Health inspection·February 8, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 02/08/2023 at 08:02 AM, Resident #123 was observed in the dining area seated in a reclining type chair being fed a pureed textured and honey consistency breakfast by a Certified Nursing Assistant (CNA). Residents Affected - Few Review of Resident #123's clinical records revealed the resident was admitted on [DATE] and readmitted on [DATE]. Medical diagnoses included but were not limited to, Cerebral Atherosclerosis; Type 2 Diabetes Mellitus without complications; Hypertensive Heart Disease with Heart Failure. Review of Resident #123's active orders as of 02/08/2023 documented an order dated 08/24/2021 for Glimepiride tablets 2 milligrams orally two times a day related to Type 2 Diabetes Mellitus without complications. Orders for Metformin tablet 500 milligrams orally two times a day related to Type 2 Diabetes Mellitus without complications, dated 08/24/2021. Record review of Quarterly Minimum Data Set (MDS) Section I for Active Diagnosis dated 11/20/2022 revealed the resident's diagnosis of Type 2 Diabetes Mellitus (DM). Record review of Quarterly Minimum Data Set (MDS) Section N for medications dated 11/20/2022 revealed the resident were receiving insulin injections seven (7) days a week. Review Resident #123's Medication Administration Records and order sheets for January 2023 revealed the resident was not receiving insulin injections. Review of Medication Administration Records for February 2023 revealed the resident was not receiving insulin injections. Review of Care Plan initiated on 03/03/2022 and revised on 03/03/2022 documented the resident has potential for fluctuating blood glucose levels related to Diabetes Goal: Will maintain blood glucose levels within the parameters set forth by physician. Interventions: Administer medications as ordered. Hemoglobin A1C [blood glucose level test] every 3 Months. Monitor for signs and symptoms of hypoglycemia - shaky, rapid heartbeat, sweating, dizzy, anxious, hungry, blurry vision, weakness or fatigue, headache, irritable. Monitor for signs of hyperglycemia- extreme thirst; frequent urination; dry skin; hunger, blurred vision, drowsiness, decreased healing, numbness of fingers, toes, mouth. Provide diet as ordered. During an interview on 02/08/2023 at 08:33, Registered Nurse, MDS Coordinator (Staff C) stated the resident's diagnosis was Type 2 diabetes Mellitus and he will check the physician orders to make sure the resident was not receiving insulin injections. On 02/08/2023 at 08:45 AM, Staff C reported that the resident's diagnosis was Type 2 Diabetes Mellitus but the resident received pills for the Diabetes, not insulin injections. Record review of Policy and Procedures for Residents assessment dated [DATE] revealed: Policy: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services (CMS). This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 If continuation sheet Page 2 of 16 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Hialeah, The 190 W 28th Street Hialeah, FL 33010 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 0641 Level of Harm - Minimal harm or potential for actual harm each resident's functional capabilities and assist staff to identify health problem for care plan development. Procedure: 1-Resident Assessment Instrument. A facility will complete a comprehensive assessment of a resident's needs, functional and health status, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: J-Disease diagnosis and health conditions. N-Medications. Residents Affected - Few Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for two (Resident #237, and Resident #123) out of 38 residents reviewed for resident assessments. As evidenced by inaccurate coding of MDS section for Discharge Status for Resident #237 and inaccurate coding of the MDS sections for Active Diagnosis and Medications for Resident #123. The facility census was 237 residents at the time of the survey. The findings included: Record review of Resident #237's Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE] Section for Identification Information in subsection A 2100 for Discharge Status documented that the resident was discharged to an Acute Hospital. Review of the Physician's Orders Sheet for November 2022 revealed Resident #237 had orders that included but not limited to: Discharge to home with her family, one time only until 11/14/2022. Review of the nurses' progress notes for Resident #237 documented on 11/14/2022 timestamped 12:28: Resident left the facility at this time. Discharge to home with her family. Resident in stable condition, no pain reported. No skin lesions. Her belongings and medicines were handed over to the family. Further review of the medical records for Resident #237 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Gout, unspecified. Resident #237 was discharged on 11/14/2022. Record