Health inspection·October 29, 2025

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, interview, and record review, the facility failed to provide supervision and a safe environment to prevent an elopement for 1 of 4 sampled residents (Resident #1). Resident #1 was a vulnerable resident who exited the facility's main front door unsupervised on 10/11/25. She was found about half mile away from the facility on a very busy 6-lane roadway at 7:32 PM by the police who were driving down the road by chance and noticed she needed assistance. The police took the resident to the facility, and the facility staff were unaware Resident #1 had left. The facility's failure to prevent Resident #1 from eloping placed this resident at a likelihood of serious harm, injury or death. While out of the facility on 10/11/25, Resident #1 was confused and unable to report to the police officer where she lived. Resident #1 could have fallen and sustained injuries, particularly while walking in the dark; drowned in nearby bodies of water; or have been struck by a car. The Nursing Home Administrator was given the Immediate Jeopardy Template on 10/28/25 at 4:39 PM. The Immediate Jeopardy (IJ) began on 10/11/25 and was removed on 10/13/25 according to the facility's Immediate Jeopardy Removal Plan. The findings included: Review of the facility policy titled Elopement and Wandering Residents revised on 03/16/23 revealed the following: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach of monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Record review revealed Resident #1 was admitted to the facility on [DATE]. The residents' diagnoses included Dementia, Memory deficit, Cerebral infarction, Atrial fibrillation and Type 2 Diabetes mellitus. The resident's medications included Aricept and Memantine for Dementia; Eliquis (a blood thinner) for Atrial fibrillation; and Metformin for Diabetes. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's Brief Interview of Mental Status (BIMS) score was 06/15, which indicated severe cognitive impairment. An Elopement Risk Evaluation dated 08/11/25 showed that Resident #1 was at risk for elopement with a score of 1 (0 indicating no risk for elopement and 1 indicating risk for elopement). Further review indicated that Resident #1 needed a walker to ambulate. After the elopement incident, Resident #1's daughter had the resident moved to a facility with a secure unit to care for residents who are at risk for eloping on 10/21/25. Review of the Police Report dated 10/11/25 documented that Resident #1 was found by the police while she was walking in traffic after sunset (sunset at 6:56 PM) East bound on a busy 6-lane roadway at 7:32 PM. In that report Resident #1 told the police officer that she walking to her daughter's house in Miami and when asked where she was coming from, she was unable to provide a location. Resident #1 was wearing dark clothing and was only able to provide her first and last name. The Page 1 of 6 105679 105679 10/29/2025 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few police officer's report indicated the officer was concerned for her safety under these hazardous conditions. The police officer had another officer check the surrounding facilities in the area, who then contacted an employee of the facility in question and confirmed that Resident #1 lived there. Resident was then returned to the facility by the police. Review of the facility's timeline investigation revealed that on 10/11/25 Resident #1 was seen by Staff B, Licensed Practical Nurse (LPN) at 7:15 PM on the B Wing and was last seen between 7:00 and 7:30 PM by Staff A, Physical Therapy Assistant (PTA) on the B Wing hallway. At 7:48 PM a police officer arrived at the facility to let them know that they found Resident #1. At 8:05 PM Resident #1 was brought back to the facility by another police officer. The facility staff timeline did not align with the time police found the resident after she walked about a half mile. On 10/28/25 at 9:02 AM, the surveyor retraced the probable steps the resident took. The walk started on B wing. Walked to the front main lobby doors and exited the facility. Walked the green sidewalk towards the parking lot. At the end of the sidewalk there's a ramp for wheelchair accessible into the parking lot. Continued walking towards the front entrance of the facility's driveway, turned left onto the sidewalk and within a few steps noted there is a non-fenced body of water on the left of the sidewalk (photographic evidence obtained). Continued walking following the sidewalk, Resident #1 crossed a driveway (a Tennis Club opened till 9:30 PM) where the sidewalks have ramps for wheelchair access on both sides. Resident #1 then crossed 95th Terrace and walked by a park and she passed another non-fenced body of water. Resident #1 again crossed a street, NW 94th Avenue, which has a traffic light for turning options between Oakland Park Boulevard into NW 94th Avenue (photographic evidence obtained), and after crossing this street (NW 94th Avenue) Resident #1 was around the 9000 block (which is where the police found her). The walk was about 0.6 miles away from the facility and took the surveyor about 16 minutes. During an interview conducted on 10/27/25 at 9:10 AM with the Director of Nursing (DON), she stated that she received a call from the facility staff around 7:50 PM letting her know that Resident #1 was found by the Police. She arrived at the facility at 8:30 PM and entered through the back door ambulance entrance. While walking towards the B Wing, she heard a beeping alarm sound coming from the front main lobby door. She did not see any staff at the front door and could not remember the code for the keypad to stop the beeping alarm. She then asked Staff C, Registered Nurse (RN) B Wing Unit Manager, for the code to the keypad to turn off the alarm. During an interview conducted on 10/27/25 at 10:36 AM with Staff D, Registered Nurse Supervisor, she stated that she was working as the manager on duty on the C Wing on the day of the elopement. She was at the nurse's station around 7:45 PM when the Police officer spoke to another Staff member to let them know that Resident #1 was found out of the facility walking on a main street. When asked by this surveyor if she heard an alarm/beeping noise around the time the resident eloped and she said no. During a phone interview conducted on 10/27/25 at 1:50 PM with Staff E, Certified Nursing Assistant (CNA) who was assigned to Resident #1 at the time of the elopement, Staff E stated that she saw Resident #1 eating her dinner in the Television Room and was later seen at the nurse's station but could not recall the exact time. A nurse approached her later to ask her about the whereabouts of Resident #1, and she answered that she did not know. Staff E stated that there was no alarm or beeping sound going off at the nurse's station at the time of the alleged elopement. When Staff E was asked if she knew that Resident #1 was at risk for elopement, she said no. During an interview conducted on 10/27/25 at 3:40 PM with Staff B, LPN, she stated that when she returned from her lunch break on 10/11/25 around 7:50 PM, she was told by Staff G, LPN that the police were coming back to the facility with Resident #1. Staff B said that she last saw Resident #1 walking in the B Wing hallway towards Staff A, PTA, around 7:15 PM. She further explained that she did not know that 105679 Page 2 of 6 105679 10/29/2025 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1 was an elopement risk. According to Staff B, no alarm was heard on the B Wing when the front main lobby door was pushed open. Staff B acknowledged that earlier that day (10/11/25) around 6:00 PM, Resident #1 asked her to speak to her daughter on the phone. However, Staff B stated she was too busy with other nursing assignments and could not help Resident #1. Resident #1 then asked the other nurse in the Unit who was also busy. Neither nurse attempted to redirect the resident or provide additional supervision. During an interview conducted on 10/27/25 at 12:55 PM with Staff C, RN Unit Manager for B Wing, she stated that Resident #1 had a daily routine which consisted of sitting on her rolling walker and looking through glass door, near the activity room, labelled as door #14. She would then come to the nurse's station and ask to talk to her daughter. On 08/11/25 Staff C noticed that Resident #1 was more agitated than usual and was pacing the B Wing hallways toward the exit doors which made her question the unusual behavior. This prompted Staff C to complete an Elopement Risk Evaluation which resulted in placing Resident #1 at risk for elopement. Resident #1's daughter was called the same day to speak to her mother to help calm her down. According to Staff C, she verbally updated all staff on the risk of elopement for Resident #1. She also said she updated the care plan with interventions to prevent elopement. Record review of Resident #1's Medical record revealed no care plan with interventions was put in place on 08/11/25 regarding risk of elopement. Further review indicated that Resident #1 did not have a care plan to address behaviors of seeking