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Inspection visit

Inspection

SUN TERRACE HEALTH CARE CENTERCMS #1053193 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain an environment that promotes dignity and privacy for one (Resident #87) of thirty five sampled residents. Findings included: A review of Resident #87's Medical Record revealed that Resident #87 was admitted to the facility on [DATE] with diagnoses of generalized anxiety disorder and chronic obstructive pulmonary disease. A review of Resident #87's Minimum Data Set (MDS) Assessment revealed, under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 14, which indicated that Resident #87 was cognitively intact. An observation of medication administration for Resident #87 was conducted on 03/16/2022 at 09:10 AM with Staff G, Registered Nurse (RN). After pulling Resident #87's medications from the medication cart, Staff G, RN knocked on Resident #87's door and asked permission to enter the room. Resident #87 granted Staff G, RN to enter her room and administer the medications. During the observation, Resident #87 requested that Staff G, RN explain the medications that she was administering to her because there were certain medications that she did not want to take. While Staff G, RN was explaining the medications to Resident #87, Staff H, Licensed Practical Nurse (LPN) knocked on Resident #87's door and entered the room. Staff H, LPN did not ask permission to enter Resident #87's room and did not announce herself while entering Resident #87's room. While Staff H, LPN was speaking to Staff G, RN, Resident #87 asked Staff H, LPN what her purpose was for coming into the room. Staff H, LPN answered Resident #87 by stating I just needed some help. Resident #87 asked Staff H, LPN if there was anything that she needed from her. Staff H, LPN exited the room without answering Resident #87's question. After Staff H, LPN exited the room, Resident #87 became angry and stated that she felt disrespected that Staff H, LPN entered the room while Staff G, RN was explaining medications to her and that the conversation could have waited until she was done speaking to Staff G, RN. An interview was conducted on 03/16/2022 at 09:25 AM with Staff G, RN. Staff G, RN stated when entering a resident's room, staff should knock on the door and announce themselves before entering the resident's room. Staff G, RN also stated she did not hear Staff H, LPN knock before entering Resident #87's room and the conversation could have waited until she was done speaking with Resident #87. An interview was conducted on 03/16/2022 at 02:25 PM with Staff H, LPN. Staff H, LPN stated she entered Resident #87's room because she needed to speak with Staff G, RN about another resident and where to find an item for that resident. Staff H, LPN also stated she did knock on Resident #87's door (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 105319 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 03/17/2022 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few before entering, but did not ask permission to enter the room. Staff H, LPN stated she was just in a hurry and she did not think about asking for permission to enter the room at the time. An interview was conducted on 03/17/2022 at 08:06 AM with the facility's Director of Nursing (DON). The DON stated multiple staff members enter resident's rooms throughout the day and should knock on the resident's door and ask the resident for permission to enter the room. Staff should respect the resident's dignity and privacy and should only enter the room if the resident states that it is ok. The DON stated that staff should address the resident and inform them if they needed to speak to another staff member in the middle of an interaction or care. A review of the facility policy titled Resident Dignity and Personal Property, with no effective date, revealed under the section titled Policy that the facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy. The policy also revealed under the section titled Procedure that staff should care for residents in a manner that maintains dignity and individuality such as knock on doors before entering; announce your presence, and include the resident in conversation. 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 03/17/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the care plan was implemented related to preventing skin impairment for one (Resident #25) of three in-house acquired pressure injury residents, and 2. facility did not ensure to implement the plan of care for Resident # 37 regarding placement of an ankle brace and podus boots. Findings included: 1. Medical record review for Resident #37 revealed that the resident was admitted to the facility on [DATE] with a re-admission date of 1/7/22. Resident #37 had multiple diagnoses not limited to paraplegia, spinal stenosis lumbar region, difficulty walking and generalized weakness. Resident #37 is alert and oriented with a BIMS (Brief Interview for Mental Status) of 14 indicating cognitively intact. A review of Resident #37's plan of care revealed that (Effective date 3/04/22) the resident was care planned for ADL (activities of daily living) self-care performance deficit related to chronic back pain, post laminectomy, impaired ROM (range of motion). Intervention: Bilateral podus boots trial by therapy. Resident utilizes a splint (Bionic Stir up Brace) for right ankle to be worn as tolerated with sneaker. Continual trial being completed with therapy. Once trial is completed nursing staff to complete. During an interview with the resident on 03/15/22 at 10:29 AM Resident #37 reported that she hasn't had her brace for her right ankle that therapy would apply, or a podus boot. On 03/15/22 at 1:05 PM an additional interview with Resident #37 was conducted in her room as she was having lunch. She just had taken off her ankle brace because it was bothering her. She reported that staff does not put on her brace. Usually, staff member (F) will put her ankle brace on, but she hasn't been in. On 03/16/22 09:52 AM resident was observed in bed doing a cross word puzzle, no brace or podus boot on. On 03/17/22 at 9:35 AM Resident #37 reported that her podus boots were on top of the