review of Resident #237 's Care Plans dated 8/3/2022 revealed: Resident's Short-term Discharge Plan: The plan for resident is to be discharge back to the community with family support. Interventions Included: The goal for the resident is to have all needs met related to discharge planning and staff to assist and coordinate with the resident as needed for a safe discharge. On 02/08/2023 at 08:21 AM, during an interview with Registered Nurse, Minimum Data Set Coordinator, (Staff C) the surveyor had Staff C check the nurses progress notes documented on 11/14/2022 that noted the resident was discharged to home with family and check the Discharge Minimum Date Set with reference dated 11/14/2022, Section A that documented that the resident was discharged to an acute hospital. Staff C acknowledged the discrepancy, Staff C stated, in this situation we would check the progress note, speak to the nurses, we would correct the discrepancy and create a modification request and submit the request to Center for Medicare and Medicaid Services (CMS). I will speak to the nurses to the floor to confirm the discharge status. Review of the facility's policy and procedures titled policy and Procedures: Residents Assessments dated 01/01/2022 states: Step 7-A Registered Nurse will sign and certify that the assessment is completed. Step 8-Each individual who completes a portion of the assessment must sign and certify the accuracy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 If continuation sheet Page 3 of 16 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Hialeah, The 190 W 28th Street Hialeah, FL 33010 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 0641 of that portion of the assessment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 If continuation sheet Page 4 of 16 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Hialeah, The 190 W 28th Street Hialeah, FL 33010 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I for individuals with a Serious Mental Illness (SMI) or Intellectual Disability (ID) or related conditions was completed at the time of admission for resident one (Resident # 54) out of one resident whose PASRR was reviewed. Residents Affected - Few The findings included: On 02/07/2023 at 10:37 AM Resident # 54 was observed lying in bed, awake. No distress noted. Observation on 02/08/2023 at 11:25 AM. Resident #54 was observed lying in bed trying to take her gown off. The nurse was called to help the resident and a Certified Nursing Assistant came and assisted the resident to get dressed. Record review of admission Record revealed the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. Medical Diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease, Unspecified, Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Anxiety, Other Bipolar Disorder and Other Depressive Episodes. Record review of Resident # 54's PASRR Level dated 05/08/2017 revealed no identification of any serious mental diagnosis under section 1A PASRR Screen Decision-Making. Review of orders dated 11/21/2022 revealed the resident was receiving Mirtazapine tablet 30 milligrams. 1 tablet by mouth at bedtime related to Other Specified Depressive Episodes. Record review of orders dated 11/21/2022 revealed the resident was receiving Clonazepam tablet 1 milligram. 1 tablet by mouth two (2) times a day related to Anxiety Disorder, Unspecified. Record review of orders dated 01/25/2023 revealed the resident was receiving Temazepam Capsules 15 milligrams orally at bedtime related to Insomnia. One capsule by mouth every night at bedtime. Record review of orders dated 01/25/2023 revealed ordered Morphine oral solution 20 milligrams/5 milliliters. Give 0.5 milliliters by mouth every two (2) hours as needed for pain related to Shortness of Breath. Record review of orders dated 02/02/2023 revealed ordered Lorazepam Oral Concentrated 2 milligrams/milliliters. Give 0.5 milligram/milliliters by mouth every 6 hours as needed for agitation, anxiety, acute seizures related to other specified Anxiety Disorders. Review of the Annual Minimum Data Set (MDS) Section A dated 06/22/2022 revealed the resident was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Review of the Quarterly MDS Section C for cognitive status dated 02/10/2022 revealed the resident's Brief Interview for Mental Status (BIMS) Summary Score was 02 out of 15 indicating the resident has severe cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 If continuation sheet Page 5 of 16 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Hialeah, The 190 W 28th Street Hialeah, FL 33010 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 0645 Level of Harm - Minimal harm or potential for actual harm Review of the Quarterly MDS Section I for active diagnoses dated 12/20/2022 revealed the resident's diagnoses of Anxiety disorder, Depression Disorder and Bipolar Disorder. Review of Quarterly