Health inspection·December 5, 2025

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** Based on observations, record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one (Resident #9) out of 6 residents reviewed for resident assessments. As evidenced by inaccurate coding of MDS for Special Treatments, Procedures, and Programs related to Oxygen therapy for Resident #9. There were 235 residents residing in the facility at the time of this survey. The findings include. During several observations on 12/02/25, 12/03/25, 12/04/25 and 12/05/25 Resident#9 was in bed with oxygen running via nasal canula.Review of the medical records for Resident #9 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to: Chronic Obstructive Pulmonary Disease (COPD)Review of the Physician's Orders Sheet for December 2025 revealed Resident #9 had orders that included but not limited to: 07/13/25-oxygen (O2) at three Liters per minute (LPM) via nasal canula (NC) continuously every shift.Record review of Resident # 9's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) unable to be determined. Section O for Special Treatments documented the resident is receiving hospice care. Oxygen therapy is not coded.Review of Resident #9's Care Plan Reference Date 11/23/25 revealed: Resident has potential for ineffective breathing pattern related to: Shortness of Breath, COVID+(resolved), (COPD), depends on continuous oxygen. Interventions include- Change Oxygen Tubing and Humidifier every night shift on Sunday. Administer oxygen as ordered.Interview on 12/05/2025 at 7:26 AM Minimum Date Set Coordinator (Staff A) stated: For assessments of the residents, we go to see the residents physically, read the residents' doctor orders, nurses' notes and medical documents of the residents to complete the assessment. The resident was not coded for oxygen therapy on the quarterly assessment dated [DATE]. The resident has an order in the system for continuous oxygen; a mistake was made in not coding the oxygen therapy in section O for Special treatments on the most recent quarterly assessment.Review of the facility policy and procedure titled MDS Assessment completion and Accuracy dated 09/2022 states: 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. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 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 observation, interviews, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) for one (Resident # 16) out of two sampled residents, as evidenced by not including Serious Mental Illness (SMI) diagnosis on the resident's PASARR form. There were 235 residents residing in the facility at the time of the survey. The findings include.Record review of a policy titled Preadmission Screening and Resident Review (PASARR) revealed it is the policy of the facility to ensure that all residents receive a PASARR in accordance with State and Federal requirements and that the PASARR is updated whenever mental health diagnoses or conditions change. Observations on 12/02/25 at 10:43 AM Resident #16 was awake in low bed, on 12/03/25 at 11:58 AM and on 12/04/25 at 12:26 PM Resident #16 was observed in room being fed by staff no concerns noted.Resident #16 was initially admitted on [DATE] and re-entered the facility on 12/11/24 with medical diagnoses that included Parkinson's Disease without Dyskinesia, Mood Disorder due to a Known Physiological Condition (Unspecified), Bipolar Disorder, Generalized Anxiety Disorder, and Major Depressive Disorder, Single Episode, Unspecified.Record review of a Significant Change - No PPS MDS dated [DATE] revealed Section A had no mention of the PASARR. Section C documented a BIMS score of 6, indicating moderate to severe cognitive impairment. Section I showed the resident had diagnoses of Anxiety, Depression, and bipolar disorder. Section N showed the resident did not receive any antipsychotic medications but did receive antidepressant and anti-anxiety medications. Record review of the care plan, with a review start date of 12/10/25 and target completion date of 03/08/26 included a focus on the use of anti-anxiety medication for an anxiety disorder, use of antidepressant medication for depression and insomnia, with goals for the resident to remain free from adverse reactions related to therapy. Interventions included monitoring and documenting reactions such as drowsiness, confusion, impaired judgment .hostility or hallucinations .prevention of over-sedation . or suicidal thoughts and obtaining psychological services when needed.Record review of a physician's orders dated 08/21/25 showed an active order for Clonazepam 1 milligram (mg) tablet, to be given twice daily for anxiety. Record review revealed the admission PASARR provided by the hospital and the PASARR completed by the facility did not document