storage bin along with her ankle brace. The resident reported that her ankle brace bothered her and needs high socks, so the brace doesn't rub against her skin. On 03/17/22 09:40 AM an interview was conducted with the Director of Nursing (DON) she was not aware the resident was not wearing podus boots throughout the survey, she stated that she would look into the matter. The DON reported back on 03/17/22 at 10:31 AM, Resident #37's ankle splint should have been applied even though it was on a trial basis. Interview with Staff member (F) was conducted on 03/17/22 at 10:43 AM regarding the ankle brace and podus boots. She reported that when she is here, she will place the ankle brace on the resident which she wears 4-5 hours. Staff member (F) was asked how about when she is not in the building since, she had been on vacation for the last week. She reports that another therapist would place the brace on the resident. She was asked if she could provide documentation that the brace has been placed on (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 03/17/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm the resident since the order of 3/4/22. She was unable to provide documentation that the brace had been placed on the resident or that the resident had refused. 2. A record review of Resident #25's care plan revealed the resident sustained a skin tear on the left lower leg, dated for 1/27/22. Residents Affected - Few Resident #25's Progress Notes, dated 2/9/22 at 10:23 a.m. revealed . the nursing staff was rounding on the unit the CNA notified the nurse that during transfer of the resident the resident obtained a skin tear to the right lower leg The area was assessed by the nurse and a skin tear measuring 5x3cm [centimeters] was noticed . Resident #25's admission record revealed medical diagnoses of Parkinson's disease, unspecified dementia without behavioral disturbance, muscle weakness, and congestive heart failure. The resident's minimum data set (MDS), dated [DATE], revealed the resident has impaired cognition and requires extensive assistance with two staff members for assistance in bed mobility, and has total dependence on staff for transfers. Resident #25's care plan revealed a focus area of The resident has actual impairment to skin integrity of the . Hx [history] of skin impairments r/t [related to] fragile skin . This focus area was initiated on 1/04/2021 with interventions of applying bilateral lower extremity geri sleeves for protection of paper-thin skin. This intervention was implemented on 01/27/2022. Resident #25's order summary report revealed an active physician order, ordered on 02/10/2022 for Patient to have BLU [Bilateral Lower] BUE [Bilateral Upper] geri-sleeves. Apply in the AM and remove in the PM. every day shift Apply. An observation on 3/14/22 at 10:14 am. of Resident #25 revealed the resident lying in bed with skin discoloration on the arms. No Geri-sleeves were observed on the resident's arms. A follow-up observation of the resident on 03/15/22 at 10:59 a.m. revealed the resident in the same bed position without Geri-sleeves placed on the arms. An interview on 03/15/22 at 1:37 p.m. with Staff B, Certified Nursing Assistance (CNA) revealed the resident has very fragile skin, so it is important to be gentle during care to prevent skin tears and alterations. An observation with Staff A, CNA of the resident revealed the resident lying in bed without bilateral upper or lower extremity Geri-sleeves in place. Staff A stated placing Geri-sleeves onto a resident is a nursing duty, not a CNA duty. An interview on 03/15/22 at 1:44 p.m. with Staff C, Licensed Practical Nurse (LPN) confirmed it was a nursing responsibility to don a resident's Geri-sleeves. Staff B confirmed the resident required Geri-sleeves for both the arms and legs, but the physician order does not specify what time of the shift the sleeves should be donned. Staff B stated she was going to don the resident's Geri-sleeves before the end of her shift. The staff member's shift ended at 3p.m. An online medical record task review for the resident with Staff B, LPN confirmed and revealed the start of the task was 7 a.m. and ended at 3 p.m. An interview with the Director of Nursing (DON) on 03/15/22 at 2:06 p.m. confirmed a CNA can place Geri-sleeves onto a resident. (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 03/17/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A follow-up interview at 2:34 p.m. on 03/15/22 with the DON revealed the physician order for the Geri-sleeves does not specify a timeframe because they are meant to be donned when care is being provided. Resident #25 is super high risk for skin tears. Therefore, the Geri-sleeves are meant to be donned during care, such as when a Hoyer lift is used, to prevent skin tears and breakage. A follow-up interview on 03/16/22 at 09:55 a.m. with Staff B, LPN confirmed she was the nurse on duty the day the resident sustained a skin tear during a Hoyer lift transfer. The skin tear occurred on the resident's leg. An interview on 03/16/22 at 10:13 a.m. with Staff D, CNA confirmed her presence during the Hoyer lift transfer in which the resident sustained a lower leg skin tear. Staff C confirmed knowledge that a CNA can don a resident's Geri-sleeves and stated staff must be very careful when providing care due to the resident being at high-risk for skin tears. Staff C stated herself and another CNA placed the resident into the Hoyer lift sling and got her into the chair. They then noticed blood on the floor and looked around to see where it was coming from. That is when they noticed a skin tear on the resident's leg, so they reported it to the nurse. During this interview, Staff D stated the resident only had Geri-sleeves for arm protection, but not for the legs/lower extremities. Therefore, during this care transfer event, nothing was donned to the resident's legs to prevent skin alteration. Further review of Resident #25's care plan revealed a focus area for The resident has potential for impaired skin integrity, initiated on 2/07/2022. Interventions for this focus area included placing Geri-sleeves to the bilateral lower extremities, initiated on 6/24/2021. An interview with the Director of Nursing (DON) on 03/17/22 at 