Health inspection·June 21, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility about 2 months ago. She explained as the grievance officer, she was responsible for handling the grievances. She indicated grievances were discussed with the interdisciplinary team. On 6/21/23 at 12:05 PM, the Administrator stated on 3/21/23, resident #3 filed a grievance because the 11 PM to 7 AM shift did not provide proper care and staff did not listen to her preferences. Review of the grievance forms showed two grievance forms dated the same day for the same issue but different wording. One form included CNAs were rough and On 3/19/23 during ADL care part of the bandage was ripped. The Administrator stated the former DON provided education to the 11 PM to 7 AM shift staff, but she could not provide evidence of the education. She recalled speaking to resident #3 to get additional details and clarify what the resident meant but did not recall the details. She stated the resident told her care had improved but the CNAs were not consistent. She stated it was not like abuse or neglect or she would have taken it a step further because they self-report. The Administrator read out loud the Physical Abuse description included in the facility's Abuse Prevention Program policy, used to educate their employees. She read, Physical Abuse: Physically harming a person through such actions as slapping, bruising, cutting, burning, physically restraining, pushing, shoving, or even rough handling. The Administrator stated this was handled as a grievance and it was not reported as abuse. Review of the Abuse Prevention Program policy and procedure, revised on 01/2022, read As part of the resident abuse prevention, the administration will 1. Protect our residents from abuse by anyone . 6. Identify and assess all possible incidents of abuse . 7. Thoroughly investigate and document . 8. Report all allegations of abuse within timeframes as required by federal requirements . 9. Protect residents during abuse investigations and protect resident(s) from further harm during the investigation by providing resident(s) with a safe environment . The document revealed the Administrator was responsible for the overall implementation of the policies and procedures that prohibited abuse. Review of the Facility Assessment Tool dated 6/05/23 revealed the staff received education and competency on Mandatory State & Federal training including abuse, neglect, and exploitation. The document read, Training that a minimum educates staff on - (1) Activities that constitute abuse, neglect . (2) Procedures for reporting incidents, of abuse . ; and (3) Care/management for persons with dementia and resident abuse prevention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105528 If continuation sheet Page 2 of 7 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 105528 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of St Cloud, The 3855 Old Canoe Creek Road Saint Cloud, FL 34769 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 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to prevent abuse, accurately report allegation of abuse to the Agency for Health Care Administration (AHCA) and thoroughly investigate an allegation of abuse for 1 of 2 residents reviewed for abuse of a total sample of 6 residents, (#1). Residents Affected - Few Findings: Review of resident #1's medical record revealed she was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, Alzheimer's disease, and dementia. Review of resident #1's admission Minimum Data Set assessment with Assessment Reference Date of 4/13/23 revealed a Brief Interview for Mental Status score of 6 out of 15 which indicated she was severely cognitively impaired. The assessment showed resident #1 required extensive assistance with Activities of Daily Living. The assessment indicated resident #1 did not reject evaluation or care needed to achieve her goals for health and well-being. Review of resident #1's medical record revealed Weekly Skin Audit was performed on 4/24/23, 5/02/23, 5/22/23 and 6/05/23. Review of the Nursing Homes Federal Reporting Five Day Report submitted to AHCA on 5/15/23 revealed an alleged abuse incident for resident #1 on 5/15/23 at 1:30 PM. The AHCA report was completed by the Administrator. The report noted resident #1 reported in Spanish that a staff member in scrubs rushed her during her meal, slapped her in the face, and punched her in her belly. The report included resident #1 was unable to describe the meal, the day it occurred or the person, and she only knew it was a female staff member. The report indicated the Interim Director of Nursing (DON) and the Administrator were notified on 5/15/23 at approximately 1:30 PM. The Investigative Findings section of the report noted resident #1 ate a type of meat and rice on the day of the incident and the facility looked at the Certified Nursing Assistants (CNAs) and nurses assigned to resident #1 on those days, 5/7/23 and 5/10/23 but they did not match the description of a light complexioned black young lady. The report included that when resident #1 was asked by the DON if she had seen the staff member in question since the incident, she responded she had not. The report showed this allegation of abuse was not substantiated and staff were provided in-service on abuse and neglect and the reporting of such. The following Witness Statements, collected during the investigation, were reviewed: CNA F - On 5/14/23 she was in resident #1's room where the resident was with her daughter and she was told a CNA, name starting with an E, had slapped her. CNA F wrote, (resident #1's name) speaks Spanish so her daughter was translating but she was also using hand gestures to demonstrate what had happened. She