Inspection·September 5, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few one nurse assigned to the unit for the shift. She stated while she monitored the resident in the common area, resident #1 fell asleep in a chair nearby and she requested he move closer, but he refused. She explained the other CNA on the unit asked her for help, so she asked the nurse to keep an eye on the residents including resident #1 when she left the area. CNA C reported when the nurse agreed she went to help the other CNA. She recalled that later as she was coming out of a resident's room with the other CNA, they were approached by another nurse from Administration who told them resident #1 had gotten outside of the facility. She said she was not aware he was missing until that time. CNA C explained the exit doors were equipped with alarms, but she did not recall hearing any alarms go off during the shift. On 9/04/25 at 6:07 AM, CNA D stated she worked on the secured unit the night resident #1 got outside the building. She confirmed there were two CNAs and one nurse assigned to work on the unit that night. CNA D explained she was not resident #1's assigned CNA and did not know him very well. She recalled seeing him wandering in the hallways, going to the doors leading to other units and the fire exit door during the shift. CNA D remembered she asked CNA C to assist her with other residents at approximately 4:30 AM. She explained she thought the nurse was supposed to be watching the residents in the common area. CNA C stated she later learned resident #1 had left the facility while she and CNA C were getting other residents out of bed. She said she was unaware resident #1 was missing until a staff member informed them. CNA D recalled she never heard an alarm sound. In a phone interview on 9/02/25 at 3:56 PM, License Practical Nurse (LPN) B recalled working 8/07/25. She explained she was not very familiar with the residents as she was an agency nurse, and it was her second day working at the facility. She stated she monitored the residents in the common area while the two CNAs worked together to get residents out of bed. LPN B reported the time came for her to start morning medication administration, so she left to go to the carts. She explained she was the only nurse on the unit for that shift and had to use two medication carts to pass medications. LPN B stated she was aware she had to keep an eye on the residents but had not been told to watch resident #1 specifically nor that he was exit seeking. She stated she never heard an alarm go off and was not aware resident #1 had left the facility until he was returned by another staff member around 6:30 AM. She recalled someone from Administration asked her if she saw resident #1 when she went to her medication cart. LPN B wondered aloud how would she have seen resident #1 since she had to do medication pass for the entire unit. LPN B stated when the wander/elopement alarm was tested that morning, it malfunctioned. She recalled the Unit Manager on the secured unit tested residents #1's electronic wander alert bracelet and it did not work. LPN B was unaware of whether resident #1's electronic wander bracelet was replaced when it was found not to be working. On 9/02/25 at 3:10 PM, LPN A stated she came to work around 6:00 AM on the morning of 8/07/25 and saw someone in the front vestibule and identified him as resident #1. LPN A stated she approached resident #1 and got him to come inside to her office in the front lobby. She recalled placing several phone calls including one to the Administrator alerting her that resident #1 had been outside the facility. She explained resident #1 remained in her office with her for about 45 minutes before she brought him back to the secured unit. LPN A stated the staff on the unit were totally unaware resident #1 was missing until she returned with him to the unit at 6:45 AM. She reminded the staff resident #1 had to be supervised and returned to her office. LPN A stated she was personally upset resident #1 had left the facility and the unit staff were unaware for over two hours. She explained he could have been hit by a car or bitten by a wild animal while outside. She reported resident #1 could also have boarded a bus that left the facility around 6:00 AM and took patients to the Veterans Administration (VA) clinic across town in another city. On 9/04/25 at 12:58 PM, LPN F confirmed she assisted in evaluating resident #1 when he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106151 If continuation sheet Page 2 of 9 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 106151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alwyn C Cashe State Veterans Nursing Home 5255 Raymond St Orlando, FL 32803 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few returned to the unit. She recalled she clocked in at 6:45 AM that morning and entered the secured unit with LPN A who had resident #1 with her. She was informed at that time that he had gotten outside the facility. LPN F stated resident #1 did wander throughout the unit but did not recall him to be exit seeking. LPN F conveyed that he did go to doors, but she did not believe he was looking to leave. She explained he was looking for his room or the bathroom. On 9/03/25 at 1:10 PM, the Unit Manager for the secured unit reported