Inspection·July 18, 2023

F 0610 Level of Harm - Immediate jeopardy to resident health or safety psychological services as ordered and directed staff to distract resident from exit seeking with pleasant diversion such as activities, food, conversation, television, and books. On 12/19/22, one to one supervision was removed from the care plan and replaced with frequent visual observations every 15-minutes which were later discontinued on 12/21/22. There were no additional interventions to monitor the resident's exit seeking behaviors. Residents Affected - Few On 7/16/23 at 1:04 PM, LPN A said resident #1 eloped from the facility a few months ago. She remembered she was in room [ROOM NUMBER] when resident #3 came and tried to tell her something. She said resident #3 was difficult to understand so she followed him back to his room. She said he pointed out the window and she saw resident #1 outside by himself, walking on the sidewalk. LPN A recalled she immediately alerted LPN B and ran out the fire exit door and headed toward the resident. LPN A said when she caught up to the resident, he was near the end of the sidewalk. He was appropriately dressed, wore shoes and had his rolling walker. Resident #1 told her he was going to Walmart to buy cigarettes. She said resident #1 was tired and short of breath as he did not have his oxygen. He agreed to go with her and she and LPN B wheeled him back into the facility on the seat of his walker. LPN A stated she wrote a statement and gave it to LPN B. She said she spoke to either the DON or Assistant DON (ADON) by telephone, not in person. She indicated she documented the incident in Risk form which she thought was part of the clinical record. On 7/16/23 at 12:55 PM, the facility's Receptionist recalled a resident had left the building and stood by the post of the facility's entrance. She said she did not see him until he was out by the door as there was a stretcher going through the door at the same time. She indicated the nurse went outside to bring the resident back. On 7/16/23 at 1:33 PM, the Receptionist clarified her earlier interview and said she saw resident #1 outside the sliding glass door near a pillar. She explained she did not go outside to bring the resident back but it took her a few minutes to ask the Concierge to go get him because she could not leave the reception desk. She noted, I guess I prioritized the reception desk. She indicated the Concierge came back and told her LPN A had seen resident #1 outside and went to get him. On 7/17/23 at 11:33 AM, the Receptionist again clarified her previous statements. She said she saw a resident in a red shirt with a rolling walker but did not realize it was resident #1. She said she was very busy and there were many visitors near the reception desk. She reported she did not see the resident leave or see him outside near the pillar. As long as he was ok, I don't know where they found him. On 4/16/23 at 3:45 PM, during an interview, the DON said resident #1 exited the facility on 4/8/23 between 11 AM and 11:15 AM. She stated the facility did not consider this event as an elopement because the staff had eyes on him the entire time. Contrary to the Receptionist's statement, the DON explained resident #1 was in the lobby and the receptionist saw him. She noted there was a transport company that was taking a large resident on a stretcher and resident #1 walked beside the stretcher undetected by the Receptionist. She stated at the same time, the Concierge was going outside to retrieve a clipboard from her car and saw resident #1 walk through the exit doors. On her way back from her car, the Concierge saw the resident near the first handicap parking spot. She explained LPN A saw resident #1 near the stop sign and the first handicap spot in the parking lot. The DON looked through the conference room window and pointed to the first handicap spot and stop sign at the end of a circular driveway underneath the portico. The DON repeated that was the area where LPN A and LPN B found resident #1. The DON stated she was out of town during the incident, but she received a phone call between 12 PM and 1 PM. She noted the ADON started the investigation, obtained witness statements and created a timeline of events. She explained the the incident did not get documented in either the Incident Log or the Reportable Log as they did not classify the incident as an elopement because (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 2 of 17 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few we had eyes on him the whole time. The DON acknowledged hazards off of the facility grounds such as the street and retention ponds but she said the resident remained in or near the facility parking lot, no hazards there. She indicated a re-enactment of the events was not done. On 7/17/23 at 1 PM, the DON provided a witness statement from the Concierge that noted she arrived for her shift at 11 AM and realized she left her clipboard in her car. She went out to her her car and observed a gentleman with a walker headed to the parking lot. I said excuse me, he didn't respond and I continued to my car. I came back up the sidewalk, passing the same gentleman, at that time he made it to the handicap parking spot. I approached the receptionist. I could hear her on the phone, and she stated a gentleman outside so I exited the building immediately to find there were two nurses and the gentleman assisting to bring him back inside. The DON did not provide an explanation as to why the Concierge did not intervene when she saw resident #1 exit the facility. At 1:14 PM, the ADON joined the meeting and noted they did not go to resident #3's room during their investigation to see out the window. The ADON said they did not interview resident #3 but added we probably should have. The ADON stated the information they gathered showed resident #1 was found by the first handicap parking spot, although the nurses' interviews reflected differently. The DON did not provide an answer when asked how staff had eyes on the resident at all times when he was outside and both the Concierge and the Receptionist were inside. The DON and ADON verified the witness statements did not reflect a timeline with locations and sequence of events. On 7/17/23 at 1:25 PM, the DON and ADON were accompanied to resident #3's room. When they looked out his window, they verified they could not see the stop sign or the first handicap parking spot. Shortly thereafter they were accompanied outside to the front of the facility