Inspection·January 8, 2021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview was conducted on 01/08/2021 at 08:10 a.m. with the Director of Rehabilitation regarding observations of Resident #98 and her concern that she was not wearing the physician ordered abductor wedge pillow between her legs while seated in a wheelchair. The Director of Rehabilitation indicated that if it was a physician order, her expectation was that Resident #98 should be wearing it. The Director of Rehabilitation confirmed the physician order in the Clinical Medical Record, and also indicated that the abductor wedge was typically labeled just abductor pillow on the care plan, and not separated between abductor wedge pillow and abductor pillow, which the latter was applied, while the resident was in bed. An interview was conducted on 01/08/2021 at 09:09 a.m., with Staff M, Licensed Practical Nurse (LPN). Staff M, (LPN) was asked who places the abductor wedge between the resident's legs when in the wheelchair for LE positioning. He indicated that he puts it on the resident and that she has never refused to wear it in all the time he has been the resident's nurse. He was further asked why the resident was not wearing it on 01/06/2020, and also why there was no documentation for that day in the MAR for the device being applied or not applied. Staff M, (LPN) was not able to provide an answer. During an interview with the Director of Nursing (DON) on 01/08/2021 at 9:18 a.m., she was informed of observations made of Resident #98. The DON reported that she was made aware of the situation from the Director of Rehabilitation. The DON stated that the CNA should be putting it on and the nurse should visually inspect that it was on since they are responsible for charting on it, or at lease verify it is place. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105319 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 105319 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Terrace Health Care Center 105 Trinity Lakes Dr Sun City Center, FL 33573 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews the facility did not ensure appropriate physician's orders were obtained and implemented for nephrostomy tubes for one (#226) of 54 sampled residents. Residents Affected - Few Findings included: A review of Resident #226's clinical record revealed she was admitted to the facility on [DATE] with a diagnosis of iron deficiency anemia secondary to blood loss, according to the face sheet in the admission record. Review of the admission summary dated [DATE] reflected a left iliac crest (rear) nephrostomy tube site and right iliac crest (rear) nephrostomy tube site. The 12/19/20 skin check indicated 2. other nephrostomy. Review of the care plan dated 12/22/20 and revised on 12/30/20 showed a Focus area of nephrostomy tubes. The interventions included change tubes as ordered and monitor tubes as ordered. A review of the Minimum Data Set (MDS) assessment, section H, bladder and bowel, dated 1/8/21 reflected an indwelling catheter (including Suprapubic catheter and nephrostomy tube). A review of the physician assistant progress note dated 12/28/20 reflected a hospitalization in October 2020 for AKI (acute kidney injury, large pelvic mass causing bilateral hydronephrosis s/p (status post) bilateral nephrostomy tube placement. A review of the physician's orders in the medical record reflected the following: 12/21/20 type of ostomy care every shift as needed for colostomy 12/21/20 type of ostomy care every shift as needed for ostomy care 12/21/20 change urostomy wafer and pouch every day using (wafer size and type), pouch type (closed or drainable). May use barrier paste/powder and skin prep as needed to ensure adhesion of wafer as needed for colostomy care. Change prn (as needed) for non-adhering wafer. 12/21/20 change ostomy wafer and pouch every day using (wafer size and type), pouch type (closed or drainable). May use barrier paste/powder and skin prep as needed to ensure adhesion of wafer every day shift for ostomy care. A review of the treatment administration record (TAR) for the months of December 2020 and January 2021 reflected the following: The ostomy wafer and pouch treatment for ostomy care were all signed beginning 12/22/20, three days after the resident was admitted , and the ostomy care every shift had also been signed beginning 12/21/20, two days after the resident was admitted . The colostomy care was not signed. On 1/08/21 at 10:54 AM, an interview was conducted with Staff J, LPN (licensed practical nurse). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105319 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 105319 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Terrace Health Care Center 105 Trinity Lakes Dr Sun City Center, FL 33573 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff J, LPN said Resident #226 has bilateral nephrostomy tubes. The nephrostomy tube care was Q (every) shift. The surveyor asked what type of care was provided to the nephrostomy tubes. Staff J, LPN said she empties it and checks the site daily. Staff J, LPN said she was not sure about the dressing change, she would have to look. She thinks it was daily. Staff J, LPN said she was going in right now to assess the nephrostomy tubes because she heard the stitches were pulling. Staff J, said she wasn't sure when the dressing changes were; it may be on her shift. She just does what was ordered and checks to make sure they were taken care of. On 1/08/21 at 11:05 AM, an observation was conducted with Staff J, LPN and Resident #226. Resident #226 was in her bed with the head of bed elevated to about seventy-five degrees. Resident #226 permitted the nurse to check the nephrostomy tubes. The left flank nephrostomy tube had an undated dressing that was wadded up around the tube near the insertion site with dried reddish-brown moist drainage. The site was slightly red at the insertion site and slightly macerated with sutures holding the tube in place. The right nephrostomy tube adhesive dressing was intact but full of bloody yellowish-clear drainage. The site was macerated and red. The dressing was also undated. Neither dressing was a wafer with pouch as indicated in the physician orders. Staff J, LPN said sometimes the doctors don't want the dressings changed until they see them for the follow up visit. She would have to check and see what the order was. In a follow up interview on 1/08/21 at 11:27 AM with Staff J, LPN she confirmed the dressings were in bad condition. She said she told the unit manager and stated that the order was not appropriate either, so she changed the dressings and the unit manager changed the order. She said she was surprised the dressings were in such bad condition, and she will have to check things herself instead of assuming they were ok. On 1/08/21 at 11:56 AM, an interview was conducted with Staff I, LPN UM (unit manager). She said Staff N, RN (registered nurse) was the unit manager on the hall for Resident #226. Staff I, LPN UM said the nurse (Staff J, LPN) told her about the dressings and asked if she (Staff I, LPN UM) knew when they were last changed. I