she came to work around 7:40 AM the morning of 8/07/25. She explained she was made aware at that time that resident #1 exited the facility earlier that morning. She stated she did a body check of the resident, and he had no injuries. She stated she checked the electronic wander alert bracelet on his ankle which was functional. The Unit Manager reviewed the progress note she wrote on 8/07/25 which indicated she placed an electronic wander alert bracelet on resident #1 and he was placed on one-to-one supervision. She acknowledged she applied a new electronic wander alert bracelet but was unable to explain why she had done so if the previous bracelet was functional. The Unit Manager elaborated that the electronic wander alert system at the emergency exit door was not working so now an employee was stationed there to monitor the door until it was repaired. On 9/03/25 at 10:33 AM, the Utilities and Maintenance Superintendent stated he was notified on 8/07/25 around 6:00 AM, that resident #1 eloped from the facility. He recalled he checked with LPN A and then went to check the doors on the secured unit. He reported that the electronic wander alert system worked when he checked it, but the system did not reset after resident #1 had pushed on the door the first time, earlier in the evening. The Utilities and Maintenance Superintendent stated there was also a red screamer alarm on the door that would alarm when its contacts were broken by opening the door, but the alarm shut itself off once the door closed and did not reset. The Utilities and Maintenance Superintendent recalled contacting a vendor to have the door and alarms evaluated. He stated someone was stationed at the fire exit door until the facility installed an upgraded electronic wander alert system to replace the one that had previously been there. In a follow up phone interview with the Utilities and Maintenance Superintendent on 9/04/25 at 11:20 AM, he stated that maintenance personnel inspected all the exit doors including the screamer alarms, electronic wander alert sensors, door code panels and fire exit door alarms. He explained they were currently being checked daily, and the logs were kept in a book which the Maintenance Mechanic could provide. The Utilities and Maintenance Superintendent reported that no door had malfunctioned previously. He did recall the electronic wander alert sensor at the fire exit door on the secured unit had been alarming in error one day prior to the elopement, as if a resident was nearby but was not. He stated the facility placed a call out for service to the door. The Utilities and Maintenance Superintendent confirmed the sensor had malfunctioned prior to resident #1 getting outside of the facility while they were still waiting for the repair appointment. On 9/04/25 at 11:45 AM, the Maintenance Mechanic returned with door checks audits. Review of the audit sheets revealed on 8/02/25 the wander alert system at the [NAME] fire exit door was alarming. A vendor was called to evaluate, and an emergency purchase order was submitted. On 8/07/25 and 8/08/25, audits showed that the sensor was out of order on the [NAME] exit door on the secured unit. On 9/05/25 at 12:38 PM, the Utilities and Maintenance Superintendent stated it had taken a little longer for the repair of the alarm at the [NAME] fire exit door because the sensor was out of stock. He explained now an employee was stationed at the door after resident #1 eloped until the wander alert was repaired. The Utilities and Maintenance Superintendent did not explain why the facility waited until after a resident eloped out the door to station an employee there. In a meeting with the Risk Manager and Deputy Director Risk Manager on 9/03/25 at 2:06 PM, the Risk Manager stated the Quality Assurance and Performance Improvement (QAPI) Committee met and reviewed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106151 If continuation sheet Page 3 of 9 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 106151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alwyn C Cashe State Veterans Nursing Home 5255 Raymond St Orlando, FL 32803 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few event and investigation in an ad Hoc meeting on 8/07/25. She stated the committee noted several areas of opportunity for improvement and began education on several topics which included functionality of doors, reporting and immediate initiation of door monitoring process if doors did not function appropriately, initiation of repairs, abuse and neglect, elopement, responding to alarms and appropriate supervision. The Risk Manager stated the QAPI Committee conducted a root cause analysis and determined the facility staff failed to provide appropriate supervision and failed to secure the fire exit door after resident #1 attempted to exit earlier during the shift. She elaborated that the setting of the alarms and door function also played a role in the elopement. The Risk Manager verified alarms were meant to assist in preventing elopement but did not substitute for staff supervision. She acknowledged staff should have been more aware of resident #1's movement through the facility and should have ensured the fire door exit was secured and re-engaged. She stated the facility investigation verified the allegation of neglect due to inadequate