the resident's mental health diagnoses of depression, anxiety, and bipolar disorder after these diagnoses became effective and began receiving treatment for these mental health conditions.During an interview on 12/02/25 at 6:53 PM the Social Services Director stated: Upon review of the admission PASARR completed at the facility and the PASARR provided by the hospital at the time of admission, findings were compared and verified. Neither PASARR contained the diagnoses listed in the medical record. The diagnoses of depression and anxiety were identified after admission and therefore were not reflected on the admission PASARR. The resident was later diagnosed with bipolar disorder. Social Services acknowledges that the PASARR should have been updated when these diagnoses became effective. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure oxygen therapy was delivered as prescribed for five residents (#9, #90, #214, #240, and #258) out of 37 residents on oxygen therapy. As evidenced by oxygen observed being administered at incorrect rates via nasal cannula from concentrators. There were 235 residents residing in the facility at the time of the survey. The findings include.During observations on 12/02/25 at 10:13 AM, 12/03/25 at 08:46 AM Resident # 9 was in bed with oxygen (02) running via nasal canula (NC) at 3.5 liters per minute (lpm).On 12/04/25 at 11:57 AM Resident # 9 was in bed with oxygen running via nasal canula at 3 liters per minute (lpm).Review of the medical records for Resident #9 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to: Chronic Obstructive Pulmonary Disease (COPD)Review of the Physician's Orders Sheet for December 2025 revealed Resident # 9 had orders that included but not limited to: 07/13/25-oxygen (O2) at three (3) Liters per minute (lpm) via nasal canula (NC) continuously every shift.Record review of Resident # 9's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) unable to be determined. Section GG for Functional Abilities documented dependent for care. Section J for Health Conditions documented Shortness of breath or trouble breathing when lying flat. Section O for Special Treatments documented the resident is receiving hospice careReview of Resident # 9's Care Plan Reference Date 11/23/25 revealed: Resident has potential for ineffective breathing pattern related to: Shortness of Breath, COVID+(resolved), (COPD), depends on continuous oxygen. Resident will have normal breathing pattern as evidenced by good skin color, and regular respiratory rate/pattern by next review date. Interventions include- Administer oxygen as ordered .During observation on 12/02/2025 at 9:35 AM Resident # 90 in bed, 02 running at 3 lpm via NCOn 12/03/2025 at 9:04 AM Resident # 90 observed in bed asleep 02 running at 2 lpm, no distress noted.On 12/04/2025 at 11:46 AM Resident # 90 observed in bed asleep 02 running at 2lpm via NC. Review of the medical records for Resident # 90 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Chronic Obstructive Pulmonary Disease (COPD). Respiratory disorders in diseases classified elsewhere, Acute and Chronic Respiratory failure with hypoxia, severe persistent Asthma with (acute) exacerbation.Review of the Physician's Orders Sheet for December 2025 revealed Resident # 90 had orders that included but not limited to: oxygen (O2) at two Liters per minute (lpm) via nasal canula (NC) continuously every shift.Record review of Resident # 90's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) unable to be determined. Section GG for Functional Abilities documented dependent for care. Section J for Health Conditions documented Shortness of breath or trouble breathing when lying flat. Section O for Special Treatments documented the resident is receiving oxygen therapy.Review of Resident # 90's Care Plan Reference Date 10/14/25 revealed: Resident is at risk for altered respiratory status/difficulty breathing r/t asthma, COPD, episodes of shortness of breath, pneumonia, Acute and chronic respiratory failure with Hypoxia. On oxygen continuously. The resident will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Interventions includeAdminister oxygen as ordered. During observation on 12/02/2025 at 10:16 AM Resident # 214 in bed oxygen (02) running at 2.5 lpm via NCOn 12/03/2025 at 8:48 AM Registered Nurse (Staff B) revealed Resident #214 went to the hospital last night for diagnosis of Pneumonia after review of lab results by the physician.Review of the medical records for Resident #214 revealed the resident was admitted to the facility on [DATE] and readmitted Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some [DATE]. Clinical diagnoses included but not limited to: Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure. Morbid (severe) obesity with alveolar hypoventilation. Chronic