Inspection·October 23, 2024

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 observations, interviews and record reviews, the facility failed to provide appropriate supervision to 1 of 3 sampled residents assessed as at risk for elopement. The deficient practice allowed Resident #1 to exit the facility on 10/12/24 at approximately 8:50 PM, through an unsecured door on the second floor. The findings included: The facility's policy, titled, Wandering and Elopements, with a revision date of March 2019, documented, in part: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified as at risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Record review revealed Resident #1, a resident with severe cognitive impairment, eloped from the facility on 10/12/24 at approximately 8:40 PM. The record revealed Resident #1 was observed by an individual from the community walking west on Silver Beach Road, a two-lane road with one lane traveling in each direction from east and west with a 30 miles per hour speed limit and no lighting. Resident #1 was found in an industrial area approximately 0.3 miles west of the facility. It was determined by the facility's investigation, that Resident #1 left her room and went through the Dining/Activities room to a staircase with two landings and 2 turns. Resident #1 then went through an area that consisted of the Human Resources office, Activities desk, and Staff Development office. At that time, there were no staff in this area as it was after hours and on a Saturday evening. Resident #1 then exited an unlocked door to an outside staircase that led to an unsecured area on the east side of the building with uneven terrain and then traveled west on Silver Beach Road and across Old Dixie Highway, a 4-lane road with two lanes traveling in each direction north and south. Resident #1 had to cross a set of two active railroad tracks used by Brightline, with trains that travel more than 80 miles per hour, as well as other transportation and freight interests/companies. Record review revealed Resident #1 was admitted to the facility on [DATE] and discharged to an Assisted Living Facility with a secure unit on 10/16/24. According to an Admission/Medicare 5-[NAME] (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 105640 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 105640 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE North Lake Care Center and Rehab 750 Bayberry Drive Lake Park, FL 33403 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)