Inspection·October 10, 2023

F 0689 care plan for elopement. Level of Harm - Minimal harm or potential for actual harm Review of the Nursing progress notes documented the following: Dated 10/06/23 15:10-Resident was observed in his wheelchair sitting outside in the smoking area and socializing with other resident after which he came inside the building and was looking out the window. Few minutes later nurse was looking for resident and resident was notable to locate missing person code was called, all staff searched the building and nearby premises. [ ] Emergency services, Administrator and DON (Director of Nursing) were called. Error in the date, should have been 10/04/23 18:50; Dated 10/05/23 03:01-Resident out of the facility; Dated 10/05/23 09:50-Resident returned to the facility by [ ] local city police department, then was transferred to [ ] local hospital for further evaluation. Residents Affected - Few Review of the Social Services progress note documented the following: Dated 10/05/23 09:45-The resident was returned to the facility today by [ ] local city law enforcement who stated that they picked the resident up near [ ] local city. Resident was interviewed on how he exited the facility and why; resident stated that he did not want to be here anymore and said the he exited through the smoking area, walked around the back of the facility and started to head toward the [ ] local city area on foot. At the time of the interview, the resident was coherent and able to answer all questions appropriately. BIMS assessment completed with resident resulting with a total score of 13 (Cognitively Intact). Due to resident being out of the facility overnight, a recommendation was made for resident to be sent to the area hospital for evaluation and resident agreed. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for August 2023, September 2023 and October 2023 documented the resident was receiving the following medications: Seroquel 25mg (milligrams) tab (tablet) 1 tab PO (by mouth) BID (twice a day) for psychosis; Quetiapine Fumarate 25mg tab 1 tab PO BID for psychosis, Insulin Lispro (1 Unit Dial) subcutaneous Solution Pen-injector 100 unit/ml inj (inject) per sliding scale for diabetes mellitus (dm), Insulin Detemir Solution 100 unit/ml inj 18 unit subq HS for dm, Lisinopril 5mg tab 2 tabs PO one time a day for hypertension and Oxycodone HCL (hydrochloride) 10mg tab 1 tab PO every 6 hours PRN (as needed) for pain. Review of the Elopement Incident Log dated September 2023-October 2023 documented the resident was listed on the Elopement Incident log for 10/04/23. Review of the Smoking Schedule documented the following: Monday-Sunday 10:00 AM to 10:30 AM; 1:30 PM to 2:00 PM; 4:00 PM to 4:30 PM and 5:30 PM to 6:00 PM. On 10/09/23 at 11:54 AM, Staff A, Licensed Practical Nurse (LPN) Unit Manager 7-3 shift stated, I was in my office, the nurse came down to tell me he didn't see the patient in his room. [ ] Staff B, Registered Nurse (RN) had him as a patient that day. He was looking for him to give him his meds. After which I told him to look in the bathroom and in the surroundings of the resident room. I asked the [ ] Staff D, CNA (Certified Nursing Assistant) if they had seen the patient. He was seen in the smoking area. His tray was waiting on him after he smokes so he could have his dinner. I went and searched. I told [ ] Staff B, Registered Nurse (RN) to tell [ ] Staff E, LPN 3-11 Supervisor that we couldn't find the patient. She called code green which is for a missing person. All the staff gathered and showed pictures of the patient and we all searched for the patient. This happened on 10/04 and the police brought him back on the 5th and the doctor said to send him to the hospital for further evaluation. Subsequent interview on 10/09/23 at 1:58 PM. She stated, When I did the report on 10/06/23 in the computer but it was linked to the 10/04/23 elopement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 2 of 4 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 On 10/09/23 at 12:57 PM, the Administrator/Risk Manager/QAA (Quality Assessment and Assurance) stated, It occurred on 10/04/23. I was notified around 6:26 PM in the afternoon that there was a missing resident. The facility immediately had called for the code green and the search for the resident continued. Myself and the DON immediately reported to the building and informed the resident was still not located. We continued with our process, we notified law enforcement and [ ] local state abuse registry agency. Law enforcement came and I have a copy of the card with report number. [ ] local state abuse registry agency did not accept the report. The resident was alert and oriented with no cognitive impairment noted on the BIMS. The facility performed an immediate head count. The police returned the resident back to the facility the next morning on 10/05/23 around 10:00 AM. The resident was found in the [ ] local city area. It was discovered that he left out of the back patio smoking door and walked west down the [ ] street and was in the [ ] local city area. He was previously homeless. He did not express wanting to leave the facility. He has a history of alcoholism. There is a designated CNA in the smoking area at all times. The last time he was seen, he was in the main dining room on the first floor. He was outside in the police cruiser and they were responsible for dropping him off to the last known address. We called fire and rescue and he was transported to the hospital. He did not come back inside the facility. He stayed outside with the police until the fire and rescue came to transport him to the hospital. He is still in the hospital at the moment. The progress note by [ ] Staff A, LPN Unit Manager 7-3 shift dated 10/06/23 15:10 is inaccurate. She needs to correct it in the system to reflect 10/04/23. The resident is at [ ] local hospital. Our immediate response, we did house wide on elopement training, abuse and neglect training, egress door checks ongoing, elopement drills that were performed, 24 hour door check done every half hour, ad-hoc QAPI (Quality Assurance Performance Improvement) meeting to include elopement and wander guard education and twice a day rounding for all egress doors. On 10/09/23 at 1:18 PM Staff B, Registered Nurse (RN) stated, He was my resident. On that day, I was passing my medication from my cart. The therapist lady came to me and asked for him. I told her to look in his room. I gave him his medications early. I went to the smoking