MDS Section N for medication dated 12/20/2022 revealed the resident was receiving antianxiety and antidepressant medications. Residents Affected - Few Review of Resident # 54's Medication Administration Record for January 2023 revealed the resident was receiving antianxiety and antidepressants medications as ordered. Review of Medication Administration Record for February 2023 revealed the resident was receiving antianxiety and antidepressants medications as ordered. Review of the Care Plan initiated on 03/30/2022 and revised on 12/28/2022. The resident was at risk for adverse reactions related to the use psychotropic meds on Anti-Anxiety Medication, on Antidepressant Medication and on Sedative Hypnotic Medication. Goal: Will remain free of signs and symptoms of over sedation and side effects related to psychotropic medication. Interventions: Involve the family and resident with the care planning process and psychotropic reduction program. Monitor behavior for effectiveness of medications. Monitor for signs and symptoms of over-sedation and/or changes in condition. Obtain laboratory tests and/or vital signs as ordered. During an interview on 02/08/2023 at 10:00 AM, Registered Nurse, (Staff J) revealed the resident is very anxious and sometimes aggressive with the Certified Nursing Assistants (CNAs) when care was provided. Staff J added that the resident behaved good with her regular CNA, but not with other CNAs. The resident would be anxious in the morning until the medication is working. Staff J reported that the resident received medications for anxiety, depression and morphine for pain as needed, and tolerated the medication well. The resident was not able to use the call light for assistance. During an interview on 02/08/2023 at 02:16 PM, the Social Services Director reported she started to work in the facility six (6) months ago. Resident # 54 was admitted in 2017. The resident did not have any significant change or any disturbing behavior. The Social Services Director revealed she reviewed the PASRR Level I with the Director of Nursing when the residents will be admitted . The Social Services Director reported that she will review the resident's ( Resident # 54) PASRR Level I with the Director of Nursing and acknowledged the PASRR Level I for this resident (Resident #54) was not completed and that she will submit it again. On 02/08/2023 at 3:02 PM the Social Services Director reported that the Level I PASRR for Resident # 54 was submitted with the resident's diagnosis. Record review of Policy and procedures for PASARR dated 01/01/2022 revealed Policy: It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-admission Screening and Resident Review, in accordance with Stated and Federal Regulations. 3-Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. The facility will not admit, on or after January 1, 1989, any new residents with a-Mental disorder, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 If continuation sheet Page 6 of 16 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Hialeah, The 190 W 28th Street Hialeah, FL 33010 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide an ongoing activities program for one out of 38 sampled residents (Resident #112). There were 237 residents residing in the facility during the survey. Residents Affected - Few The findings included: During observation of Resident #112 on 02/06/2023 at 10:37 AM, the resident was observed in bed asleep. The resident's bed was observed to be in a low position. The resident was awakened, and she was asked how she was feeling, the resident responded that she was okay. The resident was not observed to be involved in any meaningful activity. Observation of Resident #112 on 02/07/2023 at 9:37 AM while medications were being administered to one of the resident's other 3 r roommates revealed, the resident was in bed asleep. There was no radio or television (TV) on the side where Resident #112's bed was located. The only television in the room was on the opposite side of the room, in front of Resident #207. The television was being watched by Resident #207 and was on a Spanish program. The resident was not observed to be involved in any meaningful activity. Observation of Resident #112 on 02/07/2023 at 02:47 PM, the resident was observed in bed asleep, the resident was easily awakened, and reported she's okay and reported lunch was okay. There was no radio at the bedside or TV for Resident #112. The resident was not observed to be involved in any meaningful activity. Record review revealed Resident #112 was admitted to the facility on [DATE] with diagnoses to include but not limited to Hypertensive Heart Disease without Heart Failure, Unspecified Dementia, Unspecified severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The residents Brief Interview for Mental Status (BIMS) score was a 03, indicating the resident had severe cognitive