went into details stating that she had used the call button and a CNA came in and snatched it from her and slapped her in the face. Resident could not recall date and time of the incident and her story had been consistent. I advised her CNA (name of CNA) and acting DON (name). CNA G wrote, On 5/14 at around 4:30 PM I (his full name) spoke with (resident #1's name) in room (number) and her daughter regarding a complaint that the resident had been slapped in the face by an employee in a scrub outfit. The resident is Spanish speaking, so the daughter was translating. The resident could not recall accurately the date and time of the incident but only that it occurred at a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105528 If continuation sheet Page 3 of 7 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 105528 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of St Cloud, The 3855 Old Canoe Creek Road Saint Cloud, FL 34769 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 - Minimal harm or potential for actual harm mealtime. According to the daughter the resident stated that a lady fed her quickly and that the same woman fed her quickly and responded to call light. The woman was described as wearing scrubs, came into room hit the button to turn off the call light and slapped the resident on the face. The daughter asked the resident to recall the incident multiple times and the resident story was consistent other than recalling the date and time of incident. I concluded the conversation and reported the incident to my supervisor. Residents Affected - Few On 6/21/23 at 5:05 PM, the Administrator explained she interviewed CNA H over the phone. She was the CNA assigned on 11 PM to 7 AM shift on 5/14/23. CNA H told the Administrator resident #1 was provided incontinent care during her shift and she did not notice any marks or bruises during her shift. CNA I wrote the statement and signed it on 5/19/23. She noted she was resident #1's CNA for two shifts, 7 AM to 3 PM and 3 PM to 11 PM on Saturday 5/13/23. She wrote she left resident #1 well, not blue or swollen nose. She was OK. I have no schedule on Sunday and then on Tuesday family came to visit her to ask me to see the head of unit, the family stated looks like someone hit my mother and resident said the person who hit me has lighter skin than you. On 6/21/23 at 5:05 PM, the Administrator indicated the Social Services Director (SSD) was the Abuse Coordinator, but the current SSD was new to her role. The Administrator indicated resident #1's family had visited the resident on Friday 5/12/23 and expressed no concerns during their visit. She stated as far as she remembered no family visited resident #1 on Saturday. She indicated the family came on Sunday 5/14/23. She explained they reviewed the staff assignments from Saturday and Sunday and recalled the former DON was working on this investigation. When asked for the nurses' statements who had been assigned to resident #1, she stated she had to see if she could find the folder from the the former DON for additional statements, as they were not in her investigation folder. She stated they spoke to the staff, and explained CNA I, whose name begins with an E, was resident #1's regularly assigned CNA. She is also very dark. The CNA on Saturday night 11-7 was an agency CNA. The Administrator recalled speaking to an agency CNA on the phone, but the CNA did not remember resident #1. The Administrator could not provide the witness statement for that interview. She stated some documents from the investigation were not in her folder. A copy of the visitor log from 5/12-5/15/23 was requested but not provided by the Administrator. The Administrator acknowledged residents assigned to the same nurses and CNAs as resident #1 were not interviewed as part of the investigation. On 6/21/23 at 6:21 PM, the Regional Nurse Consultant stated she was involved in the investigation. She recalled resident #1's daughter was upset on 5/15/23 and the Unit Manager for unit 2 called her and asked to speak with her. She interviewed resident #1 but could not recall what she told her. She remembered learning the incident happened on a day resident #1 was served rice and meat and talking to the kitchen to determine which days they served those items. She stated she had pictures of staff ready to show resident #1, but the resident could not recall more details. She said she did not write a statement of her interview with resident #1. She explained she learned about the incident on 5/15/23 and she performed a head-to-toe assessment that day and noted no skin tears or bruises. She could not explain why witness statements dated 5/14/23 and CNA F's statement mentioned she was informed about the abuse allegation on 5/14/23. The Regional Nurse Consultant then stated she spoke with resident #1's daughter on Monday 5/15/23 and she performed the assessment, but she would have to look at everything before she responded to any other questions. I cannot tell if I spoke directly to the resident. Review of the facility's Abuse Prevention Program policy and procedure, revised on 01/2022, read As part of the resident abuse prevention, the administration will 1. Protect our residents from abuse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105528 If continuation sheet Page 4 of 7 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 105528 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of St Cloud, The 3855 Old Canoe Creek Road Saint Cloud, FL 34769 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 - Minimal harm or potential for actual harm by anyone . 6. Identify and assess all possible incidents of abuse . 7. Thoroughly investigate and document . 