Health inspection·June 16, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm 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, record review an interviews, the facility failed to provide adequate supervision for one (Resident #1) out of three residents sampled for elopement; as evidenced by on 04/05/2025 Resident #1 a vulnerable resident left the facility undetected through the facility's first floor exit/entrance door; Resident #1 was found on the sidewalk several blocks from the facility by the local law enforcement and returned to the facility within twenty (20) minutes after last seen in the facility by staff. There were 139 residents residing in the facility at the time of the survey. The findings included: The facility's location is in a residential neighborhood with busy cross streets and close to a shopping plaza located 0.1 mile from the facility. The temperature on 04/05/2025 was 88 degrees Fahrenheit. according to https://www.accuweather.com. Review of the facility policy titled Elopements revision date 12/2002 states: Staff shall investigate and report on all cases of missing residents. Policy Interpretation and Implementation 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. a. If an employee observes a resident leaving the premises, he/she should: b. Attempt to prevent the departure in a courteous manner. c. Get help from other staff members in the immediate vicinity, if necessary, and instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. Review of the facility policy titled Accidents and Incidents - Investigating and Reporting revision date 07/2017 states: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Record review of the Abuse/Neglect Log from January 2025 to June 2025 revealed the incident occurred on 04/05/25 at 11:39 AM. Page 1 of 4 686123 686123 06/16/2025 Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the Incident note dated 04/05/25 timestamped 12:20 PM documented: [Resident #1] is alert and oriented x (times) three (3), able to walk, has been admitted since 03/21/2025, today was observed by Police officers near a couple blocks away from facility. The resident was able to provide information about being admitted for therapy and gave them his daughter's phone number. Police officer called facility and let the nurse know that they were going to bring the patient back, as patient knew where he resided. Resident stated that he walked to the therapy department and spoke to the therapist to get some information about therapy scheduled for today. Therapist denied patient having any therapy sessions scheduled for today and resident decided to leave the facility. Assessment was performed, patient able to answer every question asked, very pleasant, no signs of psychological/emotional distress, no injury or skin impairment, vital signs within normal limits. Denies any pain or discomfort. Resident's physician and patient's daughter were made aware. Record review of the nurses' progress note on 04/05/25 timestamped 13:51 (1:51 PM) Documented: Patient has been closely monitored, no signs of any changes on patient state of mind and functioning. Education was provided regarding sign out procedures, also new interventions discussed with patient and daughter. Resident able to make his own decisions, Patient states that he is forgetful at times, and he forget to let the nurse know that he wanted to go out, Resident requested a form that he can use to not occur this episode again. [wander alert device] discussed, patient asked and agreed to use it as a sign to let the nurse know when he is walking around exits doors. Daughter and son-in-law also agreed. [wander alert device] placed. Psychiatric evaluation also was done by Telehealth, Brief Interview for Mental status Score (BIMS) evaluation done. Resident was moved to a room near the nurses' station. Will continue with plan of care. Review of the medical records for Resident #1 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Hypertensive Heart Disease without Heart Failure. Resident #1 was discharged from the facility on 04/18/25 to an Assistant Living Facility. Review of Resident #1's Physician's Orders Sheet for April 2025 orders included but not limited to: 04/05/25 to 04/18/25- [wander alert device] in place-every shift Monitor for placement and functioning. Per Resident and Resident Representative request, resident will transfer to an Assistant Living Facility. 04/18/25Psychiatrist Evaluation. Record review of Resident #1 's admission Minimum Data Set (MDS) dated [DATE] revealed the resident is cognitively intact. no exhibited no behaviors, for Functional Abilities the resident required partial assistance to walk 10 feet; the resident was receiving antipsychotic, antidepressant, and Antiplatelet medications and no physical restraints or alarms used. Record review of Resident #1's Care Plans Reference Date 04/05/25 revealed: Resident has determined a risk for elopement due to: had an episode of Elopement on 04/05/2025, wanders the unit and wanders near exit doors, ambulates with no devices, had expressed desire to leave. Resident will remain safe and will refrain from leaving facility unsupervised through the next review date. Date Initiated: 04/05/2025. Interventions include-Educate resident / responsible party regarding sign out procedures as needed. Encourage resident to participate in activities of choice, provide one-to-one supervision as needed. Include resident in Elopement Book. Nursing assessment to identify any changes in condition, physically/ mentally/Psychologically. Perform elopement assessments. Perform frequent observations of resident whereabouts every shift. Provide redirection. when observed going towards exit doors. A Psychiatrist evaluation to determine BIMS score, and Psychosocial/Mental distress. Room changed near to nurses' station. Update physician and responsible party if resident elopes. [wander alert device] in place as per resident request. Check placement and functioning every shift. 