Health inspection·June 27, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Services Director (SSD) stated: If a resident left AMA. I normally do a wellness check if I have the discharge location, however for [Resident #1] I did not have a location. The health care proxy is to be notified about any incident, and they are the person who is to sign a resident out AMA. The Social Services Director presented Resident #1's signed Affidavit of Health Care Proxy dated 3/3/25 indicating Patient name: [Resdient#1], Agency accepting Proxy Designation:Record review of a Policy titled Against Medical Advice effective date 05/10/2024 indicated:Procedure:5. Notify the resident's representative, family, or designated person that the resident is leaving the facility AMA and document in the medical record. Event ID: Facility ID: 105765 If continuation sheet Page 2 of 8 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 105765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens Nursing and Rehab Center 190 NE 191st Street 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to ensure one (Resident #1 out of three (Resident #1) safely and appropriately discharged to a safe location where ongoing clinical care could be provided, as evidence by on 05/05/2025 Resident #1 a vulnerable resident with clinical diagnoses of Disorganized Schizophrenia (a mental condition that cause an individual to have trouble organizing their thoughts, which can lead to behaviors that seem random) insisted on leaving the facility was presented with an Against Medical Advise (AMA) form which he refused to sign. The facility did not obtain a valid address for Resident #1's next place of residence and did not inform the resident's advocate/representative about the AMA discharge. At the time of this survey Resident #1's location is unknown. The findings include: Observational tour of the facility's exterior revealed the facility is in a residential area with high volume of traffic and cross streets; the facility is not gated at the entrance. The facility has side fences (approximately four feet at the front of the building's parking lot and to the right while entering the facility the fence is approximately six feet extending to the rear of the facility of the building. The front entrance to the building requires a code to enter and exit. Tour of the facility's interior revealed only one out of two elevators in working condition and required a code to get on and off. The stairway has an alarm with a 5-10 seconds delay before the door is opened. Every exit door has an alarm. The patios on the second and third floor are screened but a resident could easily lift the screen and jump off the patio.Review of Resident #1's closed medical records revealed the resident was admitted to the facility on [DATE] and discharged AMA on 05/05/2025. Clinical diagnoses include Colostomy status, disorganized schizophrenia, other psychotic disorder not due to a substance or known physiological condition .Review of the Physicians Orders Sheet (POS) for May 2025 included an order dated 3/17/2025 for Olanzapine Oral Tablet 10 milligrams; give 1 tablet by mouth at bedtime for Psychosis Colostomy care every shift.Record review indicated Resident #1's Care Plans Initiated: 03/18/2025, Revision on: 05/08/2025 documented: Focus area: Alteration in mood and/or behavioral status related to psychotic symptoms (Hallucinations/Delusions). Goal: Will be easily redirected and free from injury/adverse outcome related to wandering through next review. Interventions: Provide additional Social Service support as needed. Offer/provide psychosocial support services as available/accepted. Medications as ordered, Redirect patient as necessary. 15 minutes checks per facility protocol. Monitor resident ongoing psychosocial issues . Care Plan Date Initiated: 03/19/2025 Revision dated 05/08/2025-Focus: Resident wishes to stay in the facility for Long Term Care. Resident discharged AMA, forms not signed. Goal: -Resident will have no psychosocial issues regarding the decision to stay in facility for LTC. Interventions: - Monitor resident ongoing psychosocial issues. Psych consultation as necessary Review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident # 1 is cognitively intact. [NAME]- Adequate, Speech Clarity- clear speech, Makes Self Understood- usually understood/ understands . High-Risk Drug Classes taking: Antipsychotic; No wander/elopement alarm used; Active discharge planning already occurring for the resident to return to the community-YesReview of Progress Note dated 5/5/2025 02:19 (2:19 AM)-Narrative Nurses note: Resident left AMA form was not signed.Review of a Progress Noted dated 5/5/2025 2:44 AM: During the routine checkup, Staff notice [Resident #1] was not in his room. The Supervisor, primary nurse and staff searched the whole building but couldn't find the resident. The Administrator, DON (Director of Nursing) and ADON (Assistant Director of Nursing) were contacted. One of the residents shared [Resident #1] wanting to leave, and said he was tired of being locked up. MD (Medical Doctor) has also been notified. Tried reaching out to [] Florida (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105765 If continuation sheet Page 3 of 8 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 105765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens Nursing and Rehab Center 190 NE 191st Street 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Advocacy Group.but there was no response. Voicemail message was left for them to return the call . Interview on 06/25/2025 at 1:57 PM, the Director of Nursing (DON) revealed Resident # 1 went missing on the 3:00 PM to 11:00 PM shift and apparently the 11:00 PM to 7:00 PM shift staff reported the resident was found in another resident's room on the third floor. Interview on 06/25/2025 at 3:50 PM via telephone, Resident #1's Advocate stated: The last time I saw [Resident #1] was in the hospital on [DATE], I was not notified [Resident #1] is not at the facility, it is not safe for him to be out he need his medication. Interview on 06/26/2025 at 9:07 AM The DON) revealed: If a resident wants to leave AMA the staff are to notify me and either myself or staff try to convince the resident to remain in the facility. If the resident insists on leaving, the medical doctor is notified, and the resident is asked to sign a form that explains the risks. If a resident leaves AMA, we notify the MD (Medical Doctor) [local community-based State agency] and emergency contact. The most recent AMA was [Resident#1]. A night shift staff called me around 11:00 PM on 5/4/2025 and reported to me that the CNA (Certified Nursing Assistant) could not find the resident. I instructed them to look everywhere and that I would be in my way. I notified the administrator. They called me back and said they found the resident in another resident's room, and he was determined to leave. I instructed the supervisor to stay with the resident. The next morning when I came in, I spoke with [Resident #1] and the resident insisted on leaving. At that time, I checked and saw Resdient#1's BIMS (Brief Interview of Mental Status) score was 14 (score of 14 out of 15 indicate the resident is cognitively intact). I then spoke to the medical doctor and the doctor advised to let Resident #1 leave AMA. I presented the AMA form to Resident #1 and the resident refused to sign it. I did not write a progress note that the resident was here on 5/5/25 in the morning. I called three or four times to the responsible party and left a voicemail and no response. This resident has a diagnosis of Schizophrenia. During an interview on 6/26/25 at 9:42 AM, the Social Services Director (SSD) stated: If a resident left AMA. I normally do a wellness check if I have the discharge location, however for [Resident #1] I did not have a location. The health care proxy is to be notified about any incident, and they are the person who is to sign a resident out AMA. The Social Services Director presented Resident #1's signed Affidavit of Health Care Proxy dated 3/3/25 indicating Patient name: [Resdient#1], Agency accepting Proxy Designation: [Advocacy Group]. If a resident wants to leave AMA and I am present I request that they sign an AMA and advise them of the possible risks associated with leaving AMA. I don't remember if I told DCF that Resident #1 left AMA because I only forwarded the note written on 5/5/25 at 2:00 AM. On 6/26/25 at 10:50 AM The DON stated: I didn't document that the resident was found because there was a lot going on .No one called the police because the resident was found in another room.Interview on 6/26/2025 at 11:34 AM the DON reported that on 05/05/2025 Resident #1 insisted he wanted to leave and was presented with an Against Medical Advise (AMA) form, but he did not sign the AMA form and left the facility at 10:42 AM with his clothes and colostomy supplies. He was wearing shorts; we watched him cross the street to the bus stop. The Administrator (NHA) Minimum Data Set (MDS) Coordinator, Therapy Director and the Receptionist were present when the resident left. The DON revealed she was aware Resident #1 had an Advocate/Representative, and she called and left a message. The Doctor was also notified that the resident left AMA. The DON was asked why the facility did not [NAME] Act the resident for his own safety; the DON reported there was no Doctor's order to [NAME] Act the resident.Interview on 06/26/2025 at 2:10 PM with Staff C, Certified Nursing Assistant, revealed I have worked with [Resident #1] before and everybody work together with him, I remember that Sunday night about 10:00 PM they said he was missing, and we looked for him everywhere. I was leaving at 11:00 PM and they had not found him but the next day I heard that they had found him, and he had left. On (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105765 If continuation sheet Page 4 of 8 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 105765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens Nursing and Rehab Center 190 NE 191st Street 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 06/26/2025 at 2:18 PM, interview via phone with the Primary Care Physician (PCP) he stated: [Resident #1] was my patient; he was oriented and is independent. I received a call on Sunday 05/04/25 at around 11:00 PM stating [Resident #1] was missing. I did not hear from them until Monday morning and at that time they did not tell me where he was found that morning. They said he left AMA. The PCP was asked if it was safe for the resident to be out of the facility off his medication, The PCP stated, If the [Resident #1] does not get his