Obstructive Pulmonary Disease, unspecifiedReview of the Physician's Orders Sheet for December 2025 revealed Resident #214 had orders that included but not limited to: oxygen (O2) at three Liters per minute (lpm) via nasal canula (NC) continuously every shift.Record review of Resident # 214's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental status score (BIMS) 3, indicating the resident is cognitively impaired. Section GG for Functional Abilities documented dependent for care. Section J for Health Conditions documented Shortness of breath or trouble breathing when lying flat. Section O for Special Treatments documented the resident is on oxygen therapy.Review of Resident # 214's Care Plan Reference Date 11/03/25 revealed: Resident have potential for alteration in respiratory functioning related to Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea, continuous 02, history of respiratory failure. Resident will be free from respiratory distress through next review date. Interventions include-Administer oxygen as ordered, During Observation on 12/02/2025 at 9:38 AM Resident #240 in bed asleep 02 running at 3 lpm via NC.During observation on 12/03/2025 at 9:03 AM Resident #240 was out of the facility for dialysis, and at 10:46 AM the resident was back from dialysis and in bed asleep with 02 at running at 2 lpm via NC.On 12/04/2025 at 11:45 AM Resident#240 in bed asleep, 02 running at 2 lpm via NC.Review of the medical records for Resident #240 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Other Sequelae of Cerebral Infarction.Review of the Physician's Orders Sheet for December 2025 revealed Resident #240 had orders that included but not limited to: oxygen (O2) at two Liters per minute (lpm) via nasal canula (NC) continuously every shift.Record review of Resident # 240's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental status score (BIMS) 10, indicating the resident is cognitively moderately impaired. Section GG for Functional Abilities documented dependent for care. Section J for Health Conditions documented no shortness of breath. Section O for Special Treatments documented the resident is receiving oxygen therapy and Dialysis.Review of Resident #240's Care Plan Reference Date 11/06/25 revealed: Resident is at risk for altered respiratory status/difficulty breathing related to Congestive Heart Failure, episodes of shortness of breath. 02 continuous. The resident will maintain normal breathing patterns as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Interventions include- Administer medication/inhalers/nebulizers as ordered. Administer oxygen as ordered. Monitor 02 saturations as ordered/as needed Encourage adequate rest periods in between tasks/activities.During observation on 12/02/2025 at 9:55 AM Resident #258 in bed asleep, 02 running at 2.5 lpm via NC.On 12/03/2025 at 8:58 AM Resident # 258 in bed, receiving care 02 running at 2 lpm via NC.On 12/04/2025 at 11:51 AM Resident # 258 moved to another room, 02 running at 2lpm via NC.Review of the medical records for Resident # 258 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Chronic Obstructive Pulmonary Disease (COPD)Review of the Physician's Orders Sheet for December 2025 revealed Resident #258 had orders that included but not limited to: oxygen (O2) at two (2) Liters per minute (lpm) via nasal canula (NC) continuously every shift.Record review of Resident # 258's admission Minimum Data Set (MDS) dated [DATE] revealed: MDS in progress.Review of Resident # 258's Care Plan Reference Date 12/01/25 revealed: Resident is at risk for altered respiratory status/difficulty breathing related to Anxiety, COPD, episodes of shortness of breath, pneumonia. The resident will maintain normal breathing patterns as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105803 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the review date. Interventions include- Administer medication/inhalers/nebulizers as ordered. Administer oxygen as ordered. Monitor 02 saturations as ordered/as needed. Encourage and assist resident to elevate head of bed to facilitate breathing as toleratedInterview on 12/05/2025 at 12:52 PM Registered Nurse (RN), (Staff C) 7:00 AM to n3:00 PM shift, [NAME] House Unit stated: At the beginning of my shift, I make my rounds for all my assigned residents, for my residents on oxygen therapy, I check the orders in the system and make sure they match the rate on the concentrator, ensure the head of the bed is elevated, check their oxygen saturation and take vital signs. After my initial rounds at the beginning of my shift. I check on all my assigned residents at least every two hours and as needed.Interview on 12/05/2025 at 01:00 PM, Staff D, RN 7:00 AM to 3:00 PM shift, [NAME] House Unit stated: I have on my assignment right now