686123 Page 2 of 4 686123 06/16/2025 Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/16/25 at 11:57 AM Certified Nursing Assistant (CNA), (Staff B) via telephone and Spanish Translator revealed on 04/05/2025 she was assigned to Resident #1 she remember giving the resident breakfast, he was given a shower with assistance, supervised the resident dressing himself and then he left his room to go to activities. The last time I saw the resident before the elopement incident was around 11:15 AM in the common room in front of the nursing station on the 500 unit. I was told the resident was missing around 11:30 AM by the Registered Nurse (RN), nursing supervisor (Staff C) that stated the police department found the resident outside the facility. I was at work when the resident was returned to the facility, the resident appeared normal and was in very good condition. Interview on 06/16/25 at 12:06 PM Registered Nurse (RN), Unit Supervisor (Staff C), via telephone with Spanish translator revealed: On 04/05/25 I was the supervisor in charge of the facility, I received a call from the local police department around mid-morning stating they found one of the facility's residents on the sidewalk down the street and will be bringing the resident back to the facility. They were able to identify the resident from the bracelet he had on. The police department stated [Resident #1] was alert but slightly confused. After the phone call with the police department, I checked with the resident's assigned Licensed Practical Nurse (LPN), (Staff D) and CNA (Staff B), they both stated they saw the resident approximately 20-30 minutes ago. At approximately 11:40 AM, I received the resident at the entrance of the facility from the police officers, the resident appeared calm and was alert and oriented to person and place. [Resident#1] was assessed, there were no physical injuries or mental distress noted. [Resident #1] was returned to his room, the Director of Nursing (DON) and Administrator (NHA) were notified after the call from the police department and before the resident was returned to the facility. Interview on 06/16/25 at 12:16 PM via telephone, Licensed Practical Nurse (Staff D stated: I was the assigned nurse for [Resident #1] on 04/05/25 the day of the elopement incident. Around 11:00 AM was the last time I saw the resident in the facility. Staff D revealed the supervisor notified her 20 minutes later that the police department reported they found the resident and was returning him to the facility. On the resident's return to the facility, I assessed the resident, he was alert and oriented, his vital signs were stable, and the resident stated he was trying to go home. I check on my residents at least every hour to an hour and a half to make sure all my residents are doing well during my shift. On 06/16/25 at 12:25 PM, the Administrator (NHA) revealed the Director of Nursing (DON) is the person who conducted the investigation and is currently on vacation. I was informed of all the details of the investigation. I was notified by the DON around 12 noon on 04/05/25 that one of our residents was observed walking on the sidewalk outside of the facility and was returned by the police department. I was informed that the resident was alert and had a Brief Interview for mental status (BIMS) score of 14, he was calm, no injuries or areas of concern, and appeared to be in no physical or emotional distress. We notified the resident's physician, family, and psychiatrist who was able to do a telehealth assessment of the resident on 04/05/25. A [wander alert system] was put in place on 04/05/25 with the resident and family consent. The resident and family were educated on how the [wander alert device] works. All residents with [wander alert devices] were checked for placement, function and active orders, all doors were checked to make sure the wander guard system was in place and working correctly, a head count was completed, all other residents were accounted for in the building. Elopement drills and education were completed immediately with all staff. New hires have been educated upon hire about elopement, elopement drills and code pink for elopement. There is an elopement binder at each nursing station, in the therapy Department, activity department and the reception desk. The elopement binder consists of a photograph of the residents at risk for elopement and their face 686123 Page 3 of 4 686123 06/16/2025 Kendall Lakes Healthcare and Rehab Center 5280 SW 157 Avenue Miami, FL 33185

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sheets. We have implemented a lock down of the front entrance/exit door, which is now the only point of entry and put in place the visitor sign in sheet-every visitor that enters the building has to sign in, staff can use their identification badge to enter the building using the electronic door opening system and visitors have to ring the bell to be seen on the camera, in order to be granted access into the facility by the front desk staff. To leave the facility visitors must notify the reception staff to open the door to exit out of the facility or a staff member can escort the visitor to the front door and open the front door using their ID (Identification) badge to access the electronic door opening system. 686123 Page 4 of 4