impairment. The resident's primary language was documented as English. Review of Resident #112's Minimum Data Set Comprehensive assessment dated [DATE], Section F, Preferences for Customary Routine and Activities revealed the residents preferences included, music was very important to the resident, it is very important to do things with groups of people, it was important to participate in a religious service or practice, it was somewhat important to have books, newspapers and magazines, it was somewhat important to keep up with the news, and it was somewhat important to go outside to get fresh air when the weather is good. Review of Resident #112's care plans included, [Resident] will have the opportunity to participate in recreational activities through next review. Include resident in relaxing activities. Include resident in special events. Invite resident to go outside to get fresh air when the weather is appropriate to enjoy from facility's patio. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 If continuation sheet Page 7 of 16 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Hialeah, The 190 W 28th Street Hialeah, FL 33010 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 0679 Keep communication with family members offering video calls. Level of Harm - Minimal harm or potential for actual harm Offer 1-1 informal visits in room for socialization with activity staff. Residents Affected - Few Another care plan for Resident #112 included, [Resident] is potential for cognitive problem related to Difficulty Making Decisions, Impaired Decision Making, [ .] has episodes of confusion at times and able to make little to no decisions of daily life. [Resident] will be able to communicate basic needs on a daily basis through the review date. [Resident] will maintain current level of cognitive function through the review date. Administer medications as ordered. Monitor/document for side effects and effectiveness. Communicate with the resident/family/caregivers regarding resident's capabilities and needs. Encourage activities of choice. Encourage small group discussion/participation as appropriate. Praise all efforts made. Provide opportunities for resident to give his/her name. Provide prompts and cues as needed. Provide safety measures at all times. Provide staff's name with each interaction and prompt resident to repeat and rephrase as needed. Staff to address resident by name daily at each interaction. Use simple terms, phrases, direct yes/no questions and allow time for resident to comprehend and respond. During the review of Resident #112's electronic medical record, it was noted there were no activities progress notes from 06/01/2022 to 02/08/2023. During interview and observation of Resident #112 on 02/08/2023 at 09:30 AM with Staff G, a Registered Nurse, Staff G reported the resident was getting a shower. It was noted, this was the first time the resident had been observed out of her room during the facility's survey. Interview on 02/08/2023 at 04:10 PM with Staff I, the Activities Director about the resident's activity notes. Staff I reported, she was new and had been at the facility for 1 week and was being trained. Staff I was asked to find the activities progress notes and was unable to find the activities notes for Resident #112. Observation of Resident #112 on 02/08/2023 at 04:20 PM revealed, the resident was in bed with her head covered with a blanket. There was no TV or radio at the side where the resident bed was located. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 If continuation sheet Page 8 of 16 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Hialeah, The 190 W 28th Street Hialeah, FL 33010 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/08/2023 at 05:40 PM with Staff I, the following documents were presented, a copy of the facility's Activities Program Policy and Procedures. Resident #112's Quarterly Activity evaluation dated 01/03/2023 was presented. The residents' February 2023 list showing activities provided to Resident #112 was presented and reviewed. During the review of the February 2023 list of activities, it was documented the resident had been provided the following activities from 01/26/2023 to 02/08/2023-television group, television in room, music in group, social group/club, reminiscing memory stimulation, conversation with the resident and snack time. On 02/06/2023, the list documented at 2:45 PM, there was conversation with the resident. There was no other activity documented as being provided to the resident on 02/06/2023. On 02/07/2023, the list documented at 12:21 PM, there was conversation with the resident. On 02/07/2023, the list documented at 12:22 PM, there was a TV in the resident's room and the resident had snack time. There was no other activity documented as being provided to the resident on 02/07/2023. On 02/08/2023, the list documented at 12:13 