area and I didn't see him out there. There were other residents out there but he wasn't there. I went upstairs to look for him and he was nowhere. I told my manager that he was missing. This was around 5:33 PM. She asked what happened and said he should be outside smoking. It was two of us looking for him. At the time he left the building, I was passing meds and it was a smoking break. Morning meds and afternoon meds were given around 12:37 PM. He was a diabetic and he received insulin. He never talked about leaving the facility. He was alert and oriented times two. He was able to be a steady walker and used a wheelchair also. On 10/09/23 at 1:36 PM Staff C, CNA stated, Thirty minutes for the patient in the smoking area. When everybody was outside smoking, when the time is done everybody came back inside. All of them, went into the dining room. One of the patient asked me for some water and I gave it to him in the dining room. The patient was in the dining room. I went to drive one of the patients to his room. I didn't pay attention to him once he was inside. I guess that is when he left. The therapy woman came to me looking for him for therapy and I told her, the last time I saw him he was in the dining room. I was assigned to the smoking area on that day. On 10/09/23 at 2:04 PM Staff D, CNA stated, When I came, I signed my name. I go to the dining room to make rounds. I saw him sitting down with two CNAs. I make rounds in the hallways. I left and went to put a patient in the bed to change him. When the food came for him, I went back to the dining room to tell him his food was there. I saw him outside smoking. I told him and he said he was smoking. He would not eat early, he would eat later. He had good sense. He walk by himself. [ ] Staff A, LPN Unit Manager 7-3 shift came to me and said she didn't see the patient. I told her two CNAs were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 3 of 4 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 105903 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Azure Shores Rehab 800 NW 95th Street Miami, FL 33150 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 with him outside and I didn't know anything. Level of Harm - Minimal harm or potential for actual harm On 10/09/23 at 2:20 PM Staff E, LPN, 3-11 Supervisor stated, On that day I was working the 200 wing med cart. The nurse that was responsible for the patient, alerted me that he was unable to locate [ ] Resident #1. I locked my med cart. We called the code green and started the elopement process. I notified the Administrator and the DON. This was around 5:45 PM. The DON and Administrator arrived to the building. The police was called and they came and took the report from me. When he came in he was alert and oriented times three. He was able to walk, his gait was unsteady and he used a wheelchair. He did not exhibit any wandering or exit seeking behavior. Residents Affected - Few On 10/09/23 at 2:51 PM, the DON stated, The 10/04 incident, they called us after the search for the resident, they couldn't find him. They called the Administrator, myself and the police. We interviewed the staff and the residents that were with the resident who eloped. We started in-services on elopement, the doors were checked, abuse training was given and training on wander guards. He was last seen sitting looking through the window in the dining room. He used a cell phone for the residents to make a telephone call. We don't know who he was calling. The police brought him back the next day. He went to the hospital via [ ] local emergency services. On 10/09/23 at 2:55 PM, the Social Services Director stated, I was told by the Administrator that the resident was brought back to the facility by law enforcement. According to law enforcement, they picked him up from a property in [ ] local city. The homeowner called the police because he was on their property with indecent exposure. Law enforcement picked him up for the indecent exposure. They saw in their data base that we reported a missing person and they brought him back to us. Once they got here, we asked him some questions. We recommended he go to the emergency room for an evaluation. He has a history of homelessness and a history of alcohol abuse. He is still at [ ] local hospital to my knowledge. On 10/10/23 at 7:38 AM observation and interview of the First Floor Dining Room, Smoking Area and Parking Lot with the Administrator. He stated, He was able to walk out the dining room door, which has an alarm. When talking to the staff the alarm did not sound. It was reported the alarm did not sound. There was a code to get out of the dining room door. The secondary siren was not going off when he went out the door. We don't know if someone deactivated the alarm for the smoking breaks. We interviewed the resident when he returned with the police to see if he saw someone put in the code and if he knew the code to get out of the back dining room door and he said, no. Only staff have the code to the back dining room door. We did re-education on the secondary alarm in the event that the main alarm fails. When you walk out the back dining room into the smoking patio area, there is no fence or barrier to prevent someone from walking out into the parking lot. That is how the resident was able to leave the facility through the parking lot. One CNA is assigned specifically each shift and one activity worker assigned for smoking breaks. Since the elopement incident, we have continuing facility wide education for egress door checks and staff protocol during smoking times. After the last smoking break at 6:00pm, the staff are responsible for verifying that the main dining room door is locked and a new locking system was put in for that door and the key for the secondary alarm is located on the 100 wing nursing med cart. We are locking the first main floor dining room after the last smoking break at 6:00 PM so that residents won't be able to go in there. If the residents want to go into a dining room, they can go to the dining room on the second floor to socialize, which has been renovated. On 10/05/23 we have an invoice for a wood fence to be installed to be an enclosure for the back patio smoking area. It will be an eight foot fence. I am asking for an updated surveillance system. There are no cameras. I have requested to install and update surveillance systems for all first floor egress doors and parking lot. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105903 If continuation sheet Page 4 of 4