supervision. On 9/04/25 at 11:30 AM, the Director of Nursing (DON) stated the expectation was for staff to conduct rounds on residents every couple of hours and as needed. The DON reviewed resident #1's care plan and stated the documentation for rounding was kept in a notebook at the nurse's station on the unit. On 9/04/25 at 12:27 PM, the DON returned and confirmed she had located the rounding notebook. She acknowledged there was no documentation by staff to show rounds were conducted every hour on resident #1 as instructed in his care plan. Review of the facility's policy and procedure for Abuse, Neglect and Exploitation/Misappropriation of Resident property revised 3/01/24 revealed neglect meant a failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. The document added that neglect could also be defined as carelessness which causes or could reasonably cause a serious physical or psychological injury or a substantial risk of death to a resident. The document identified one of the potential signs of physical neglect as leaving someone unattended who needed supervision. Review of corrective measures implemented by the facility revealed the following, which were verified by the survey team at the time of the survey: *On 8/07/25 at 6:45 AM, resident #1 returned to the secured unit with facility staff. He was assessed on return to the facility and had no injuries. A head count was conducted to verify the safety of all residents. Resident #1 was placed on one-to-one supervision. *Patient Health Questionnaire (PHQ) evaluations were completed by the Licensed Clinical Social Worker for resident #1 for three consecutive days- 8/07/25, 8/08/25 and 8/09/25. Resident #1 did not exhibit any signs or symptoms of mental anguish or distress. *On 8/07/25, employees were assigned to sit near the exit door on every shift until all the alarm settings and door functions were completed on 8/19/25. The person designated to monitor the door had full view of the other two doors located on the secured unit. *On 8/07/25 hourly unit monitoring was initiated and facility management increased their presence on the floor. *On 8/07/25, the facility conducted an elopement drill and continued daily drills from 8/07/25 to 8/13/25 on every shift. Elopement Drills were completed weekly on each shift starting on 8/14/25 to present. *On 8/08/25, the maintenance team was educated by the Administrator to ensure doors functioned appropriately and if identified as dysfunctional to immediately initiate door monitoring process, notify the Nursing Home Administrator (NHA), DON and Operations Review Specialist and begin repairs as appropriate *On 8/07/25, staff education began which included abuse, neglect, responding to alarms, resident monitoring/supervision and accountability:8/07/25 - Tota1: 48 employees- 36%8/08/25 - Tota1: 58 employees- 43%8/09/25 - Total: 71 employees- 53%8/10/25 - Total: 78 employees- 58%8/11/25 - Total: 91 employees- 67%8/13/25 - Total: 108 employees-80%8/14/25 - Tota1: 128 employees-95% Remaining staff will be educated upon return from leave and are scheduled to work. *All audits for corrective measures were reviewed in the Ad HOC QAPI meetings held (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106151 If continuation sheet Page 4 of 9 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 106151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alwyn C Cashe State Veterans Nursing Home 5255 Raymond St Orlando, FL 32803 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete on 8/07/25, 8/08/25, 8/12/25, 8/13/25, 8/15/25, 8/22/25, and 8/29/25. *All audits for corrective measures were reviewed in monthly QAPI meeting held on 8/20/25 and will be reviewed monthly for a minimum of three months or more until substantial compliance is achieved *Interviews were conducted on 9/05/25 with 14 staff members representing all shifts (6 CNAs, 1 Registered Nurse, 3 LPNs, 2 environmental services and 2 dietary staff). Staff interviews revealed they were knowledgeable of the elopement policy and procedures, appropriate response to alarms and supervision of all residents to include those at risk for elopement, abuse and neglect. The resident sample was expanded during the survey to include four additional residents who were at risk for elopement. Observations, interviews, and record reviews conducted revealed no concerns related to elopement risk evaluations, care plans and physician orders for residents #8 through #11. Based on the facility's corrective actions, the survey team determined the facility was in substantial compliance on 8/20/25. Event ID: Facility ID: 106151 If continuation sheet Page 5 of 9 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 106151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alwyn C Cashe State Veterans Nursing Home 5255 Raymond St Orlando, FL 32803 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 observation, interview, and record review, the facility failed to provide adequate supervision to maintain a secure environment to ensure vulnerable residents did not exit the facility without supervision for 1 of 7 residents reviewed for elopement, of a total sample of 11 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was outside the facility unsupervised, there was reasonable likelihood he could have fallen, become lost, been accosted/harmed by a stranger or been hit by a car. On 8/07/25 at approximately 4:32 AM, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. The facility was unaware of resident #1's whereabouts until staff located him in the front entrance hall outside the facility at approximately 6:00 AM. The facility failed to ensure resident #1 was adequately supervised to ensure vulnerable residents did not exit the facility without staff knowledge. Review of information provided by the facility revealed a total of 23 residents were identified as at risk for elopement on the first day of survey. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy starting on 8/07/25 and was removed on 8/11/25. The scope and severity of the deficiency was decreased to a D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The noncompliance at F689 was determined to be past noncompliance as of 8/20/25.Findings: Cross reference F600. Resident #1, an [AGE] year-old male, was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease, muscle weakness, difficulty in walking, unspecified dementia, cognitive communication deficit, brief psychotic disorder, major depressive disorder and need for assistance with personal care. Review of the Minimum Data Set quarterly assessment with assessment reference date of 6/19/25 revealed resident #1 had a Brief Interview for Mental Status score of 4/15 which indicated he had severe cognitive impairment. The assessment indicated resident #1 exhibited wandering behavior and walked independently up to 150 feet. A care plan initiated 4/21/25 and revised 8/07/25 indicated resident #1 exhibited wandering behavior and moved with no rational purpose, seemingly oblivious to needs or safety. The care plan detailed resident #1 was identified as an elopement risk. Interventions included placement of an electronic wander alert bracelet on resident #1 and hourly rounding. Review of physician orders revealed an active order dated 10/23/24 for an electronic wander alert bracelet to be applied to resident #1's left lower leg. In a phone interview on 9/02/25 at 2:25 PM, Certified Nursing Assistant (CNA) C verified resident #1 was on her assignment on 8/07/25. She recalled providing him with a snack at some point during the night while he sat at a table across from where she was monitoring residents in the dayroom. CNA C explained there were two CNAs on the unit that night. The other CNA asked her for help, so she asked the nurse to keep an eye on the residents in the dayroom. She conveyed the nurse agreed to help watch the residents so she went to help the other CNA. CNA C recalled as she was coming out of a resident's room with the CNA D, they were approached by another nurse who worked in Administration who told them resident #1 had gotten outside of the facility. She said she was not aware he was missing until that time. CNA C explained the exit doors were equipped with alarms, but she did not hear any alarms go off during the shift. On 9/04/25 at 6:07 AM, CNA D stated she worked on the secured unit the night resident #1 got outside the building. She confirmed there were only two CNAs and one nurse working that night. CNA D explained she was not his assigned CNA. She did recall seeing resident #1 wandering in the hallways and that he had gone to the fire exit door during the night. She had last seen him in the common area at some point during the early hours of the morning but could not recall exactly what time. CNA D did recall she asked CNA C (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106151 If continuation sheet Page 6 of 9 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 106151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alwyn C Cashe State Veterans Nursing Home 5255 Raymond St Orlando, FL 32803 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 to assist her with getting some of the residents up around 4:30 AM. She stated the nurse was supposed to watch the residents. CNA C stated she later learned resident #1 had left the facility while her and CNA D assisted other residents out of bed. She was unaware he was missing until a staff member informed them. She stated she never heard an alarm sound. In a phone interview on 9/02/25 at 3:56 PM, License Practical Nurse (LPN) B recalled working on 8/07/25. She stated she monitored the residents in the common area while the two CNAs worked together but had to start her medication administration, so she left. LPN B explained she was the only nurse on the unit for that shift and had to use two different medication carts to pass medications. She stated she never heard any alarms go off and was not aware resident #1 had left the facility until he was returned by another staff member which she believed was around 6:30 AM. On 9/02/25 at 3:10 PM, LPN A stated she normally worked in the Admissions department and usually worked 8:00 AM to 4:30 PM. She explained she came in early and would stay late as needed due to admissions. LPN A recalled she came to work early on 8/07/25. She reported she arrived at approximately 6:00 AM and saw someone in the front vestibule. She realized the person was resident #1. LPN A stated she approached resident #1 and got him to come inside with her to her office in the front lobby. She recalled placing several phone calls including one to the Administrator