medication, he will get worse. We got him from another county pretty much while he was at the facility he was ok; he needs his medication and needed to continue taking it because he was stable. I was not aware he was with the advocate program. When this kind of patient try to leave, he should be [NAME] Acted. The PCP was asked if a Physician's Order is required for a [NAME] Act, the PCP stated no, the facility have the right to call 911 because maybe at that time when he wanted to leave, he was experiencing or was in altered mental status. We have had patients that try to leave, and it is hard to escape from that facility. I was not notified until Monday morning and that was after he had already left AMA. Interview on 06/26/2025 at 2:35 PM, the Administrator (NHA) was asked about the incident related to Resident # 1 leaving the facility; the NHA stated: He left AMA, he did not tell us where he was going, it is not uncommon for homeless people to want to leave so he may have gone back to the streets, the doctor was called per the DON. The NHA was asked if she contacted the Advocate/ Representative, she stated: I left a message I only have a phone number. He usually makes his decision; he signed his admission package when he came in., we did not do a wellness check because according to Social Services Director (SSD), she reported it to [local community-based State agency], but they did not take the case. No police report or missing person reports were done because he left AMA. When asked if the resident can survive without meds, the NHA stated: Yes, he may have psychotic episodes, but he lived on the streets before he has no income .and when he needs supplies he will go to the hospital .He can change the colostomy bag himself. The staff reported he was missing at nighttime on the 11:00 PM to 7:00 AM shift and they found him in another resident's room (room number unknown). He said the next morning I can't be here. The NHA was asked if the resident's doctors were notified; the NHA stated: The primary doctor was called and I do not know if the Psychiatrist was called The NHA was asked if she thought a resident would be safe on the streets, she responded yes. He refused to sign the AMA. I witnessed him leaving. The NHA was asked if the Social Services Director (SSD) was made aware that the resident wanted to leave and, the NHA revealed the SSD was not involved. Follow up interview on 06/26/2025 at 3:38 PM, the SSD was asked if she had tried to encourage the resident not to leave the facility. The SSD stated: I was not involved and was not notified until after the resident ha left. The SSD further revealed: [Resident #1] expressed at times that he wanted to leave but not aggressively and was redirected. If I knew what was happening, I could have redirected him. I was at the facility that Monday he was not here when I put my note in; it is a concern that he is out there on his own . Interview on 6/27/25 at 9:50 AM, Staff G, Registered Nurse (RN) stated I am familiar with [Resident #1]. I have been his nurse several times. He was very quiet and short with words and always walking around. He never expressed any desire to leave the facility. He always took his medicine. I was told that this resident eloped. I would not consider that a safe discharge due to his Schizophrenia. Review of a Psychiatric Note for Resident #1 dated 3/24/2025 indicated: Resident #1 is very delusional, says the government has given him authority to take as much ecstasy as he wants and his family was executed, Diagnosis: Psychotic disorder .Schizophrenic disorganized type, recommendation to increase Olanzapine to 10 mg at bedtime.Interview via telephone on 06/27/2025 at 12:39 PM with the Psychiatrist, he stated: I know that resident he was new, but he is Schizophrenic and with those types of patients moods will change (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105765 If continuation sheet Page 5 of 8 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 105765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens Nursing and Rehab Center 190 NE 191st Street 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 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete without warning; he needs to take his medication to remain stable; and if he left without saying where he is going that is dangerous because; He may be roaming around the streets and will get in trouble and the police will lock him up and maybe put him in a psych unit. I was informed a week ago that he was not in the facility. The facility should have tried to find out where he was and where exactly he was going. The expectation is for the facility to notify me immediately before they let him leave. the plan when he was admitted was for him to stay in the facility. The facility should have a protocol in place for a psychotic patient like [Resident #1]. This is a major concern because I was only told that he was not in the facility a week ago. On 6/27/25 at 1:50 PM with Staff I, Licensed Practical Nurse (LPN) that was assigned to Resident #1 on the date of the incident stated: I don't remember that resident [Resident #1]. I don't remember any resident going missing on my shift. I don't remember, I don't know that resident. When asked if she recalled residents on any of her assignment with colostomy she stated: I don't remember. Staff I