8. Report all allegations of abuse within timeframes as required by federal requirements . 9. Protect residents during abuse investigations and protect resident(s) from further harm during the investigation by providing resident(s) with a safe environment . The document revealed the Administrator was responsible for the overall implementation of the policies and procedures that prohibited abuse. Residents Affected - Few Review of the facility Assessment Tool dated 6/05/23 revealed the staff received education and competency on Mandatory State & Federal training including abuse, neglect, and exploitation. The document read, Training that a minimum educates staff on - (1) Activities that constitute abuse, neglect . (2) Procedures for reporting incidents, of abuse . ; and (3) Care/management for persons with dementia and resident abuse prevention. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105528 If continuation sheet Page 5 of 7 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 105528 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of St Cloud, The 3855 Old Canoe Creek Road Saint Cloud, FL 34769 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow appropriate infection control precautions when moving between resident rooms to prevent cross-contamination and exposure to infectious microorganisms according to established guidelines, (room [ROOM NUMBER] and #104). Residents Affected - Few Findings: On 6/20/23 at 10:30 AM, during tour of the facility, Personal Care Attendant (PCA) A entered room [ROOM NUMBER] which had a sign on the door indicating contact isolation. PCA A did not perform hand hygiene nor donned a gown and gloves. She grabbed a plastic clear bag which contained linens, towels and gowns, removed it from room [ROOM NUMBER], exited the room, and entered room [ROOM NUMBER] with the bag. On 6/20/23 at 10:46 AM, PCA A stated she was required to perform hand hygiene and don personal protective equipment (PPE) when she entered an isolation room. She stated she needed to wear the PPE only when providing care. She acknowledged she was not supposed to take items from one isolation room into any other room because that is considered cross contamination. She said, Stuff like this I can do because it is clean linens that was inside of the bag. She stated she had provided personal care to residents in room [ROOM NUMBER] and she took the bag to room [ROOM NUMBER] to provide care to both residents in that room. She indicated the resident on precautions in room [ROOM NUMBER] returned from the hospital the day before and was not on isolation before going to the hospital. She recalled the Unit Manager told her when she went into room [ROOM NUMBER] to provide care, she needed to wear PPE. When asked when she received infection prevention and control training, she stated she had not received training in this facility. On 6/20/23 at 12:09 PM, PCA B indicated she began working at the facility on June 1st, 2023. She stated she had not received training on Infection Prevention and Control. On 6/20/23 at 4:26 PM, the Infection Preventionist (IP) stated her responsibilities included prevention of infections by following the facility's Infection Prevention and Control Program policy and procedure. She explained she educated staff on any infections residents had. She stated her emphasis was on hand washing to prevent infections. She explained the type of isolation a resident had was based on the type of infection identified on the laboratory results and in consultation with the physician. The IP stated she had not had a chance to review the resident's chart from room [ROOM NUMBER] but knew the resident was readmitted the previous night with Methicillin-Resistant Staphylococcus Aureus (MRSA) and were awaiting physician's response on the course of treatment and isolation precautions. She shared the facility had a lot of new staff and they provided brief training on isolation precautions. She indicated she had not performed any audits on isolation rooms. She explained when entering a contact isolation room, she expected staff to first perform hand hygiene, don gown, gloves, and mask when providing direct care to the resident. She indicated it was not acceptable to remove a bag from an isolation room and take it to another resident's rooms as it was considered contaminated. She stated PCAs were not supposed to be assigned to residents in isolation rooms. On 6/21/23 at 1:51 PM, the Director of Nursing (DON) confirmed PCAs were not supposed to be assigned to any resident on isolation precautions. She explained staff were expected to follow infection prevention and control policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105528 If continuation sheet Page 6 of 7 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 105528 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of St Cloud, The 3855 Old Canoe Creek Road Saint Cloud, FL 34769 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 0880 Level of Harm - Minimal harm or potential for actual harm Review of the policy and procedure titled Infection Prevention and Control Program, dated 2017, read, The primary mission is to establish and maintain and infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. It included, Standard and transmission-based precautions to be follow to prevent the spread of infections. Residents Affected - Few Facility Assessment reviewed 1/02/23 read, Infection Control - a facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program. The form listed Competencies which included, Infection Control - hand hygiene, isolation, standard universal precautions included use of personal protective equipment, MRSA . precautions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105528 If continuation sheet Page 7 of 7