alerting her of resident #1 being found outside the facility. She explained resident #1 remained in her office with her for about 45 minutes until she brought him back to the secured unit. LPN A stated the staff on the unit were not aware resident #1 was missing until she returned him to the unit at 6:45 AM. She reminded the staff he should be supervised and returned to her office. She recalled it was dark outside when she arrived at work that morning. LPN A stated she was upset resident #1 had gotten outside of the facility. She explained he could have been hit by a car or bitten by a wild animal while outside. She reported resident #1 could also have boarded the bus that departed the facility around 6:00 AM and took patients to another Veterans Administration clinic in another city. On 9/04/25 at 12:58 PM, LPN F confirmed she assisted in evaluating resident #1 when he returned to the unit the morning he eloped. She recalled she clocked in at 6:45 AM that morning and entered the secured unit with LPN A who had resident #1 with her. She was informed at that time he was found outside the facility. LPN F stated resident #1 usually did wander throughout the unit but she had not known him to be exit seeking. She explained he may go to the door, but he was not looking to exit. In a phone interview on 9/03/25 at 12:15 PM, resident #1's daughter confirmed she was notified by the Director of Nursing (DON) that her father had left the facility unsupervised. She recalled being told he pushed on the fire door once around 12:30 AM but was unable to get out but repeated his actions again around 4:30 AM. She stated she was told that no one heard an alarm. Resident #1's daughter expressed she did not understand why no one heard the alarms as they were loud. She stated she had no idea how he found his way to the front of the building. She verified she was aware her father entered the front vestibule but was unable to get himself back into the facility. The daughter wanted to express she was happy with the facility except in the case of this event. In a meeting with the Risk Manager and Deputy Director Risk Manager on 9/03/25 at 2:06 PM, the Risk Manager stated the Quality Assurance and Performance Improvement (QAPI) Committee initially met to review the event and investigation on 8/07/25. She stated the committee noted several areas of opportunity for improvement and began education on several topics which included abuse and neglect, elopement, responding to alarms and appropriate supervision. The Risk Manager stated the QAPI Committee conducted a root cause analysis and determined the facility staff failed to provide appropriate supervision. She elaborated that the setting of the alarms and door function also played a role in the elopement. The Risk Manager verified alarms were meant to assist in preventing elopement but did not substitute for staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106151 If continuation sheet Page 7 of 9 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 106151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alwyn C Cashe State Veterans Nursing Home 5255 Raymond St Orlando, FL 32803 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 supervision. She acknowledged staff should have been more aware of resident #1's movement through the facility. Review of the policy and procedure for Elopement/Wandering Residents revised 6/02/21 revealed an elopement occurred when a resident left the premises or a safe area without authorization and/or necessary supervision to do so. The document indicated that a resident who left a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration, and/ or medical complication, drowning or being struck by a motor vehicle. The document provided information that while wander, door or building alarms can help to monitor a resident's activities, they did not replace necessary supervision. On 9/03/25, resident #1's likely elopement route was retraced. He exited the facility through the secured unit's [NAME] fire exit door, walked in the dark across a paved parking area and entered a two-lane road. He proceeded down the road until he reached a sidewalk access. Resident #1 walked along the sidewalk until he reached another exit door area and entered the grassy area next to it alongside a fence. He continued to walk around the grassy area and through several landscaped beds until he reached the front of the building and entered the vestibule through the sliding glass doors. He was unable to enter the front lobby through the next set of locked sliding glass doors. Resident #1 was located sitting in the vestibule area by a staff member coming to work at approximately 6:00 AM. Along the route, he passed an electric generator, commercial dumpsters and a fenced retention pond with an unlocked gate. He walked along uneven surfaces and passed through areas with yard debris, sprinklers and landscape lighting. Requests to view video footage from cameras located in and out of the facility were not met. In a joint interview on 9/03/25 at 9:58 AM, the Nursing Home Administrator (NHA), the Deputy Director, Deputy Director Risk Manager, and Facility Risk Manager confirmed the facility originally had video footage from inside the facility, and of some locations outside the facility from the morning of 8/07/25, but said