near the Stop sign and the first handicap parking spot. They validated they could not see resident #3's bedroom windows and it would not have been possible for LPN A to have seen resident #1 at the stop sign near the first handicap parking spot. They were informed the resident was found off facility property. The DON stated she was not aware. The DON and ADON were shown the spot where LPN A and LPN B found the resident, near the end of the paved sidewalk. The DON acknowledge the hazards such as the retention ponds across the street, the wooded area, and the vehicular traffic. The DON confirmed the investigation was not thorough or effective. On 7/17/23 at 2:38 PM, the Regional Nurse Consultant, (RNC) stated she was told resident #1 was in the line of sight of staff at all times after he exited the facility. She indicated she reviewed the witness statement yesterday. She said the facility policy did not define elopement but added that if a resident was somewhere he or she should not be, it could be an unsafe situation. She was informed the facility had not submitted either an Immediate or 5 Day report to the Agency for Health Care Administration. The RNC indicated it was up to the Administrator and DON's discretion to submit an Immediate and 5 Day report. She conveyed, In light of new findings we have to continue the investigation. On 7/17/23 at 6:47 PM, during a telephone interview, LPN B recalled on Saturday, of the Easter Weekend, 4/8/23, resident #1 eloped from the facility prior to 12 PM. She remembered resident #3 informed LPN A that resident #1 was outside of the facility when he looked out his window. LPN B said she followed LPN A and they both exited the facility through the emergency fire exit door. She stated they caught up with the resident and he was near the end of the sidewalk, close to a wooded area. She noted the resident was tired because he was not used to walking that far in the heat. She recalled the Concierge was in the lobby when they returned with the resident, not outside. LPN B remembered the Concierge and the Receptionist suggested the resident may have exited along side the transport company that was taking another resident out. LPN B said she wrote a witness statement and spoke to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 3 of 17 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few DON or ADON on the phone 2 or 3 times. She also spoke with the facility Administrator who was now the Regional [NAME] President of Operations and the RNC by 3 way call. She stated the Regional [NAME] President and the RNC did not want her to document the elopement incident in the clinical record. She explained they wanted her to include in her witness statement that staff had eyes on the resident the entire time and that he was alert and oriented. She noted the resident was confused and told them she was not comfortable with this. She added the facility management never wanted staff to put a note in the medical record of any incidents including falls. LPN B provided a screen shot of a text she received from the ADON. The image reflected it was sent by the ADON on 4/8/23, instructing LPN B, Don't document anything in PCC (the facility electronic medical record) regarding [resident #1] until I get it cleared. On 7/18/23 at 1:20 PM, during an interview with the DON and ADON, the ADON stated she had instructed the Weekend Supervisor to obtain witness statements from the staff involved in the elopement incident. She said she spoke with LPN B on her personal phone and took a verbal statement from the Receptionist. The ADON stated she did not communicate with the staff involved by email or texts. The DON and ADON were informed the elopement incident was not documented in the clinical record. The ADON responded and said she should have instructed the staff to make sure it was documented. She added that education was provided during orientation, to ensure incidents are documented in the progress notes. The ADON was shown the screen shot of the text she sent to LPN B that instructed her not to document the elopement in the progress notes. The ADON acknowledged she sent the text to LPN B and instructed LPN B not to make a nurse/incident note in the medical record. The ADON explained she had communicated with the Regional [NAME] President and the RNC at the time and was directed not to document the elopement in the medical record unless it was cleared. Neither the DON or ADON explained how a nurse obtained clearance to document an incident in the clinical record. Review of the facility's immediate actions to remove Immediate Jeopardy were verified by the survey team. 1. The facility conducted an ad hoc QA&A meeting on 7/17/23 which included the facility Administrator, DON, Medical Director via telephone, and additional staff members. No additional recommendations were made at that time. 2. Root Cause Analysis completed 3. Incident reports reviewed from the last 30 days to ensure proper investigations were completed. No further concerns noted. 4. Education on 7/17/23 through 7/18/23 related to the facility elopement policy and timely completion of a comprehensive investigation by the Regional Nurse Consultant, DON and Administrator. Education sign in sheets noted 187 staff received education. 5. Facility Administrator and Director of Nursing educated on 7/18/23 related to position duties- including risk management, facility elopement policy, timely completion of a comprehensive investigation, QAPI/QAA implementation process and reporting of incidents/accidents process by the Regional [NAME] President of Operations and Regional Nurse Consultant. On 7/18/23 the facility's ad hoc QA&A meeting attendance sign in sheet was reviewed which included the Administrative Staff and the Medical Director who attended by phone. The facility provide an Accident Investigation Report which will be used as guide to include steps for interviews, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 4 of 17 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete investigation and reporting. There were forms for staff witness statements and an elopement decision tree. The facility provided sign in sheets for staff education on Abuse, Neglect, Exploitation and Elopement. The sign in sheets reflected all 187 facility staff received education including the Administrator, DON. The Administrator and DON received further education on Risk Management and the completion of a comprehensive investigation. Fifteen staff were interviewed from various disciplines