to communicate with family and daughter, or of pacing around exit doors. During an interview conducted on 10/27/25 at 4:30 PM with Staff H, CNA she stated that she worked on the C Wing on 10/11/25 from 3:00 PM to 11:00 PM. She further stated that she never heard any alarm or saw a light at the nurse's station at the C Wing. According to Staff H if someone opens the front lobby main door and the door is engaged, she will hear a sound and see the light go ON at the nurse's station. During an interview conducted on 10/27/25 at 4:35 PM with Staff I, CNA who worked on C wing, she stated that when someone tries to go out of the front main lobby door an alarm will go off, but no alarm went off on 10/11/25. During an interview conducted on 10/27/25 at 4:40 PM with Staff D, Registered Nurse Supervisor, she stated that normally no alarm or light comes ON at the nurse's station if someone attempts to open an engaged/locked door. According to Staff D on 10/11/25 between 7:00 PM and 8:00 PM she was at the C Wing nurse's station. She did not hear an alarm at the C Wing but acknowledged hearing the alarm when she came closer to the facility main lobby and assisted the DON with the code to disengage the front door alarm. In a phone interview conducted on 10/27/25 at 5:35 PM with Staff A, PTA, he stated that he worked on 10/11/25, and last saw Resident #1 between 7:00 PM to 7:30 PM, judging by the light outside. He recognized Resident #1 who was ambulating in the hallway near the activity room and appeared agitated. He helped to redirect Resident #1 towards the B Wing and continued with his assignments. During an interview conducted on 10/28/25 at 12:00 PM with the Maintenance Director, he stated that he came into the facility the next day (10/12/25) after the resident eloped to ensure all door alarms were properly functioning. He explained that the front main lobby door is equipped with a Magnetic Lock which connects to a device called Door Annunciator, located at both nurse's stations. The front main lobby door, when the bar is pressed, opens after 15 seconds and the magnetic lock alarm goes off. A passcode is needed to stop the alarm. He also explained that the main front lobby door has a red round alarm box called Screamer located on the left side of the door. The Screamer is turned on with a key and once activated (opening the door) it would go off for 30 seconds and stop. On 10/12/25, when testing the doors, he realized that the Door Annunciator device on the C Wing showed that the main lobby switch light was ON but no sound was heard. A closer look at the device showed that the red button (Audible Shunt) was pushed in the silent position/mode. When he went to the B 105679 Page 3 of 6 105679 10/29/2025 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few wing, he realized that the Door Annunciator device did not have a designated alarm switch for the main lobby door. He explained that the Door Annunciator is a device that was placed on the back wall of each of the nurse's station (B and C Wing) to notify staff that a specific exit door in the facility has been dislodged. In addition, he pointed out that the Audible Shunt red button on the devices can disable the alarm sound when pushed in the silent position/mode. During an interview conducted on 10/28/25 at 8:34 AM with Staff K, Receptionist, she stated that she works from 10:00 AM to 6:00 PM every other weekend. Prior to the incident, the front main lobby doors were unlocked between 8:00 AM to 7:00 PM, and visitors would be able to come in and out without any alarm sounding off (doors were disengaged). Staff K reported that an elopement binder is located at the receptionist desk with a picture and the name of all residents that are at risk of elopement. When asked about Resident #1 she said that she did not remember if she was one of the residents in the binder. According to Staff K, Resident #1 was not safe to go out on her own and would only go out when family came to visit. During an interview conducted on 10/28/25 at 5:16 PM with Staff J, Receptionist, she stated she was working the night of the elopement on 10/11/25 (Saturday) and left around 6:30 PM but normally leaves at 6 PM on Saturdays. She confirmed the front main lobby doors automatically locked at 7:00 PM. Prior to the incident, the front main lobby doors used to remain unattended and unlocked from 6:00 PM to 7:00 PM, locked from 7:00 PM to 8:00 AM, and then would unlock at 8:00 AM. Upon starting her shift she reviews the elopement binder located at the receptionist desk. When asked if she was aware that Resident #1 