they did not consider saving the footage as they did not think it would be needed. Historical weather data revealed that on the morning resident #1 eloped, 8/07/25, the temperature at 3:53 AM was 77 degrees Fahrenheit and fair skies. The temperature reached 78 degrees Fahrenheit by 4:53 AM. Sunrise occurred at 6:51 AM, (retrieved on 9/03/25 from www.wunderground.com). Review of immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team at the time of the survey: *On 8/07/25 at 6:45 AM, resident #1 returned to the secured unit with facility staff. He was assessed on return to the facility and had no injuries. A head count was conducted to verify the safety of all residents. The required notifications were made to the physician and family. Resident #1 was placed on one-to-one supervision. *Patient Health Questionnaire (PHQ) evaluations were completed by the Licensed Clinical Social Worker for resident #1 for three consecutive days- 8/07/25, 8/08/25 and 8/09/25. Resident #1 did not exhibit any signs or symptoms of mental anguish or distress. *On 8/07/25, resident #1 was re-evaluated for elopement risk and the elopement risk care plan was updated. *On 8/07/25, employees were assigned to sit near the exit door on every shift until all the alarm settings and door functions were completed on 8/19/25. *On 8/07/25, a vendor was called and came in to assess the door and submit work order. *On 8/07/25, the red screamer alarm annunciator was changed to alarm continuously until silenced by use of a key. *On 8/07/25, all resident wander alert bracelets were checked for all residents identified as at risk for elopement and verified as functional. *On 8/07/25, all residents were reassessed for elopement risk and re-evaluated on 8/11/25. *On 8/07/25, all elopement binders in place were reviewed by Registered Nurse (RN) Supervisor and found to be accurate with 23 residents identified as at risk for elopement. Elopement binders were updated with every new admission, new elopement assessment, discharge and as needed. *On 8/07/25, all locations of the wander alert system were evaluated and found to be in working order. *On 8/07/25, Maintenance (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106151 If continuation sheet Page 8 of 9 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 106151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alwyn C Cashe State Veterans Nursing Home 5255 Raymond St Orlando, FL 32803 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Department staff audited wander alert system for functionality at all locations and conducted daily audits for one month and then weekly thereafter. *On 8/07/25, maintenance checked all doors to ensure they locked and latched; and audited the doors for functionality daily for week then weekly for three months then monthly thereafter. *On 8/08/25, care plans were reviewed for all residents identified to be at risk for elopement. *Wander alert bracelets are checked daily for functioning and noted on the Treatment Administration Record. *On 8/07/25, the facility conducted an elopement drill and continued daily drills from 8/07/25 to 8/13/25 on every shift. Elopement Drills were completed weekly on each shift starting on 8/14/25 to present. *On 8/08/25, the maintenance team was educated by the Administrator to ensure doors functioned appropriately and if identified as dysfunctional to immediately initiate door monitoring process, notify the Administrator, DON and Operations Review Specialist and begin repairs as appropriate. *On 8/07/25, staff education began which included abuse, neglect, elopement policy and responding to alarms, and door alarm function: 8/07/25 - Tota1: 48 employees- 36%8/08/25 - Tota1: 58 employees- 43%8/09/25 Total: 71 employees- 53%8/10/25 - Total: 78 employees- 58%8/11/25 - Total: 91 employees- 67%8/13/25 Total: 108 employees-80%8/14/25 - Tota1: 128 employees-95%Remaining staff will be educated upon return from leave and are scheduled to work. *On 8/12/25, the magnetic lock on the fire exit door was repaired *On 8/19/25, the elopement/wander alert device was upgraded on the identified fire exit door. *All audits for corrective measures were reviewed in the Ad HOC QAPI meetings held on 8/07/25, 8/08/25, 8/12/25, 8/13/25, 8/15/25, 8/22/25, and 8/29/25. * All audits for corrective measures were reviewed in monthly QAPI held on 8/20/25 and will be reviewed monthly for a minimum of three months or more until substantial compliance is achieved. *Interviews were conducted on 9/05/25 with 14 staff members representing all shifts (6 CNAs, 1 RN, 3 LPNs, 2 environmental services and 2 dietary staff). Staff interviews revealed they were knowledgeable of the elopement policy and procedures, appropriate response to alarms and supervision of all residents to include those at risk for elopement, abuse and neglect. The resident sample was expanded during the survey to include four additional residents who were at risk for elopement. Observations, interviews, and record reviews conducted revealed no concerns related to elopement risk evaluations, care plans and physician orders for residents #8 through #11. Based on the facility's corrective actions, the survey team determined the facility was in substantial compliance on 8/20/25. Event ID: Facility ID: 106151 If continuation sheet Page 9 of 9