that included Therapy, CNAs, Nursing, Activities and Dietary. The staff spoke about their recent education on elopement, abuse, neglect and exploitation and that they were mandatory reporters. The staff spoke about and indicated understanding and competency with elopement drills. Event ID: Facility ID: 106123 If continuation sheet Page 5 of 17 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0622 Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to allow a resident to remain in the facility, failed to provide rationale as to why the resident's care needs could not be met at the facility and failed to document attempts at meeting those needs before transfer for 1 of 3 residents reviewed for transfers of a total sample of 8 residents, (#1). Findings. Resident #1 was admitted to the facility on [DATE] under Hospice care with diagnoses of Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Major Depressive Disorder, Dementia, Nicotine Dependence and Brief Psychotic Disorder. Review of the Nursing admission assessment dated [DATE] indicated the resident was not an elopement risk with a score of 5. A score of 10 or higher indicated risk for elopement. Resident #1's comprehensive Hospice Care plan was initiated on 7/1/22 with plan for the resident to remain at the facility long term hospice care due to chronic diastolic heart failure. The resident's admission Minimum Data Set (MDS) assessment dated [DATE] noted resident #1 had adequate hearing and clear speech. The resident had the ability to express his ideas and understood others. Despite the resident's ability to express himself and understand others neither the Brief Interview for Mental Status (BIMS) nor the Staff Assessment for Mental Status was conducted. Review of monthly nursing summaries from June 2022 to November 2022, all noted resident #1's cognition was clinically stable and he was not an elopement risk. Review of the nurse's progress note dated 12/6/23 indicated the resident was observed smoking a cigarette in his room. The nurse noted the resident was instructed to extinguish the cigarette and was informed the facility was a non-smoking facility. Resident #1 expressed understanding that he was in a non-smoking facility. The nurse informed the Hospice provider and received new orders for nicotine patches. Three days later on 12/9/22, the Director of Nursing, (DON) documented a progress note that indicated the resident had a change in condition for altered mental status. The note read, .Resident is confused more than normal, states he was looking for another resident's room but is seeking the exits. An elopement care plan was initiated on 12/9/22 with interventions for one to one supervision, psychological services as ordered and directed staff to distract resident from exit seeking with pleasant diversion such as activities, food, conversation, television, book, etc. The medical record progress notes from 11/22/22 to 5/17/23 indicated the resident received regular visits from a Psychiatric Mental Health Nurse Practitioner (PMHNP). On 12/23/223 the resident had a follow up visit with the PHMNP. She noted, .Alert and orientated x3. Affectively blunted. Mood is irritable . The PHMNP noted the resident had paranoid delusions that people were out to harm him. He reported someone is trying to kill him. He saw a person standing in the doorway of his room, holding a gun. He reports there was a helicopter landing on the roof of the building. The PHMNP noted the resident was unstable and added the antipsychotic medication Seroquel, 25 mg twice a day for brief psychotic disorder. There was no indication she had diagnosed resident #1 with dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 6 of 17 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0622 Level of Harm - Actual harm Residents Affected - Few On 7/16/23 at 1:04 PM, LPN A said resident #1 eloped from the facility a few months ago. She remembered she was in room [ROOM NUMBER] when resident #3 came and tried to tell her something. She said resident #3 was difficult to understand so she followed him back to his room. She said he pointed out the window and she saw resident #1 was by outside by himself, walking on the sidewalk. LPN A recalled she immediately alerted LPN B and ran out the fire exit door and headed towards the resident. LPN A said when she caught up to the resident, he was appropriately dressed, wearing shoes and had his rolling walker. Resident #1 told her he was going to Walmart to buy cigarettes. She said resident #1 was tired and short of breath as he did not have his oxygen. He agreed to go with her and she and LPN B wheeled him back into the facility on the seat of his walker. On 7/16/23 at 3:45 resident #1's elopement was discussed with the Director of Nursing, DON. She indicated the resident had eloped from the facility on 4/8/23 between 11 AM and 11:15 AM. She said when the resident returned to the facility, on 4/8/23, he was immediately placed on 1:1 supervision which was subsequently decreased to 15-minute checks on 4/10/23. The 15 minute checks were discontinued on 4/18/23. The DON stated resident #1 made no further elopement attempts while he was on the 1:1 supervision or 15-minute checks. She added resident #1 was transferred to a sister facility that had a locked unit. She did not respond when asked why the resident was discharged from the facility when the resident did not make any further attempts to leave. On 4/10/23 the PHMNP had a follow up visit with resident #1. The resident reported people were chasing him around and he had paranoid thoughts that a man is out to harm him. He cut the interview short and said he was too tired to answer any more questions. The PHNP noted, Dementia persisting with behavioral disturbance. She also noted that the resident was unstable but did not require any medication changes. Ongoing medical stabilization and emotional support would be good enough. The PHMNP did not indicate the resident needed be transferred to another facility with a locked unit. A review of the progress note by the Advance Practice Registered Nurse dated 5/11/23 showed the resident was placed on 1:1 supervision for wandering. There was no documentation the resident was exit seeking. On 5/15/23 the PHMNP saw resident #1 and noted in her progress note the resident was managed effectively in the nursing home and all ADLs (Activities of Daily Living) are provided. Her recommendations included, Patient is getting adequate level of care giver support in the facility. No significant changes