Inspection·August 23, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (11:00 PM to 7:00 AM shift) stated: I got to know him for a short period of time before that happened he wanted to know where the front patio and back patio was located this was on the 20th at approximately 2:00 AM he asked if there is a place to go out to have some fresh air I told him it too late to go out on the patio, he said he was hungry and we gave him some apple sauce, he ate the applesauce and he said he was still hungry so the supervisor went to the kitchen got two sandwiches and gave them to him he ate and went to sleep. Before I left at the end of my shift, I changed him and left him in his room. The next day (08/21/2025) when I came in at the start of my shift he was on the back porch with the security guard and other residents, he said he was hungry, and we gave him some apple sauce and he said he was still hungry so he supervisor went with the supervisor to the kitchen, and he got two sandwiches he ate the and went to bed. On the 21st He woke up early in the morning and went to take a shower the nurse was with him, and we gave him towels he dressed himself, about 6:30 AM he went through the double doors, and I continued working with my other patients. The other shift came, and they were asking if we saw [Room Number], I never knew he would leave because he was compliant. Interview on 08/22/2025 at 2:28 PM Staff B, Registered Nurse (RN)- Day Shift stated, On that day the outgoing nurse told me I can do my rounds, and I asked her where he (Resident #5) was, and she told me he may be on the patio. She told me that the last time she saw the resident was about at 6:30 AM. I told her I needed to see the patient because I did not know him. When I went to his room he was not there. I called the supervisor and the DON (Director of Nursing); and the outgoing nurse stayed and helped to look for him, but we did not find him, so they called code green (elopement code). I did not know him, and they showed me his picture when we were searching for him.During a telephone interview on 08/23/2025 at 9:55 AM, Staff C, RN-Night Shift Supervisor revealed: The resident (Resident #5) is very alert, and he is close to the kitchen most of the time and he walks around the facility socializing with everyone. He was not an exit seeking resident and never gave problem. I usually sit downstairs when I finish my rounds, when I did my second round he was in his room the patient (Resident #5) asked for food and security opened the kitchen and I got some sandwiches and gave the food to him (Resident #5) in his room. During my third round at about 7:10 AM the nurse came and told me a resident was missing, and I called a code green. I called maintenance and looked at the camera showing him leaving through the laundry room exit. Interview on 08/23/2025 at 9:58 AM, the Risk Manager revealed the elevators are not equipped with [wander alert system] . the exit doors are alarmed and will sound when approached. Resident #5 was alert, did not have and did not have a [wander alert system] in place. He eloped during a laundry delivery through the back door after asking for food. The resident has a known history of elopement and has not yet been located. Interview on 08/23/2025 at 10:03 AM the Maintenance Director revealed all exit doors on the first floor are equipped to detect the [wander alert] and will alarm when triggered. If the door is pushed, it must be held for 15-30 seconds before a loud alarm will sound. A key is required by maintenance staff to reset the stairwell alarms.Telephone interview with translation assistance by the NHA on 08/23/2025 at 10:05 AM, Staff D, Floor Tech revealed, on 08/21/2025 around 6:00 AM to 6:15 AM the security called and asked him to open the laundry door because he was dealing with another delivery in the kitchen. Staff D, Floor Tech revealed unlocked and disarmed the door and did not stay during the delivery because he went to pick up the soiled linen. Staff D, Floor Tech revealed he does not remember shutting and locking the door and gate and did not see the resident leaving.On 08/23/2025 at 10:41 AM Staff E, Certified Nursing Assistant (7:00 AM to 3:00 PM shift) stated: I remember the resident, he is alert and like to walk around the facility. Wednesday (8/20/2025) was the first time I worked with him. After I changed him that afternoon, he asked for food around 2:00 PM and he sat on the patio where (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105510 If continuation sheet Page 2 of 3 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 105510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Unity Healthcare and Rehabilitation Center 1404 NW 22nd Street Miami, FL 33142 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 FORM CMS-2567 (02/99) Previous Versions Obsolete they smoked, and I left at about 3:15 PM. On Thursday (8/21/2025) at the start of my shift when I did my rounds I did not see him in his room so I asked the nurse where is my resident because he was not in bed; the nurse said he just had a shower and because he is always walking back I went looking for him and did not see him so I tell the nurse and the nurse told the supervisor then they called a code green and we searched for him, I drove in my car all the way past [streets] and around but did not find him we kept searching the police came and still not find him. Telephone interview on 08/23/2025 at 10:50 AM Staff F, Licensed Practical Nurse (7:00 PM t0 7:00 AM shift) revealed, on 08/20/2025 to 08/21/2025 I worked with him he is alert he followed instruction; I administered medication to him, and he took them one by one. Around 2:00 AM, he was walking back and forth and was given two sandwiches after he ate, he went back to bed. Around 6:00 AM He showered himself and after his shower when I did rounds, he was in his room in the bed. During shift transfer we did not see him I told the supervisor, and a code green was called.On 08/23/2025 at 11:41 the DON revealed: On Thursday (08/21/2025) I got a call that there was a missing resident. I told them he always goes to sit on the patio, the code green was already started and once I got here we created a command center. Record Review of the facility's policy titled: Safety and Supervision of Residents indicate:Policy StatementOur facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Policy Interpretation and Implementation Facility-Oriented Approach to Safety1. Our facility-oriented approach to safety addresses risks for groups of residents.2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. Event ID: Facility ID: 105510 If continuation sheet Page 3 of 3