was asked about the medication that was not administered nor signed off on the Medication Administration Records (MAR) on 05/04/2025, Staff I, again stated: I don't remember why I didn't sign the MAR. Review of the facility's policy provided titled Against Medical Advice, Effective date: 05/10/2024. Policy: A physician's order should be obtained for all discharges unless a resident or representative is discharging himself or herself against medical advice.Procedure: 1. Should a resident, or his or her representative request an immediate discharge; notify the physician and document in the medical record.2. If the resident or representative insists upon being discharged without the approval of the physician, the resident and/or representative should sign a Release of Responsibility (AMA) form. Should either party refuse to sign the release, such refusal is to be documented in the medical record. 5. Notify the residents' representative, family, or designated person the resident is leaving the facility AMA and document in the medical record. Event ID: Facility ID: 105765 If continuation sheet Page 6 of 8 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 105765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens Nursing and Rehab Center 190 NE 191st Street 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store food under sanitary condition in two out of two snack/nourishment refrigerator on the resident's unit. as evidenced by residents' foods brought to the facility by visitors and family were observed unlabeled and not appropriately dated. This deficient practice has the potential to affect residents receiving food brought in from outside sources. The findings include.Observation on 06/25/2025 at 3:15 PM of the facility's Nourishment Pantries refrigerators that stores resident's food that is brought into the facility by visitors, family and other outside sources revealed the refrigerator on the second floor had 17 unlabeled grocery type bags with food items and three plastic containers in plastic bags with food items dated 05/29/2025 and had no names. The third-floor refrigerator also had several unlabeled undated plastic bags with food items. Interview on 06/25/2025 at 3: 25 PM Interview with Staff J, Registered Nurse revealed (RN) stated: all these foods belong to the residents. items in the refrigerator located in the pantry to residents. Interview on at 3:45 PM, the Assistant Director of Nursing acknowledged the concerns and revealed: Food should be labelled and dated with the resident's name and should be discarded after three days. Review of the facility's policy titled: Foods Brought in By Family and Visitors indicate:POLICY:It is the policy of this facility to permit liberalized diets as much as possible. Staff must be aware of foods brought to a resident by family/visitors.PROCEDURE:1. Family members/visitors must inform the nursing staff of their desire to bring foods into the facility.5. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator (used for resident items). Containers must be labeled with the resident's name, the item and the use by date.6. The facility staff, in charge of cleaning the common area refrigerator, is responsible for discarding perishable foods on or before the use by date/3days. The family is responsible for discarding perishable food stored in personal refrigerators kept in resident rooms. Event ID: Facility ID: 105765 If continuation sheet Page 7 of 8 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 105765 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens Nursing and Rehab Center 190 NE 191st Street 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to honor their policy for Foods brought in by family/visitors for one (Resident #13) out of three sampled residents as evidenced by the facility's staff refuse to warm Resident #13's food brought in by family. The findings included: During observation on 06/25/25 at 12:55 PM Resident #13 was observed seated in her wheelchair at the bedside. Resident #13 revealed she had a recent disagreement with the dietary manager about her food that had been brought in by her brother being too burnt when staff warmed it up in the kitchen .As a result the Dietary Manager is unwilling to warm her food in the kitchen. The resident further explained the microwaves were removed and residents must warm up outside food in the kitchen. Interview on 06/25/25 at 02:25 PM, the Dietary Manager reported there is currently no microwave on each floor, as the previous ones were removed due to repeated damage and have not been replaced. Per facility policy, staff are not permitted to reheat outside food brought in by residents or their families. Only food prepared in-house may be reheated. This policy has been longstanding, though there have been numerous complaints from residents regarding the inability to warm up outside food. Review of the facility's undated policy titled: Foods brought in by family/visitors. POLICY: It is the policy of this facility to permit liberalized diets as much as possible. Staff must be aware of foods brought to a resident by family/visitors. PROCEDURE: 10. Outside food/liquids is only permitted to be reheated by dietary staff to prevent the possibility of bums or injury. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105765 If continuation sheet Page 8 of 8