PM, there was conversation with the resident and the resident was at a social group club. On 02/08/2023, the list documents at 12:14 PM, the resident was given snack time and reminiscing memory stimulation. Staff I was informed during this review that the resident does not have a TV at the bedside and that the TV in the resident's room is on the opposite side of the 4-resident bedroom and that the resident's primary language was English. There was no documentation from 01/26/2023 to 02/08/2023, that the resident had been involved in a religious service, that the resident had a reading activity, time outdoors and no phone activity with family and/or a friend as documented on the resident's activity preferences. During the review of the facility's policy and procedure for the Activities Program dated 01/01/2022, the policy documented the Purpose was to provide an ongoing program of activities designed to appeal to the resident's interests and to enhance his or her highest practicable level of physical, mental, and psychosocial well-being. The guidelines included, but was not limited to: 1. Identify and involve each resident in an ongoing program of activities designed to appeal to his or her interests and needs. 2. Enhance the residents highest practicable level of physical, mental, and psychosocial wellbeing by offering a program of activities that provides the following: A heightened sense of wellbeing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 If continuation sheet Page 9 of 16 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Hialeah, The 190 W 28th Street Hialeah, FL 33010 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 0679 Promotion of feelings of self-esteem, pleasure, comfort, education, creativity, success, and independence. Level of Harm - Minimal harm or potential for actual harm Produce something useful and provide purpose. Religious activities Residents Affected - Few Activity Participation Records: The activity staff shall record residents' activity attendance and participation in the task in [ brand cloud-based healthcare software provider]. Make use of task information as data for summary within the resident activity assessments and/or progress notes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 If continuation sheet Page 10 of 16 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Hialeah, The 190 W 28th Street Hialeah, FL 33010 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 - 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 and interview, the facility failed to ensure 1 out of 9 sampled residents (Resident #112) reviewed for Accidents and environment remained free of accident hazards. Resident #112 had an electrical socket next to bed that had exposed electrical wires. There were 237 residents admitted to the facility during the survey. The findings included: During observation of Resident #112 on 02/06/2023 at 10:37 AM, the resident was observed in bed asleep. The resident's bed was observed to be in a low position. The bed was against the wall and there was an electrical socket on the wall where the cover of the electrical socket was detached from the socket. The electrical socket was above the resident's bed and electrical cords were observed to be exposed. The socket was observed to be connected to a cover for other wiring extending down the wall and was next to the resident. This tubing was within the reach of the resident. The resident was awakened and asked how she was feeling, and she said she was okay. (Photo obtained of the electrical socket) Observation of Resident #112 on 02/07/2023 at 9:37 AM while medications were being administered to one of the resident's 3 other roommates revealed the resident was in bed asleep and the electrical socket remained with the exposed wiring. Observation of Resident #112 on 02/07/2023 at 02:47 PM, the resident was observed in bed asleep, the resident was easily awakened, and reported she's okay and lunch was okay, two half siderails were up, the resident's bed was against the wall. The electrical socket remained with the exposed wiring. Record review revealed Resident #112 was admitted to the facility on [DATE] with diagnoses to include but not limited to Hypertensive Heart Disease without Heart Failure, Unspecified Dementia, Unspecified severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The residents Brief Interview for Mental Status (BIMS) score was a 03, indicating the resident had severe cognitive impairment. During the Life Safety Code Survey tour of the facility at 3:02 PM on 02/07/2023 with the Maintenance Director, it was observed that there was a damaged electrical receptacle with exposed wiring in Resident #112's room. During an interview and observation on 02/08/2023 at 09:30 AM with Staff G, a Registered Nurse, about the electrical outlet in Resident #112's room, Staff G reported the resident was getting