are needed. At the same time, she noted, The patient requires to go to higher level of care (locked memory care unit). The PHMNP did not provide any evidence of why the resident would benefit from a locked unit, only that he needed one. Review of the medical record noted a transfer form that indicated the resident was transferred to another nursing home on 5/17/23. The form indicated the facility could not meet resident #1's needs. The explanation on the transfer form read, Resident is confused and wanders building IDT (Interdisciplinary Team) felt [name of another nursing home] would be better for him-brother agreed. Further review of the form revealed that neither the physician nor the resident signed the transfer form. There was no documentation of the which resident needs the facility could not meet or why another nursing home would be better for him when he had been at this facility for almost one year. On 7/18/23 at 1:47 PM, resident #'1's discharge was discussed with the DON and ADON. The DON said resident #1 had increased exit seeking behavior which contradicted her previous statement made on 7/16/23 at 3:45 PM where she noted the resident had made no further attempts to exit. She was informed there was no documentation of exit seeking behavior in the clinical record after the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 7 of 17 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0622 Level of Harm - Actual harm Residents Affected - Few elopement on 4/8/23. She explained the facility had wanted to transfer the resident to a facility with a secure unit, but he did not have a diagnosis of dementia. She indicated she had spoken with the PHMNP and diagnosis of dementia was added to resident #1's diagnoses list. The DON stated they had spoken to resident #1's brother and he agreed with the transfer. When asked if resident #1 had been deemed incapacitated to make medical decisions, the DON said he was his own person and was not deemed incapacitated. On 7/18/23 at 2:14 PM, during a telephone interview, the resident's brother explained the resident told people he was the emergency contact. The brother stated he lived in another state and did not make any decisions for resident #1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 8 of 17 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 - 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 record review, and interviews, the facility failed to prevent a vulnerable, cognitively impaired resident from exiting the facility, unsupervised and failed to provide adequate supervision and secure environment for 1 of 8 sampled residents reviewed for elopement, (#1). On 4/8/23 at 11 AM, resident #1 walked past the facility's receptionist and exited through the facility's front doors. The staff were unaware the resident had exited the facility, unsupervised until another resident observed the resident outside through his bedroom window and alerted staff. Licensed Practical Nurse (LPN) A and LPN B ran outside and caught up with the resident after he had ambulated a total of 600 feet with his rolling walker off the facility grounds and onto a sidewalk, parallel to a moderately traveled road and brought him back. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, drowned in a retention pond or been hit by a car. The facility's failure to provide a secure environment and adequate level of supervision, resulted in Immediate Jeopardy starting on 4/8/23. The Immediate Jeopardy was removed on 7/18/23 and scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Finding: Cross Reference F610, F835 Resident #1 was admitted to the facility on [DATE] under Hospice care with diagnoses of Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Major Depressive Disorder, Dementia, Nicotine Dependence and Brief Psychotic Disorder. Review of the Nursing admission assessment dated [DATE] indicated the resident was not an elopement risk with a score of 5. A score of 10 or higher indicated risk for elopement. The resident's admission Minimum Data Set (MDS) assessment dated [DATE] noted resident #1 had adequate hearing and clear speech. The resident had the ability to express his ideas and understood others. Despite the resident's ability to express himself and understand others neither the Brief Interview for Mental Status (BIMS) nor the Staff Assessment for Mental Status was conducted. Review of monthly Nursing Summaries from June 2022 to November 2022, noted resident #1 was not an elopement risk. Review of the nurse's progress note dated 12/6/23 indicated the resident was observed smoking a cigarette in his room. The nurse noted the resident was instructed to extinguish the cigarette and was informed the facility was a non-smoking facility. The nurse informed the Hospice provider and received new orders for nicotine patches. Three days later on 12/9/22, the Director of Nursing, (DON) documented a progress note that indicated the resident had a change in condition for altered mental status. The note read, .Resident is confused more than normal, states he was looking for another resident's room but is seeking the exits. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 9 of 17 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 - Immediate jeopardy to resident health or safety Residents Affected - Few An elopement care plan was initiated on 12/9/22 with interventions for one to one supervision, psychological services as ordered and directed staff to distract resident from exit seeking with pleasant diversion such as activities, food, conversation, television, book, etc. A nursing progress note dated 12/10/22 indicated the County Sheriff was at the facility for a 911 telephone call made by the resident claiming he was abducted. The resident told a Certified Nursing Assistant, (CNA), he had called his girlfriend. He later clarified his girlfriend was abducted, and he wanted 911 to find her. On 12/19/22, one to one supervision was removed from the care plan and replaced with frequent visual observations every 15-minutes which were later discontinued on 12/21/22. There were no additional interventions to monitor the resident's exit seeking behaviors until he eloped from the facility on 4/8/23. On 12/20/22, resident #1 was seen by a Psychiatric Mental Health Nurse Practitioner, who noted the resident was taking antidepressant medication, Trazadone, 100 mg at bedtime, antianxiety medication, Lorazepam, 1 mg every 8 hours for anxiety and another antidepressant, Duloxetine 60 mg daily for depression and anxiety