five (5) residents with continuous oxygen, I know what their orders are, I am the regular nurse on the unit. for those residents when I start my shift, I check the concentrators to make sure they are running at the correct rate, ensure the head of the bed is elevated, check the oxygen saturation and take vital signs. After my initial rounds at the beginning of my shift. I check on all my assigned residents at least every two hours and as needed. I know that sometimes other staff that go into the residents' room may bump or hit the concentrators by accident and may cause the flow rate to go up or down, I am also aware that it is my responsibility as the assigned nurse to make sure the residents' oxygen is running at the correct rate at all times, that is why I make sure to check on the residents on oxygen therapy at least every two hours.Review of the facility policy and procedure Titled Oxygen Concentrator revision date 05/04/23 states: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. Staff responsible for the use and care of oxygen concentrators receive training on oxygen safety and the functionality of the device.Oxygen is administered under orders of the attending physician, except in the case of an emergency. Event ID: Facility ID: 105803 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 105803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2025 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observation, interviews, and record review, the facility failed to develop and implement an effective Quality Assurance and Performance Improvement (QAPI) program. As evidenced by repeat citations related to F0584 - Housekeeping and Maintenance, F0645 - Pre-admission Screening and Resident Review (PASARR, F0695 - Respiratory Care and F0867- QAPI/Quality Assessment and Assurance (QAA) Improvement Activities). There were 235 residents residing in the facility at the time of the survey. The findings include. Review of the facility's survey history revealed during the recertification survey with an exit date of 06/26/2024, the facility was cited: F0584: Safe/Clean/Comfortable/Homelike Environment; F0645-PASARR (Preadmission Screening and Resident Review), for incomplete PASARR documentation, and F0695-Respiratory/Tracheostomy Care and Suctioning for failure to ensure prescribed respiratory care and F0867- QAPI/Quality Assessment and Assurance (QAA) Improvement Activities).During the current survey with an exit date of 12/05/2025, the surveyors identified repeated deficient practices for: F0584: Safe/Clean/Comfortable/Homelike Environment; F0645- PASARR (Preadmission Screening and Resident Review), and F0695: Respiratory/Tracheostomy Care and Suctioning. Interview with the Administrator on 12/05/2025 at 7:18 PM, revealed the QAA committee meets on the first Friday of each month and the last meeting was held on November 7, 2025 the committee includes the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Admissions, Social Services, MDS, Activities, Dietary, Wound Care, Restorative Nurse, Infection Preventionist, Therapy, Central Supply, Housekeeping, Maintenance, Committee Physician, and Pharmacy. the QAA committee is meant to improve the quality of care and services by reviewing practices, identifying problems or opportunities for improvement, and putting corrective actions in place. It's a team effort, and everyone's input is used to find solutions and make improvements. When asked how the committee knows when an issue comes up, staff said concerns are raised during daily morning meetings, through audits, or staff reporting processes and issues are reviewed by department heads during rounds, prioritized based on risk and resident impact, and addressed immediately if they are high risk. The QAA committee revisits interventions to make sure they are working, provides re-education if needed, and incorporates staff feedback to ensure corrective actions stay effective with setting a timeframe, usually about three months, and then review progress. Monitoring is ongoing through rounds, audits, teachable moments, monthly town halls, and safety committee activities. The committee tracks improvement using audits, observations, and comparing reports to previous data to make sure interventions are working. Review of the policy titled Quality Assurance and Performance Improvement (QAPI) and dated 11/28/2012 revealed that nursing home QAPI is the coordinated application of two mutually reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving. Quality Assurance (QA): QA is the specification of standards for quality of care, service and outcomes, and systems throughout the facility for assuring that care is maintained at acceptable levels in relation to those standards Event ID: Facility ID: 105803 If continuation sheet Page 7 of 7