a shower. At this time, the electrical outlet had been repaired, but the metal tubing covering the other wiring was still present. Staff G reported, the resident pulls on the metal tubing on the wall. Staff G was shown the picture of the broken electrical outlet. Staff G was asked, what does she do when she finds something like the broken outlet, she reported, she reports it to the charge nurse. Interview on 02/08/2023 at 09:40 AM with Staff H, Charge Nurse, and Licensed Practical Nurse (LPN), about what they do when they identify broken things in the environment, she reported, they document it in the Maintenance Book. Staff H presented the maintenance repair logbook that was kept at the nurses' station on the Center Court Unit. The repair book was reviewed and the repair for the room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 If continuation sheet Page 11 of 16 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Hialeah, The 190 W 28th Street Hialeah, FL 33010 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 - Minimal harm or potential for actual harm Residents Affected - Few outlet cover was documented as repaired on 02/07/2023. Staff H reported, maintenance staff checked the maintenance log daily and makes the repairs. Interview on 02/08/2023 at 09:42 AM with the Director of Nurses (DON), about the electrical outlet in Resident #112's room, he reported the Nurses and Certified Nursing Assistants must report these findings. The DON was shown a picture of the broken outlet. The DON was informed, Staff G reports, Resident #112 pulls on the metal tubing on the wall that is connected to the electrical outlet. The facility's accident hazards policy and procedure was requested. Review of the facility's policy and procedure for Reporting Accidents and Incidents dated 01/01/2022, documents The facility will ensure that: a. The resident environment remains as free from accident hazards as is possible. This section of the policy was not followed. Review of the facility's undated policy and procedure for Preventive Maintenance and Inspection documents, In order to provide a safe environment for residents, employees and visitors, a preventive maintenance program has been implemented to promote the maintenance of fixtures and equipment in a state of good repair and condition. The section for Work Orders and Service Requests documents, A system for work orders is established among all staff, elders, and . [Preventive Maintenance] employees that provides rapid communication regarding equipment problems. The work order system includes documentation of: the problem, Date the problem was identified, who was notified, correction action (servicing, repair or replacement), and completion date. This portion of the policy was not followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 If continuation sheet Page 12 of 16 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Hialeah, The 190 W 28th Street Hialeah, FL 33010 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure pharmaceutical procedures were followed during medication administration for two (Resident # 52 and Resident #78) out of seven (7) residents sampled, as evidenced by the correct medication dosage amount not being available on Manor two (2) Carts Number one (1) and three (3) for medication administration to residents, Middle cart on Center Court unit. Loose pill found in Cart One (1) on [NAME] House unit. This had the potential to affect the 237 residents residing in the facility at the time of the survey. The findings included: On 02/06/2023 at 9:00 AM during medication administration observation with Licensed Practical Nurse, (Staff D) on Manor two (2), Cart #3, Resident #78's Fish Oil 1000 Milligram (MG) one (1) capsule was not available for medication administration. Staff gave Resident #78, two (2) 50MG Fish oil capsules. Interview on 02/02/2023 at 9:05 AM Staff D stated the 1000 MG fish oil capsule is on order. The facility's pharmacist present stated he will be checking on the house stock and correcting the order right away and there is no harm to the resident in giving two 50MG capsules of fish oil, instead of one 1000 MG capsule as ordered. Review of the medical records for Resident #78 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Other Hyperlipidemia. Review of the Physician's Orders Sheet for February 2023 revealed Resident #78 had orders that included but not limited to: Fish Oil capsule 1000 MG- Give 1 capsule by mouth one time a day related to hyperlipidemia. Review of Resident #78 's Annual Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented the Brief interview for Mental status Score was 5 on a 0-15 scale indicating the resident is cognitively impaired. On 2/6/ 2023 at 9:25 AM during medication administration observation with Registered Nurse, (Staff F) on Manor 2, Cart 1, Resident# 52's Seroquel 25 MG tablet was not available