said I did not. Staff I, LPN UM reported that on admission the UM does the admission, the chart check, the medication, puts the treatment in place, or the UM can call the doctor and get the treatments in place. The admitting nurse does the admission assessment. We do have an admitting nurse who does some of the admission assessments, but usually it was done by the floor nurse. On 1/08/21 at 12:06 PM, an interview was conducted with Staff N, RN UM for Resident #226. Staff N, RN said one of the management team and the unit managers audits the charts. Whoever discovers the area would notify the physician and get treatment orders. Staff N, RN UM confirmed Resident #226 had nephrostomy tubes. Staff N, RN UM said that treatment for nephrostomy tubes would be to cleanse with normal saline, check for signs and symptoms of infection, and check the tube. The treatment was a split dressing and secure with paper tape. The surveyor asked if the treatment that had been ordered was appropriate. Staff N, RN UM said, Not typically, we would use that on an ostomy or urostomy. Staff N, RN UM also said it was brought to his attention that Resident #226 didn't have a nephrostomy treatment, so he notified the physician and put the treatment order in today. The surveyor asked about the treatments that were signed indicting they were being done and Staff N, RN UM said he would have to look into it. On 1/08/21 at 12:32 PM, an interview was conducted with the DON (director of nursing) and NHA (nursing home administrator). The DON said Staff I, LPN UM reported Resident #226 had a dressing on and the surveyor didn't see an order for a dressing. Staff N, RN UM said the surveyor asked him who does (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105319 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 105319 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Terrace Health Care Center 105 Trinity Lakes Dr Sun City Center, FL 33573 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 0684 Level of Harm - Minimal harm or potential for actual harm the reviews. The DON said she thinks there was a batch order and nephrostomy was not an option, so they didn't change it. The DON confirmed the treatment was not an appropriate nephrostomy dressing order. She confirmed the treatments had been signed for a colostomy and urostomy. When they did her skin check they should have realized she had nephrostomy tubes and put in correct orders for flushing and dressing. Residents Affected - Few On 1/08/21 at 1:43 PM, another interview was conducted with the DON. She said Resident #226 could get an incisional site infection if they don't change the dressings regularly. The DON also said she spoke to the nurses and they said they have been changing the dressings everyday until yesterday when the resident refused. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105319 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 105319 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Terrace Health Care Center 105 Trinity Lakes Dr Sun City Center, FL 33573 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure an indwelling urinary catheter bag and tubing was maintained off the floor to prevent potential infection for one resident #(243) during two of two observations, of 5 residents with catheters. Findings included: On 1/05/21 at 4:30 PM, an observation of Resident #243 revealed he was lying in bed with the urinary catheter bag and tubing on the left side of the bed hanging from the bed frame and resting on the floor. The catheter bag was completely on the floor. On 1/07/21 at 8:44 AM, another observation was conducted. Resident #243 was in his bed watching TV. The bed was in the low position near the floor. The catheter bag was sitting completely on the floor near the head of the bed on the resident's left side facing the door. The tubing was also on the floor. On 1/07/21 at 8:46 AM, an interview and observation was conducted with Staff I, LPN UM. Staff I, LPN UM confirmed the catheter bag and tubing were on the floor. A review of Resident #243's clinical record revealed a diagnosis of obstructive and reflux uropathy according to the face sheet in the admission record. On 1/08/21 at 8:55 AM, an interview was conducted with the DON. She said the catheter should not touch the floor. The following information was found at https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html: Catheter-Associated Urinary Tract Infections (CAUTI) Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) III. Proper Techniques for Urinary Catheter Maintenance III.B.2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105319 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 105319 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sun Terrace Health Care Center 105 Trinity Lakes Dr Sun City Center, FL 33573 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record review the facility failed to ensure laboratory services were provided in a timely manner in accordance with physician orders for one (#112) of 54 sampled residents related to a lipid panel. Residents Affected - Few Findings included: A medical record review was conducted for Resident #112 to ensure that the Medication Regimen Review recommendations were being followed. A review of Resident #112's admission record revealed a diagnosis of hyperlipidemia. A review of the Pharmacist Medication Regimen Review for the last three months revealed that on 11/22/2020 a recommendation was made for a lipid panel now and every 12 months to monitor the medication of Atorvastain. There was a physician signature on the form acknowledging the pharmacist recommendation and a signature by Staff C, Registered Nurse (RN) Unit Manager (UM) that documented noted and the date of 11/30/20. Further medical record review revealed a physician's order was written in the computerized system on 11/30/2020 for a lipid panel in the a.m. and then yearly per pharmacy recommendation. A review of the lab records, however, revealed that the order was not followed through on and no lipid panel had been conducted. An interview was conducted with Staff C, RN UM on 1/7/2021 who confirmed that the order had not been conducted for the lipid panel until the surveyor asked for the resident's Medication Administration Record yesterday, 1/6/2021. On 01/08/21 at 12:19 P.M., an additional interview was conducted with the DON (Director of Nursing) in regard to following a physician's order. The DON confirmed that she was not aware that the order for the labs had not been followed through on until the surveyor had requested the documentation. Facility then had a STAT order for the labs on 1/6/2021. The DON reports that there is no facility policy for following physicians' orders as this was a standard of care. A telephone call was made to the facility Pharmacist on 1/8/2021 at 1:49 p.m. He was asked if he had expectations of the facility following recommendations. The pharmacist stated that once the physician reviews the recommendation and approves it, the facility must follow through. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105319 If continuation sheet Page 7 of 7