Health inspection·April 7, 2022

F 0677 Level of Harm - Minimal harm or potential for actual harm could cut resident fingernails if they were not diabetic. Employee E confirmed Resident #12's nails were long and full of black substance and stated she would be cleaning and cutting his nails. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105526 If continuation sheet Page 2 of 5 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 105526 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #5) of two residents sampled for a review of range of motion services from a total of 16 sampled residents. The findings include: A review of Resident #5's medical record revealed he was admitted to the facility on [DATE], with the most recent readmission on [DATE]. His diagnoses included hemiplegia following cerebral vascular accident, affecting left dominant side, intestinal obstruction, gastritis, reduced mobility, morbid obesity. A review of the quarterly minimum data set (MDS) assessment, dated 1/12/22, revealed the resident had a brief interview for mental status (BIMS) score of 13, indicating cognitively intact. He also required 2-person assist with bed mobility, dressing and personal hygiene and required 1-2 person assist with transfers and toileting. Resident #5 had a contracture to his upper left hand. A review of the resident's care plan revealed the resident had impaired mobility and was at risk for contractures. He was observed removing his splints. Interventions included to splint as tolerated, notify physician if range of motion (ROM) deteriorated, keep call light, bedside table, and telephone within reach. A review of Resident #5's restorative care plan dated 11/27/21 thru 11/26/22, revealed resident was to receive restorative nursing program (RNP) splint application to right hand utilizing a right resting hand splint to decrease extension tone in the third and fourth digits. Splint was to be applied at bedtime and removed in the morning before breakfast or as tolerated by resident. On 4/4/22 at 11:38 AM, Resident #5 was observed without a splint on is right hand. When asked if he wears a splint. The resident stated, he wears a splint on the right upper extremity (RUE) at night during the week when Employee D a Certified Nursing Assistant (CNA) was assigned to him, but on the weekends, no one applied the splint. On 4/5/22 at 9:01 AM, Resident #5 was observed with a rolled-up wash cloth in his left hand. The splint for his right hand was sitting on a stack of pillows. (Photographic evidence obtained) On 4/6/22 at 8:05 AM, the resident was observed eating breakfast in his bed. When asked if the splint was applied last night. The resident replied, yes, Employee D, CNA, Always puts it on me at night. When asked if anyone else applied the splint, he replied, No. On 4/6/22 at 8:10 AM, Resident #5's restorative nursing logs for the months of February, March, and April 2022 were reviewed with the Director of Nursing (DON). The logs revealed only one set of initials (Employee D, CNA) signing off for the application of the splint to the right hand. The logs revealed no documentation of splint application for Feb. 6, 12, 13, 19, 20, 25, 26, 27, 28; March 3, 8, 14, 21, 26, 27, 28, 31; and April 4, 2022. (Photographic evidence obtained) The DON confirmed the missing documentation. When asked who was responsible for applying the splint when Employee D, CNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105526 If continuation sheet Page 3 of 5 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 105526 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was not working. The DON stated, The CNA assigned to the resident is responsible for the task and if it was not documented it was not done. When asked who was responsible for the follow up on the status of the Restorative program. The DON stated no one was assigned responsibility to provide oversight of the program. On 4/7/22 at 8:43 AM, an interview was conducted with Employee E, CNA. When asked if there were residents that needed splints, she replied, yes, a couple. When asked if CNAs could apply splints, she stated only, if they were on the Restorative Program. She explained that if a resident was getting therapy services, then the task was performed by them. When asked if the CNAs received training on the application of the splints, she stated, yes. When asked if they had to document the application of a splint, she stated yes, in the Restorative book. On 4/7/22 at 8:55 AM, Resident #5 was observed sitting in bed. When asked if his splint was applied last night, he replied, No, Employee D, CNA was off last night. A review of the Restorative log for 4/6/22 revealed no documentation to indicate splint was applied. On 4/7/22 at 9:10 AM, an interview was conducted with Employee F, CNA. When asked if there were any residents who wore splints, she replied, Yes. When asked if CNAs could apply splints, she replied, Yes. When asked if she received training on the application of splints, she replied, Yes. When asked if CNAs documented the application of splints, she replied, Yes, in the Restorative Book. On 4/7/22 at 10:15 AM, a follow up interview was conducted with the DON. When asked who was responsible for the Restorative program, she stated, No one is in charge of the program it is a shared responsibility with the nurses. When asked how many residents were receiving Restorative Nursing Services, she stated, she did not know. When asked if anyone followed up on whether the services were being performed, she stated, the logs make it evident if the services are being performed. On 4/7/22 at 10:40 AM an interview was conducted with Employee G, a Physical Therapy Assistant (PTA). When asked if Therapy was responsible for the oversight of the Restorative Nursing Services program, she stated no, it is completely turned over to nursing. When asked who trains the CNAs on the application of splints, she stated, they can do the initial training and periodically if staff ask. Further record review for Resident #5's revealed a Discharge Summary by Physical Therapy that read, Goals met. Recommend restorative treatment to maintain progress made with functional mobility. On 1/14/22, the physician wrote an order to discharge from skilled therapy to Skilled Nursing Facility with RNP. A review of the facility's policy and procedure for Restorative Nursing Services (Revised July 2017) read: Residents will receive restorative nursing care as needed to help promote optimal safety and independence. 2. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabiliative care. 3) Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. (Copy obtained) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105526 If continuation sheet Page 4 of 5 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 105526 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace at Bishop's Glen, The 900 Lpga Blvd Holly Hill, FL 32117 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview, record review, and facility assessment tool review, the facility failed to ensure a registered nurse (RN) worked at least 8 consecutive hours a day, seven days a week on four separate occasions. Registered nurses provide assessments, care to clinically complex patients and supervision to licensed practical nurses. The findings include: During a tour of the facility on 4/4/22 at 9:17 AM, the daily staffing sheet was observed posted at the nurse's station. There were no Registered Nurse (RN) hours listed on the daily staffing calculations. Review of the Calculating State Minimum Nursing Staff for Long Term Care Facilities form provided by the facility dated 3/20/22 through 4/2/22 revealed on 3/20/22, 3/21/22, 3/26/22, 3/27/22 and 4/2/2022 there were 0 hours documented in the RN hours column. (Copies obtained) During an interview with the Staffing Coordinator and Interim Director of Nursing (IDON) on 4/6/22 at 1:10 PM, they confirmed there were less than 8 RN hours on the days in question. The Staffing Coordinator stated the shortage was a result of staffing changes. The IDON acknowledged, she was an RN but had not served as a charge nurse in the facility. She stated that she was unaware of the wording in the regulations permitting her to serve as a charge nurse when the facility census was less than 60. A review of the Facility Assessment Tool updated on 4/1/2022, identified the Interim DON, as a RN and read: To determine if they facility has sufficient staffing the following should be considered: Review expectations for federal minimum staffing requirements at the federal and state level. Federal law requires nursing homes to have sufficient staff to meet the needs of residents, to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week 483.35(b)(1) and must designate a licensed nurse to serve as charge nurse on each tour of duty 483.35(a)(2). . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105526 If continuation sheet Page 5 of 5