for medication administration. Interview on 2/6/2023 at 9:26 AM Staff F stated, I will cut the Seroquel 50 MG tablet available on the medication cart in half, I have worked on Manor 2, Cart 1 before and they have had the 25 MG Seroquel on the cart. I noticed that I could not cut the 50mg Seroquel in half, I called the Registered Nurse, Charge nurse for Manor 2 unit (Staff E) to let him know what I was going to do, [Staff E] said he will get the medication from the e-kit. Staff F reported that the nurse on the 3:00 PM to 11:00 PM shift reorders the medication for the residents. Staff F explained; the resident has a nighttime dose of Seroquel 50mg that is why we have the 50MG dose in stock for this resident. During an interview on 2/6/2023 at 9:27 AM, Registered Nurse, Charge nurse for Manor 2 unit (Staff E) verified the resident did not have any Seroquel 25 MG on the medication cart, Staff E stated he will get the medication from the e-kit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 If continuation sheet Page 13 of 16 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Hialeah, The 190 W 28th Street Hialeah, FL 33010 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2/6/2023 at 9:30 AM; the Facility's Pharmacy Consultant stated the facility reorder medications when there are few left on the bingo cards. Staff F demonstrated how to re-order medications in the electronic Medication Administration (EMAR) system but could not verbalize when they would or are required to reorder the medication. Staff F, was asked at what point would she reorder the medications based on the amount on the bingo card, Staff F did not answer. The facility's Pharmacist stated they are supposed to reorder the medications when there are a few left on the bingo card. On 2/6/2023 at 9:33 AM Staff E returned to medication cart 1 on Manor 2 unit with an individual packet of Seroquel 25 MG that was verified by Staff F. On 2/6/2023 at 9:50 AM Staff F went into the EMAR system to verify the Seroquel 25 mg was reordered for the resident. The EMAR revealed the Seroquel 25 MG was reordered on 1/18/23 and 1/2/23. The nurse reordered the Seroquel 25 MG on 2/6/23 and stated the charge nurse placed a follow up call to the pharmacy regarding the medication. Review of the medical records for Resident #52 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Bipolar Disorder, Depressive Disorder, and Unspecified Psychosis. Review of the Physician's Orders Sheet for February 2023 revealed Resident #52 had orders that included but not limited to: Seroquel Tablet 25 MG-Give 1 tablet by mouth one time a day related to Unspecified Psychosis. Record review of Resident #52 's quarterly Minimum Data Set (MDS) dated [DATE] revealed: section C for Cognitive Patterns documented Brief Interview for Mental Status Score 8, on a 0-15 scale indicating the resident is cognitively moderately impaired. Review of the facility's policy and procedures titled, Medication Ordering and Receiving from Pharmacy states: If not automatically refilled by the pharmacy, repeat medication (refills) are written on a medication order form/ordered by peeling the top label from the physician order sheet and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and or ordered electronically. Order as follows: Reordering of medications is done in accordance with the order and delivery schedule developed by the pharmacy providers. Quantities of medications sent from the pharmacy may vary in accordance with payer status, insurance plans, or law. Examples include Medicare A vs. Medicaid, plan limitations on quantities under Medicare Part D, and quantity ordered by the prescriber. Reorder medication in advance of need, as directed by the pharmacy order and delivery schedule, to assure an adequate supply is on hand. When reordering medications that requires special processing, order at least 7 days in advance of needs. On 2/7/2023 at 11:44 AM, inspection of medication cart number one on [NAME] House Unit revealed a loose white round pill with the number 260 in one of the drawers in the cart. The white round pill appeared to be a Zinc tablet when compared to the Zinc medications bingo card blister pack. On 02/08/2023 at 11:14 AM, in an interview Registered Nurse (Staff K) for Manor Court was asked what a nurse should do when a loose pill is discovered. Staff K reported the nurse has to place the pill in a drug disposable bottle and that there is one in the med room. If a narcotic is found, 2 nurses would verify the waste and document it on the narcotic count sheet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 If continuation sheet Page 14 of 16 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Hialeah, The 190 W 28th Street Hialeah, FL 33010 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review the facility failed to ensure the dishwashing machine was operating properly. This has the