related to depression. The Practitioner asked the resident if he had any plans to elope from the facility and the resident responded, I tried to leave once but they caught up with me. I am not, can I do that again. I just want to wait and see what happens. The resident was seen again on 12/23/22 for reports of being unstable, requiring psychiatric assessment. The Practitioner reported the resident had paranoid delusions, he reports that people want to harm him and/or trying to kill him. He reported seeing a person standing in the doorway of his room, holding a gun and seeing a helicopter land on the roof of the building. Review of the monthly Nursing Summary dated 12/30/22 noted the resident 's cognition as clinically stable and noted he was not an elopement risk despite him voicing exit seeking statements and paranoid delusions. On 1/14/23, a nursing progress note documented the resident telephoned 911 and a Law Enforcement Officer came to the facility and spoke to the resident. The resident told the Officer he wanted to get out of here and go home to the place by the Walmart. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident's BIMS score was 10 out of 15 that indicated his cognition was moderately impaired. The assessment noted he did not exhibit any wandering behaviors and he required limited assistance of 1 staff person for transfers, walking and locomotion. On 7/16/23 at 1:50 PM, resident #3 explained a few months ago, he was in his room and when he looked out his window, he saw resident #1 outside, walking away from the facility. He said he had seen resident #1 in the facility and thought, what in the world is he (resident #1) doing out there? Resident #3 said. He said he quickly found a nurse and reported it to her. On 7/16/23 at 1:04 PM, LPN A said resident #1 eloped from the facility a few months ago. She remembered she was in room [ROOM NUMBER] when resident #3 came and tried to tell her something. She said resident #3 was difficult to understand so she followed him back to his room. She said he pointed out the window and she saw resident #1 was by outside by himself, walking on the sidewalk. LPN A recalled she immediately alerted LPN B and ran out the fire exit door and headed towards the resident. LPN A said when she caught up to the resident, he was appropriately dressed, wearing shoes and had his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 10 of 17 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 - Immediate jeopardy to resident health or safety Residents Affected - Few rolling walker. Resident #1 told her he was going to Walmart to buy cigarettes. She said resident #1 was tired and short of breath as he did not have his oxygen. He agreed to go with her and she and LPN B wheeled him back into the facility on the seat of his walker. On 7/16/23 at 1:21 PM, resident #1's exit route from the facility was retraced with LPN A. The resident would have walked past the receptionist's desk and walked through the inner glass sliding doors. The inner sliding doors were controlled by the receptionist, who was responsible for allowing visitors in and out of the facility. The resident then exited by the outer doors which opened and closed automatically. The resident would have stayed to the right of the facility and followed the sidewalk adjacent to the curved driveway that ran under the portico. The resident walked on the sidewalk that ran parallel to both the parking lot and the facility and then turned left, through the parking lot to reach the sidewalk that ran parallel to the road, a total of 600 feet. LPN A pointed to the spot she found the resident and noted he faced the ponds across the street, and looked confused. There were two retention ponds noted across the street full of water and to the right, was a hospital's emergency entrance. On 7/16/23 at 12:55 PM, the facility's receptionist recalled a resident had left the building and stood by the post of the facility's entrance. She said she did not see him until he was out by the door as there was a stretcher going through the door at the same time. She indicated the nurse went outside to bring the resident back. On 7/16/23 at 1:33 PM, the receptionist clarified her earlier interview and said she saw resident #1 outside the sliding glass door near a pillar. She explained she did not go outside to bring the resident back but it took her a few minutes to ask the Concierge to go get him because she could not leave the reception desk. She noted, I guess I prioritized the reception desk rather than the resident. She indicated the Concierge came back and told her LPN A had seen resident #1 outside and went to get him. On 7/17/23 at 11:33 AM, along with the Director of Nursing, (DON) the receptionist again clarified her previous statements. She said she saw a resident in a red shirt with a rolling walker but did not realize it was resident #1. She said she was very busy and there were many visitors near the reception desk. She explained she was responsible for controlling the front door, allowing people in and out of the building. She reported she did not see the resident outside near the pillar. As long as he was ok, I don't know where they found him. The DON stated it would be expected the receptionist go outside to investigate and/or retrieve the resident. On 7/16/23 at 3:45 PM, the DON spoke about the incident and the facility's investigation. She said at the time the receptionist observed resident #1, a larger male resident was being transported on a stretcher, out of the facility. She indicated resident #1 walked beside the stretcher and the receptionist did not see him exit the doors. She said at the same time, the Concierge was going to her car to retrieve something.The resident was walking with his walker as the Concierge exited the facility. She explained the Concierge tried to get the resident #1's attention but the resident did not answer. The DON did not explain why the Concierge did not intervene as the resident walked out of the facility. When the Concierge walked back towards the facility entrance, she saw resident #1 on the sidewalk near the stop sign by the first handicap parking spot. She stated this was at the same time LPN A, came outside with another nurse and escorted the resident back into the facility. The DON noted the incident occurred on Saturday, 4/8/23, 1 day before Easter Sunday, between 11 AM and 11:15 AM. She said she was out of town, but the Assistant Director of Nursing made sure all the witness statement were taken and the