was at risk for elopement and she stated no. At the end of her shift, she puts everything away, lets the C Wing staff know that she is leaving and closes the double doors that lead from the main lobby to the two units (B wing and C wing). The facility submitted an acceptable Immediate Jeopardy removal plan on 10/29/25, and it stated the Immediate Jeopardy was removed on 10/13/25. The implementation of the removal plan was verified onsite by the surveyors on 10/28/25 and 10/29/25: 1. On 10/11/25 at approximately 8:05 pm Resident # 1 returned to facility, placed on one-on-one supervision. Evaluation by LPN revealed no signs of injury or distress. Care Plan updated to reflect current care needs. A head count was conducted of current residents at the facility by RN supervisor. No concerns were identified. Record review of Resident #1's verified the resident was placed on one-on-one supervision as noted in the observation work sheets from 10/11/25 starting at 8:15 PM to 10/21/25. Evaluation by LPN revealed no signs of injury or distress. Care Plan updated to reflect current care needs on 10/11/25.Verified the head count audit, which listed 118 residents, completed by the facility on 10/11/25. 2. On 10/11/25 current facility residents had elopement risk screens completed. Two additional residents triggered at risk for elopement. Orders and Care Plan were updated to reflect current needs based on updated Elopement Risk Evaluations. Verified the Elopement Evaluations conducted on 10/11/2025 for all the residents (118). 3. On 10/12/25, elopement risk binders were reviewed to ensure they contain photos and demographic information of residents evaluated to be at risk for elopement. The surveyors reviewed and verified the 3 elopement binders located at the Receptionist desk, C Wing nurse's station and B Wing nurse's station were accurate. 4. Elopement Drills to include door alarm drills conducted each shift starting on 10/11/25 through 10/26/25. Education on elopement process, exit seeking behaviors and exit seeking behavior process/procedures discussed after each drill. Verified sign-in sheets by all staff for elopement drills completed from 10/12/25 and 10/13/25. 5. Education for current staff initiated on 10/11/25 related to the facility Elopement/ Wandering Residents policy, Abuse, Neglect, Misappropriation and Exploitation, elopement/exit seeking behaviors identification, staff notification of elopement risk, location and contents of elopement risk binders, initiating enhanced supervision for residents actively exit seeking, responding to door 105679 Page 4 of 6 105679 10/29/2025 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few alarms and proper actions to take once determined to be exit seeking or at risk for elopement. It also included the change to entry and exit of the facility through designated doors. Licensed nurses received specific education on exit seeking behavior and initiating appropriate care plan, orders and adding the elopement risk alert to the gray bar (this is in the electronic medical record and shows immediately below the picture of the resident in both the nurses charting system and the CNA charting system), immediately updating the elopement risk binders, creating a new elopement risk assessment in the computer and notifying nursing management. Receptionist received specific education followed by specific competencies on monitoring the door alarm system and notification to maintenance if a failure is identified, understanding the importance of the elopement binder and reviewing it at the beginning of each shift worked, and the proper procedures of resident LOA, signature for each oncoming and off-going shift on the clipboard indicating they had both appropriately initiated or deactivated the screamer alarm and for their review of the elopement binder, the process of utilizing the video doorbell for visitor/vendor entry and exit and notification of nursing manager if exit seeking behavior is identified. Education was conducted on 10/12/2025 with IDT team on the process of identification, care planning, prevention, and response of elopement/exit seeking behaviors in morning meeting by progress/behavior note review and a review of the elopement risk UDAs, admission and readmission assessments (that contain the elopement risk evaluation for new residents) completed. Verified In-Services conducted for all in-house staff from 10/11/25 to 10/13/25 on all three shifts by interviews with staff on all three shifts. 