potential to affect 218 who ate by mouth out of 237 residents who reside in the facility at the time of survey. Residents Affected - Some The findings included: On 02/06/2023 at 1:09 PM during the first observation of the dishwashing in progress revealed the dishwashing machine was a [ brand] multi tank machine high temp sanitization. The three temperature gauges was noted with the following temperature readings - Wash was noted at 155 degrees Fahrenheit (F) instead of 150 F. Rinse was noted at 170 F (supposed to be 165 F) The final rinse was noted at 110 F (supposed to be 180 F). (Photographic evidence) On 02/06/2023 at 11:40 AM, the Dietary Manager stated that for a few months they were already providing the residents with disposables cups for cold and hot drinks. The Dietary Manager explain this was done because when the dish machine runs for extensive periods of time the power goes off, thus the reason the facility decides to wash only the plates, silver wear, and bowls for the soup and the facility was using disposable cups and glasses. They are working on the electrical systems. As soon as they fix it, we will start using the regular cups and glasses. On 02/06/2023 at 01:15 PM, the Dietary Manager stated, when the problem started the Administrator has been in charge of getting electricians to come and check, but up to now they had not fixed it. On 02/06/2023 at 01:18 PM, the Administrator stated, that the dish machine has been giving some problems a few days ago but the Director of Maintenance, would have more information about that. On 02/07/2023 at 09:35 AM during the second observation the Dishwashing was in progress. It was noted that the [ brand] multi tank machine high temp sanitization dishwashing machine temperature gauge for the wash temperature was 160 F (supposed to be 150 F), gauge for rinse was noted at 175 F (supposed to be 165 F) and the gauge for final rinse was noted at 190 F (supposed to be 180 F). On 02/07/2023 at 09:40 AM, the Dietary Manager stated that the day before the final rinse temperature was low because a switch, the Buster, was off and they did not check it before they started the cycle to wash the dishes. On 02/07/2023 at 09:54 AM the Maintenance Director, stated that he has been working in the facility for eleven months already. The problem with the dish washing machine is due to an overload in the buildings' electricity. There is a project going on with the electricity and the city. This issue with the dishwashing machine has been ongoing for around two months, since then the facility has been trying to fix it. Record review revealed the electrician invoice showed that the work was completed on 12/2022 but the problem still existed. Review of the Resident Council Meeting dated 11/30/2022 with start time 10:00 AM and adjourned time 11:30 AM revealed in attendance with residents were the Administrator, Social Director, and Activities Director. All members were informed the facility continues to use disposable utensils during mealtimes due to the dishwashing machine currently not working. The December Resident Council Meeting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 If continuation sheet Page 15 of 16 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Terrace of Hialeah, The 190 W 28th Street Hialeah, FL 33010 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some notes dated 12/30/2022 with start time 10:30 AM and adjourned time 11:30 AM revealed, residents were informed that the facility continues to use disposable utensils during mealtimes due to dishwasher currently not working. Residents understood and did not share any concerns with the information shared with them. Review of the facility's policies and procedures revealed: Guideline: The dining service staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food. Procedure: 1. All dishwashing machines should be operated according to manufacturer recommendations. Tableware, utensils, and pots and pans should be cleaned and sanitized in either a high-temperature dishwashing machine that uses hot water, or chemical-sanitizing dishwashing machine that uses a chemical sanitizing solution. 2. Check the dishwashing machine before first use. If the dishwashing machine has not been used several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function. 3. If the machine is found to be out of the acceptable range for either final rinse temperature or proper chemical sanitizing concentration, do not proceed to wash dishes. Empty dishwashing machine, check nozzle and empty bottom screen and restart the dishwashing machine. 4. If the dishwashing machine cannot be repaired in timely manner, the facility will utilize the manual dishwashing procedure. Paper good may be used as a temporary measure until the dishwashing machine is repaired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 If continuation sheet Page 16 of 16