facility created a timeline based on the statements. When informed that resident #1's elopement was not documented in his medical record, the DON explained they did not consider it as an incident that needed to be reported, so it was not recorded on either the Incident Log or Reportable Log. The DON added, we felt like we had eyes him the entire time. She acknowledged there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 11 of 17 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 - Immediate jeopardy to resident health or safety Residents Affected - Few were hazards such as the retention ponds and street traffic, but noted the resident was near the facility's parking lot. She indicated she was responsible for the investigation, but the ADON handled this investigation. The DON said that a re-enactment of the elopement incident was not done. On 7/17/23 at 6:47 PM, LPN B stated she was familiar with resident #1 and frequently saw him in the hallways. She said she tried to engage him in conversation but his cognition varied from day to day. Some days you could talk to him and have a conversation, on other days he would be confused, looking for his parents or children. She remembered on Saturday of Easter Weekend, 4/8/23, resident #3 alerted LPN A to look out his bedroom window. She said LPN A saw resident #1 outside the facility on the sidewalk, near the road. LPN B explained she saw LPN A running toward the nursing station, saying something like he was outside. LPN B stated she followed LPN A and both nurses exited the emergency fire exit door at the end of the hallway. She noted resident #1 was past the parking lot, and they caught up with him on the sidewalk. She reported he was across from the hospital's emergency entrance. She indicated he was tired, and not used to walking that far in the heat. LPN B recalled it was hot because she was still sweating when she got back inside. She said they had the resident sit on the seat of the rolling walker and they wheeled him back to the front entrance of the facility. LPN B recalled the Concierge was in the lobby area when they brought the resident back. She remembered the receptionist and the Concierge suggested resident #1 may have exited when the transport company took another resident out of the facility. She explained she assessed the resident, found no injures and his vital signs were in range. He was put back to bed because he was tired, and he slept. She said resident #1 mentioned he was going to a gas station and joked that he had not had a cigarette in a long time and that he really needed one. Review of the facility's immediate actions included the following that were verified by the survey team. 1. Review of Resident #1's clinical record revealed no further incidents up until discharge from the facility on 5/17/23. 2. On 7/17/23 current facility residents had elopement risk screens completed. No residents were newly identified to be at risk for elopement. 3. Elopement Drills conducted on 7/17/23 and 7/18/23 with an established schedule to continue weekly drills until substantial compliance was determined by the QA committee. 4. Education on 7/17/23 through 7/18/23 related to the facility's elopement policy. Education provided by Regional Nurse Consultant, DON and Administrator. The staff educated comprised of 187 total facility employees 5. Education on 7/18/23 related to allowing visitors entrance and exit by facility staff members only via manual access button located behind the receptionist's desk. Three of 3 front desk staff received the education. On 7/18/18, the staff sign in sheets for elopement, abuse, neglect, exploitation and the required immediate reporting of incidents training revealed all 187 facility employees had received the education. The front desk staff education was reviewed that included ensuring visitors entry/exit to the facilty. The facility provided audits of elopement drills that had been conducted. Fifteen staff interviews were conducted from 7/17/23 to 7/18/23 that included CNAs, Dietary, Activity, Nursing and Therapy staff. The staff spoke about the recent education on elopement, abuse, neglect and exportation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 12 of 17 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 - Immediate jeopardy to resident health or safety The staff demonstrated their understanding of the education and their role in the prevention of elopement. The staff noted they had participated in elopement drills. The facility provide copies of the quiz/test that demonstrated the staff's understanding of the education. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 13 of 17 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to effectively provide supervision and secure environment to prevent elopement and failed to conduct thorough investigation to prevent further elopement for 1 of 8 sampled residents, (#1). Residents Affected - Few On 4/8/23 at 11 AM, resident #1 walked past the facility's receptionist and exited through the facility's front doors. The staff were unaware the resident had exited the facility, unsupervised until another resident observed the resident outside through his bedroom window and alerted staff. Licensed Practical Nurse (LPN) A and LPN B ran outside and caught up with the resident after he had ambulated a total of 600 feet with his rolling walker off the facility grounds and onto a sidewalk, parallel to a moderately traveled road and brought him back. While resident #1 was out of the facility unsupervised, there was likelihood he could have fallen, drowned in a retention pond or been hit by a car. The facility's Administration failed to ensure resident #1 received adequate supervision to prevent elopement and failed to collect factual evidence to ensure a complete and thorough elopement investigation was performed. These failures impeded the Administration's implementation of safeguards to prevent further elopements and resulted in Immediate Jeopardy that started on 4/8/23. The Immediate Jeopardy was removed on 7/18/23, after verification of the facility's Immediate Jeopardy removal plan. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy. Findings: Cross Reference F610, F689 Resident #1 was admitted to the facility on [DATE] under Hospice care with diagnoses of Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Major Depressive Disorder, Dementia, Nicotine Dependence and Brief Psychotic Disorder. Review of the Nursing admission assessment dated [DATE] indicated the resident was not an elopement risk with a score of 5. A score of 10 or higher indicated risk for elopement. The resident's admission Minimum Data Set (MDS) assessment dated [DATE] noted resident #1 had adequate hearing and clear speech. The resident had the ability to express his ideas and understood others. Despite the resident's ability to express himself and understand others neither the Brief Interview for Mental Status (BIMS) nor the Staff Assessment for Mental Status was conducted. Review of a progress note dated 12/9/22 by the Director of Nursing, (DON) indicated the resident had a change in condition for altered mental status. The note read, .Resident is confused more than normal, states he was looking for another resident's room but is seeking the exits. An elopement care plan was initiated on 12/9/22 with interventions for one to one supervision, psychological services as ordered and directed staff to distract resident from exit seeking with pleasant diversion such as activities, food, conversation, television, and books. On 12/19/22, one to one supervision was removed from the care plan and replaced with frequent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 14 of 17 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few visual observations every 15-minutes which were later discontinued on 12/21/22. There were no additional interventions to monitor the resident's exit seeking behaviors. On 7/16/23 at 1:50 PM, resident #3 explained a few months ago, he was in his room and when he looked out his window, he saw resident #1 outside, walking away from the facility. He said he had seen resident #1 in the facility and thought, what in the world is he (resident #1) doing out there? Resident #3 said. He said he quickly found a nurse and reported it to her. On 7/16/23 at 1:04 PM, LPN A said resident #1 eloped from the facility a few months ago. She remembered she was in room [ROOM NUMBER] when resident #3 came and tried to tell her something. She said resident #3 was difficult to understand so she followed him back to his room. She said he pointed out the window and she saw resident #1 was by outside by himself, walking on the sidewalk. LPN A recalled she immediately alerted LPN B and ran out the fire exit door and headed towards the resident. LPN A said when she caught up to the resident, he was appropriately dressed, wearing shoes and had his rolling walker. Resident #1 told her he was going to Walmart to buy cigarettes. She said resident #1 was tired and short of breath as he did not have his oxygen. He agreed to go with her and she and LPN B wheeled him back into the facility on the seat of his walker. On 7/16/23 at 1:33 PM, the facility's receptionist recalled a resident had left the building. She said she did not see him as there was a stretcher going through the door at the same time. She explained she did not go outside to bring the resident back because she could not leave the reception desk. She noted, I guess I prioritized the reception desk rather than the resident. She said she was very busy and there were many visitors near the reception desk. She explained she was responsible for controlling the front door, allowing people in and out of the building. As long as he was ok, I don't know where they found him. On 7/16/23 at 3:45 PM, the DON spoke about the incident and the facility's investigation. She said at the time the receptionist observed resident #1, a larger male resident was being transported on a stretcher, out of the facility. She indicated resident #1 walked beside the stretcher and the receptionist did not see him exit the doors. She said at the same time, the Concierge was going to her car to retrieve something.The resident was walking with his walker as the Concierge exited the facility. She explained the Concierge tried to get resident #1's attention but the resident did not answer. When the Concierge was walking back towards the facility entrance, she saw resident #1 on the sidewalk near the stop sign and the first handicap parking spot. The DON did not explain why the Concierge did not intervene as the resident walked out of the facility. The DON noted the incident occurred on Saturday, 4/8/23, of the Easter weekend between 11 AM and 11:15 AM. She said she was out of town, but the Assistant Director of Nursing made sure all the witness statement were taken and the facility created a timeline based on the statements. When informed that resident #1's elopement was not documented in his clinical record, the DON explained they did not consider it as an incident that needed to be reported, so it was not recorded on either the Incident Log or Reportable Log. The DON added, we felt like we had eyes on him the entire time. The DON did not provide an answer when asked how staff had eyes on the resident at all times when he was outside and both the Concierge and the Receptionist were inside. She acknowledged the resident would have encountered hazards such as retention ponds and street traffic while he was outside but he was only in the parking lot. She indicated a re-enactment of the elopement was not done. On 7/17/23 at 1:14 PM, during an interview with the DON, the Assistant DON, (ADON) joined the meeting and stated they did not go to resident #3's room during their investigation to see out the window. The ADON said they did not interview resident #3 but added we probably should have. Contrary to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 15 of 17 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few LPN A's statement that the resident was located at the end of the sidewalk close to a wooded area, the ADON stated from the information they gathered, resident #1 was found by the first handicap parking spot. The DON and ADON verified the witness statements did not reflect a timeline with locations and sequence of events. On 7/17/23 at 1:25 PM, the DON and ADON were accompanied to resident #3's room. When they looked out his window, they verified they could not see the stop sign or the first handicap parking spot. Shortly thereafter they were accompanied outside to the front of the facility near the Stop sign and the first handicap parking spot. They validated they could not see resident #3's bedroom windows and it would not have been possible for LPN A to have seen resident #1 at the stop sign near the first handicap parking spot to have eyes on him at all times. They were informed the resident was found off facility property. The DON stated she was not aware. The DON and ADON were shown the spot where LPN A and LPN B