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