of the courtyard. He was standing there. The resident was under her supervision. Then saw him walking towards the parking lot, she did not think anything of it and continued her phone call. Then she saw him walking away and she thought maybe he was being discharged . He was steady walking out of the parking lot, and then she started to drive behind him. The manager called into the building and spoke to the ADON who told her the resident was not discharged . The manager stated she followed the resident to the facility across the street, and another employee and the ADON went out and got him back from their sister facility. In the past he verbalized he wanted to leave and was easily redirected. The manager could not explain why she was not aware of his elopement risk status, as she did not intervene when the resident was first spotted outside the facility and if he was in such close supervision, why she had to drive behind him or what actions she could have taken if another vehicle posed a danger to the resident, how could she reach the resident to prevent injury. There were no responses to the questions. Interview with the Registered Nurse, who wrote the progress note dated 08/08/24, that was later removed from the record, was conducted on 10/03/24 at 10:32 AM. The nurse stated he has been on vacation for three weeks and has poor recollection of the event. The nurse stated the note may have been written on the incorrect resident, and that is the reason why it was removed, but he could not recall who the other resident was; there have been a few residents trying to leave the building in the past few months. The nurse stated if he finds someone outside the facility, that is not supposed to be unsupervised, he will report it. The nurse recalled later on the resident was placed on one-to-one supervision and is not able to provide any other details. Interview with DON conducted on 10/03/24 at approximately 2:45 PM revealed the elopement assessment for Resident #1 was not completed accurately, the resident was not in a secured unit, and he had the ability to ambulate independently with or without the use of assistive devices. The investigation determined Resident #1 did not receive appropriate supervision to prevent the elopement. Resident #1, a vulnerable adult with dementia and Encephalopathy, was able to leave the premises without the staff knowledge. When the staff allegedly saw the resident outside, did not immediately intervene, indicating the lack of knowledge of his elopement risk, despite documentation of the behavior, the resident was able to go across the street, walking through a four-lane street with considerable traffic and ended up at another nursing facility, unable to verbalize why he was there. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 5 of 6 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 105399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sea Breeze Rehab and Nursing Center 3663 15th Ave Vero Beach, FL 32960 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 - Minimal harm or potential for actual harm The facility failed to thoroughly investigate the root cause of the event; the limited investigation was unable to determine how the resident exited the facility; failed to identify the event as an elopement and failed to complete the required reporting of the adverse event. In addition, the facility failed to develop and implement corrective actions to minimize reoccurrence and update the plan of care with the intervention of one to one supervsion after the event. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105399 If continuation sheet Page 6 of 6