found the resident, near the end of the paved sidewalk. The DON acknowledge the hazards such as the retention ponds across the street, the wooded area, and the vehicular traffic. The DON confirmed the investigation was not thorough or effective. On 7/17/23 at 2:38 PM, the Regional Nurse Consultant, (RNC) stated she was told resident #1 was in the line of sight of staff at all times after he exited the facility. She indicated she reviewed the witness statement yesterday. She said the facility policy did not define elopement but added that if a resident was somewhere he or she should not be, it could be an unsafe situation. She was informed the facility had not submitted either an Immediate or 5 Day report to the Agency for Health Care Administration. The RNC indicated it was up to the Administrator and DON's discretion to submit an Immediate and 5 Day report. She conveyed, In light of new findings we have to continue the investigation. On 7/17/23 at 6:47 PM, during a telephone interview, LPN B recalled on Saturday, of the Easter Weekend, 4/8/23, resident #1 eloped from the facility prior to 12 PM. She remembered resident #3 informed LPN A that resident #1 was outside of the facility when he looked out his window. LPN B said she followed LPN A and they both exited the facility through the emergency fire exit door. She stated they caught up with the resident and he was near the end of the sidewalk, close to a wooded area. She noted the resident was tired because he was not used to walking that far in the heat. She recalled the Concierge was in the lobby when they returned with the resident, not outside. LPN B remembered the Concierge and the Receptionist suggested the resident may have exited along side the transport company that was taking another resident out. LPN B said she wrote a witness statement and spoke to the DON or ADON on the phone 2 or 3 times. She also spoke with the facility Administrator who was now the Regional [NAME] President of Operations and the RNC by 3 way call. She stated the Regional [NAME] President and the RNC did not want her to document the elopement incident in the clinical record. She explained they wanted her to include in her witness statement that staff had eyes on the resident the entire time and that he was alert and oriented. She noted the resident was confused and told them she was not comfortable with this. She added the facility management never wanted staff to put a note in the medical record of any incidents including falls. LPN B provided a screen shot of a text she received from the ADON. The image reflected it was sent by the ADON on 4/8/23, instructing LPN B, Don't document anything in PCC (the facility electronic medical record) regarding [resident #1] until I get it cleared. On 7/18/23 at 1:20 PM, during an interview with the DON and ADON, the ADON stated she had instructed the Weekend Supervisor to obtain witness statements from the staff involved in the elopement incident. She said she spoke with LPN B on her personal phone and took a verbal statement from the Receptionist. The ADON stated she did not communicate with the staff involved by email or texts. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 16 of 17 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 106123 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Viera Del Mar Health and Rehabilitation Center 2355 Vidina Drive Viera, FL 32940 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 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and ADON were informed the elopement incident was not documented in the clinical record. The ADON responded and said she should have instructed the staff to make sure it was documented. She added that was education provided during orientation, to ensure incidents are documented in the progress notes. The ADON was shown the screen shot of the text she sent to LPN B that instructed her not to document the elopement in the progress notes. The ADON acknowledged she sent the text to LPN B and instructed LPN B not to make a nurse/incident note in the medical record. The ADON explained she had communicated with the Regional [NAME] President and the RNC at the time and was directed not to document the elopement in the medical record unless it was cleared. Neither the DON or ADON explained how a nurse obtained clearance to document an incident in the clinical record. Review of the facility's Immediate Jeopardy removal plan included the following that was verified by the survey team. 1. The facility conducted an ad hoc Quality Assurance Performance Improvement (QAPI) meeting on 7/17/23 which included the facility Administrator, DON, Medical Director via telephone, and additional staff members. No additional recommendations were made at that time. 2. Root Cause Analysis completed 3. Elopement Drills conducted on 7/17/23 and 7/18/23 with an established schedule to continue weekly until substantial compliance is determined by the QA committee. 4. Education on 7/17/23 through 7/18/23 related to the facility elopement policy and timely completion of a comprehensive investigation. Education provided by the Regional Nurse Consultant, DON and Administrator. Those educated comprised 187 total facility employees. 5. Facility Administrator and Director of Nursing educated on 7/18/23 related to position duties- including risk management, facility elopement policy, timely completion of a comprehensive investigation, QAPI/QAA implementation process and reporting of incidents/accidents process by the Regional [NAME] President of Operations and Regional Nurse Consultant. On 7/18/23 15 staff, including Certified Nursing Assistants (CNA)s, Therapy staff, Nurses, Dietary and Activies staff, were interviewed. They indicated they received recent education on elopement and incident reporting to their direct supervisors and/or the facility's Administrative staff. The staff discussed their involvement and participation in elopement drills. The staff spoke about their role in providing supervision to prevent elopement. Education sign in sheets were reviewed and it was determined the Administrator, DON, ADON, RNC and [NAME] President of Operations attended in-service on Abuse, Neglect Adverse Reporting, Elopement, Wandering and Supervision. The facility provided their Elopement decision tree, routine resident checks, potential adverse report sheet and resident interview forms with prompts for Abuse, Neglect and Exploitation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106123 If continuation sheet Page 17 of 17