9:02 a.m. revealed CNAs are allowed to don a resident's Geri-sleeve. the resident sustained a skin tear on the lower leg during a Hoyer lift transfer. The Hoyer lift slings compress the person and move against the skin, so for someone like Resident #25 with very fragile skin, could cause a sheering effect. The Geri-sleeves act as a extra layer of skin to assist in skin protection and skin integrity. The DON confirmed the goal is to implement a resident's care plan. 3. A policy review of Baseline, Resident Centered Comprehensive Care Plans, & Care Plan Summary, copyrighted in 2018, revealed the purpose of the policy is Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuality of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur . Included within the procedures is . Comprehensive Care Plans must be developed within 7 days after completion of the comprehensive assessment . and review and revise the care plan after each assessment . If the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes must be incorporated into an updated summary provided to the resident and his or her representative, if applicable. 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 03/17/2022 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement pressure injury prevention measures for one (Resident #25) of three residents sampled for in-house acquired pressure ulcers. Residents Affected - Few Findings included: Resident #25's admission record revealed medical diagnoses of Parkinson's disease, unspecified dementia without behavioral disturbance, muscle weakness, and congestive heart failure. The resident's minimum data set (MDS), dated [DATE], revealed the resident has impaired cognition and requires extensive assistance with two staff members for assistance in bed mobility, and has total dependence on staff for transfers. Further review of the resident's MDS revealed the resident is at risk for developing pressure ulcers/injuries. The resident has one or more unhealed pressure ulcers/injuries. Resident #25's care plan revealed a focus area for The resident has potential for impaired skin integrity, initiated on 2/07/2022, with interventions of encouraging patient to float heels whenever in the bed, initiated on 5/28/2021 Resident #25's order summary report revealed active physician orders for Skin prep to bilateral heels every shift for DTI [deep tissue injury] right heel, ordered on 05/28/2021, and Float heels when in bed on 2 pillows every shift for DTI right heel, ordered on 05/28/2021. Resident #25's order summary report revealed an active physician order revealed active physician orders for Skin prep to bilateral heels every shift for DTI right heel, ordered on 05/28/2021, and Float heels when in bed on 2 pillows every shift for DTI right heel, ordered on 05/28/2021. An observation on 3/14/22 at 10:14 am. of Resident #25 revealed the resident lying in bed without pillows in place to float the resident's heels. A follow-up observation of the resident on 03/15/22 at 10:59 a.m. revealed the resident in the same bed position without pillows in place to float the resident's heels. An interview on 03/15/22 at 1:37 p.m. with Staff B, Certified Nursing Assistance (CNA) revealed the resident has very fragile skin, so it is important to be gentle during care to prevent skin tears and alterations. A pillow is placed behind her arm and hip to assist with position. The resident is currently being treated for a pressure injury on the back of her leg on her thigh I think and on her heel. Staff B confirmed the resident did not have pillows underneath her feet. Staff B stated the resident had the pillows underneath her heels at night and so they were removed to give her a break from the elevation. An observation on 03/15/22 at 1:44 p.m. with Staff C, Licensed Practical Nurse (LPN) around Resident #25's room revealed no pillows were available to place underneath the resident's feet/heels. Staff C stated the purpose of floating a resident's heels is to prevent and/or assist in preventing the development of a deep tissue injury/pressure ulcer. An interview on 3/15/22 at 2:06 p.m. with the Director of Nursing (DON) confirmed the resident is (continued on next page) 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 03/17/2022 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete at risk for pressure ulcers. The DON confirmed that when a resident is in bed, the expectation would be for the heels to be floated. The DON confirmed the expectation is for pillows to be underneath the resident's heels to float them to reduce the risk of developing a pressure ulcer. A policy review of Skin Integrity, dated 09/2017, revealed the purpose is To provide consistent assessment and evaluation, monitoring, documentation, and implementation of therapeutic interventions to heal and maintain skin integrity, unless clinically unavoidable. To promote the prevention of pressure ulcer/injury development; To promote the healing of existing pressure ulcers/injury (including prevention of infection to the extent possible); and to prevent development of additional pressure ulcer/injury. Underneath the section Assessment/Evaluation, revealed A resident care plan will be created to assist with maintaining intact skin integrity, prevention of pressure ulcers of healing of any non-intact skin. Care plan will include measurable goals and appropriate interventions . treatment orders will be implemented per Physician's orders. Event ID: Facility ID: 105319 If continuation sheet Page 7 of 7

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Citations

3 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0550GeneralS&S Dpotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0686GeneralS&S Dpotential for harm

    F686 - Skin Integrity

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

FAQ · About this visit

Common questions about this visit

What happened during the March 17, 2022 survey of SUN TERRACE HEALTH CARE CENTER?

This was a inspection survey of SUN TERRACE HEALTH CARE CENTER on March 17, 2022. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SUN TERRACE HEALTH CARE CENTER on March 17, 2022?

Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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