6. Huddles are conducted at the beginning of each shift to discuss elopement risk and fall risk residents. This is an added communication to ensure staff are aware of at-risk residents. Verified with multiple staff interviews on all three shifts. 7. Door function and alarms were checked by the Administrator on 10/11/2025 and the Maintenance Director on 10/12/25, all doors and alarms were functioning appropriately. During the review by Maintenance Director on 10/12/2025, the C wing annunciator was noted to be muted. The volume of the annunciator was increased, and the button was disabled to remove the ability of staff to adjust the volume by vendor on 10/13/2025. Verified by observation and testing of the door annunciators on both Wings (C and B Wings). 8. Education provided by Staff Development Coordinator, DON and Administrator.There are156 total facility employees (Nursing, Dietary, Laundry, Housekeeping, Therapy, Administrative staff, Receptionists, Maintenance).All156 staff received education on the facility elopement/ Wandering Residents policy, Abuse, Neglect, Misappropriation and Exploitation, elopement/exit seeking behaviors identification, staff notification of elopement risk, location and contents of elopement risk binders, initiating enhanced supervision for residents actively exit seeking, responding to door alarms and proper actions to take once determined to be exit seeking or at risk for elopement. It also included the change to entry and exit of the facility through designated doors.There are 43 total licensed nurses in the facility and 4 total receptionists in the facility.All 43 licensed nurses received education on exit seeking behavior and initiating appropriate care plan, orders and adding the elopement risk alert to the gray bar (this is in the electronic medical record and shows immediately below the picture of the resident in both the nurses charting system and the CNA charting system), immediately updating the elopement risk binders, creating a new elopement risk UDA and notifying nursing management. as of 10/13/25.All 4 receptionists have been educated on monitoring the door alarm system and notification to maintenance if a failure is identified, understanding the importance of the elopement binder and reviewing it at the beginning of each shift worked, and the proper procedures of resident LOA, signature for each oncoming and off-going shift on the clipboard indicating they had both appropriately initiated or deactivated the screamer alarm and for their review of the elopement binder, 105679 Page 5 of 6 105679 10/29/2025 Regents Park of Sunrise 9711 W Oakland Park Blvd Sunrise, FL 33351

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the process of utilizing the video doorbell for visitor/vendor entry and exit and notification of nursing manager if exit seeking behavior is identified as of 10/13/2025.Verified In-Services conducted for all in-house staff from 10/11/25 to 10/13/25 on all three shifts.Also verified by interviews with staff on all three shifts, including licensed nurses, and 3 of 4 of the Receptionists. 9. Newly hired staff and staff members on leave will receive education at orientation or prior to working their next scheduled shift. Verified the educational material the facility will use for orientation of new employees. 10. Root Cause Analysis (RCA) completed on 10/12/25 and reviewed by QAPI. Additional contributing root causes were identified and addressed in QAPI on 10/13/2025, as outlined below. These factors were staff response, staff knowledge of elopement risks and resident safety, appropriate plan of care/interventions for residents, muting of the C wing annunciator. Reviewed the original Root Cause Analysis completed by the facility. 11. The facility conducted an ad hoc QAPI meeting on 10/13/25 which included the Facility Administrator, DON, Medical Director via telephone, and additional staff members. The Performance Improvement Plan was accepted by the committee. The annunciator and the correction plan of the annunciator was reviewed in QAPI as indicated by the review of the maintenance enhancement plan. Door alarm annunciator volume increased on C wing, mute button on C wing annunciator disabled. Reviewed staff education completed including identification and response/process of exit seeking behaviors, elopement drills conducted. No additional recommendations were made at that time.Record review verified the sign-in sheet for the ad-hoc meeting on 10/13/25.Interviews conducted with the DON, Administrator, and the Medical Director confirmed that the ad hoc meeting was conducted on 10/13/25, and the door annunciators and staff education were addressed. 105679 Page 6 of 6