Health inspection·June 11, 2025

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lying flat. The assessment noted the resident had a fall in the last 2-6 months prior to admission and had no falls while at the facility. A review of the resident's active physician's orders revealed no order for oxygen therapy or care of oxygen delivery devices, such as cleaning, maintenance, or monitoring of equipment, or the resident's response to oxygen therapy from her date of admission on [DATE] through 06/09/25. A review of the medication administration record (MAR) and treatment administration record (TAR) for June 2025 revealed no evidence that oxygen therapy or care of oxygen delivery devices, such as cleaning, maintenance, or monitoring of equipment, or the resident's response to oxygen therapy was provided/received. A review of Resident #20's patient-centered care plan, created on 05/21/25, revealed a respiratory focus noting the resident had the potential for difficulty in beathing related to chronic obstructive pulmonary disease (COPD), asthma and chronic respiratory failure. The care plan goal noted the resident's respiratory symptoms would be managed through the next review. Interventions included: Administer medications/treatments as ordered. Monitor oxygen saturation, monitor vital signs and lung sounds, administer oxygen as ordered, assess respiratory status: rate, depth, pattern and skin color. On 06/10/25 at 3:17 PM, an interview was conducted with Registered Nurse (RN) A, who reported that she had worked at the facility since August of 2024. She explained the process to ensure residents received the accurate O2 flow rate included receiving a report from the outgoing nurse, checking O2 flow rates while administering medications, and checking how many liters the resident should be on. The outgoing nurse would give a report on each resident and whether there were any changes with the residents. She further explained that when she entered a resident's room, she would look for kinks in oxygen tubing and look at the amount of water in the concentrator. She administered medications in the morning, early afternoon, late afternoon and evenings. RN A began her shift today at 7:00 AM. On 06/10/25 at 3:23 PM, she was accompanied to Resident #20's room and she checked for kinks in the oxygen tubing. RN A bent down to read the flow rate at eye level, and reported that the oxygen flow rate was set at 3.5 liters per minute (L/min.). On 06/10/25 at 03:25 PM, RN A was asked to locate the physician's order for Resident #20's oxygen. She checked electronic medical record (EMR) and stated she could not find an order for oxygen for Resident #20. She was asked to locate where the administration of O2 was documented on the medication administration record (MAR). RN A stated she could not find the administration of O2 on Resident #20's MAR. She explained that there would typically be an order for O2 tubing changes, which would be changed on Thursdays; however, she could not find an order for O2 tubing changes. On 06/10/25 at 3:32 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The Director of Nursing (DON) was on leave and not available for interview. The ADON explained that the process to ensure residents received the accurate oxygen flow rate began when the resident was admitted to the facility. She said that the resident would come into the facility with an oxygen order. If the resident came from a hospital, the nurses were to take the discharge order from the hospital and confirm the order. Once the nurse confirmed the order, they contacted the facility's Medical Director, and the physician would confirm the final order. The ADON further explained that when a nurse entered into a resident's room, they should look at the O2 tank, look at the flow rate, and verify the flow rate with the physician's order. She explained that occasionally a resident or their family would manipulate the flow rate, but the nurse was responsible for matching the O2 flow rate with the doctor's order. She further explained that when O2 was administered, it should be documented on the medication administration record (MAR). Nurses on each shift should mark on the MAR that oxygen (continued on next page) 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 06/11/2025 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 0695 was given according to the physician's order. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Oxygen therapy (clinical manual, dated 06/2015 and reviewed 09/2022, 10/2023 and 10/2024), revealed the responsible party: RN, LPN. Residents Affected - Few Policy Guideline: 1. Residents who require oxygen therapy will have a physician order in their medical record which includes amount of O2 to be administered, route of administration and indication of use. 2. Residents who require O2 therapy will have an ongoing assessment of respiratory status and response to respiratory therapy. 3. Monitoring of spO2 levels and/vital signs as ordered will be documented in medical record . . 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 06/11/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to remove grease from fryers and failure to clean grease build-up and food debris inside and around both fish fryers. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 06/09/25 at 11:35 AM. During the tour, it was observed that both fryers located between the ovens were filled with used grease and covered with a significant build-up of food grime and grease. Additionally, grease and food debris were splattered on both sides of the fryer and floor area in front of and around the fryer. (Photographic evidence obtained) On 06/10/25 at 1:42 PM, the same observations were made again of the fryers located between the ovens, filled with used grease and covered with a significant buildup of food grime and grease. Additionally, grease and food debris were splattered on both sides of the fryer and floor area in front of and around the fryer. New observations of grease build-up were made inside the front door area underneath the fryer. (Photographic evidence obtained) An interview was conducted on 06/10/25 at 1:46 PM with [NAME] B. She reported that the kitchen equipment was cleaned daily and kitchen staff had not used the fryer for over one year. An interview was conducted on 06/10/25 at 1:49 PM with Dietary Aide C who reported the cook was responsible for cleaning kitchen equipment after every meal and deep clean at the end of each day. An interview was conducted on 06/10/25 at 1:54 PM with the Dietary Director, who reported that all staff were responsible for cleaning kitchen equipment, including the fryer, which the kitchen had not used since 11/2024. A review of the facility's policy and procedure titled Cleaning Instructions: Fryers, chapter 5: 5-19 (undated), revealed: Fryers will be cleaned on a regular basis and cared for in such a way to maintain optimum production. Procedure: 1. Be sure the fryer has cooled completely prior to removing all oil from the fryer . 3. Scrub down the sides and bottom of the deep fryer according to manufacturer's directions . 4. Sanitize. 5. Check with maintenance department on the proper disposal of used oil. Cleaning Instructions: Floors, Tables, and Chairs, Chapter 5-15 (undated) revealed: Kitchen and dining room floors, tables, and chairs will be cleaned and sanitized regularly. Procedure: 1. Sweep and clean kitchen floors after each meal. Sanitize at least once daily. Move major appliances at least once a month (as appropriate) in order to facilitate cleaning behind and underneath them. (Copy obtained) Reference: FDA Food Code 2022, https://www.fda.gov/media/164194/download, (Accessed on 06/16/2025) Chapter 4. Equipment, Utensils, and Linens 4-6 Cleaning of Equipment and Utensils, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment Food-Contact Surfaces and Utensils. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. (B) (continued on next page) 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 06/11/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105526 If continuation sheet Page 5 of 5