Inspection·June 6, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete has to be changed again within 24 hours. We should not use gauze for our PICC line dressing. We should be using only a transparent dressing applied over a bio patch. Review of the facility policy and procedure titled Catheter Insertion and Care with the last approval date of 2/22/2024 read, Policy: Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated loosened or soiled catheter site dressings . General guidelines . 4. Use a sterile, transparent, semi-permeable membrane (TSM) or gauze dressing. If gauze dressing is used, cover the gauze with TSM dressing and change the dressing every 48 hours. 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 06/06/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the areas of the kitchen, walk-in cooler, walk-in freezer, reach-in freezer, and stock room (Photographic evidence obtained). Findings include: During an observation while conducting a walk-through tour of the kitchen with the Dietary Manager (DM) on 6/3/2024 starting at 8:40 AM, there were one large, perforated pan with raw chicken pieces thawing that was not in running water or covered; one sheet pan with 20 packages containing meat products with no identifying label or date on the pan or packages; three cases of health shakes, each containing 72 individual cartons, that were completely thawed and were in a case that read, Keep Frozen; and three containers containing pesto with no date or identifying label in the walk-in cooler. There was one opened large clear bag of a breaded food product with no label or date on the product in the walk-in freezer. There was French fries left opened and exposed to the elements in the reach-in freezer. During an interview on 6/3/2024 at 8:45 AM, the DM stated that the raw chicken on the large pan should have been submerged under running water. The DM confirmed the large sheet pan with 20 packages of meat product found in the walk-in cooler was deli turkey and did not have a label or date. The DM stated that the cases of health shakes should have been stored in the freezer as marked and the amount pulled to thaw according to the prescribed health shakes needs. The DM confirmed that the pesto containers should have been labeled or kept in the original container and dated. The DM stated that the food product found open in the walk-in, and reach-in freezer should have been closed properly, labeled, and dated according to policy. During an observation while conducting the follow-up kitchen tour with the DM on 6/4/2024 at 6:30 AM, there were one large and uncovered clear container with white dry powdery content with no identifying label or date in the kitchen prep area; one pan with a white substance partially covered in plastic with part of the product exposed with no label or date, on the bottom shelf of the prep table; one opened container of dry instant mashed potatoes; one chemical spray bottle marked heavy duty degreaser on the shelf between the exposed pan and the opened potato container; approximately 190 glass plates and bowls that were not inverted or covered in a shelf in the kitchen; two opened bread packages with use-by dates of 5/26 and 6/02; five pans of food that had no identifying label in the reach-in refrigerator; and one large opened bag of sugar with no opened date. During an interview on 6/4/2024 at 6:45 AM, the DM confirmed that the observed products had no label or date and identified the large clear container with dry powdery content as food thickener. The DM identified the pan with a white substance that was partially exposed as flour. The DM stated that the chemical spray bottle should not have been stored near any food products. The DM stated the glass plates and bowls should have been stored inverted or covered and were not stored properly. The DM verified the bread product was outdated and should have been discarded on the labeled dates of 5/26 and 6/02. Review of the facility policy and procedure titled Thawing with no date read, Purpose: Foods are thawed properly to prevent food borne illness. Procedure . 2. Thaw foods according to one of the following choices as indicated . Submerged under running water. (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 06/06/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the facility policy and procedure titled Food Storage Overview with no date read, Procedure . 5. Chemicals must be clearly labeled, kept in original containers when possible, and kept in a locked area away from food . 8. All stock is to be rotated . b. Food should be dated with date received as it is placed on the shelves . Refrigerator Storage: 12. Leftover food is stored in covered containers or wrapped securely. Each item is clearly labeled and dated before being refrigerated . 14. Refrigeration . e. Foods are to be covered, labeled, and dated including month, day, and year . Freezer Storage: 15. Frozen Foods . c. All foods should be covered, labeled, and dated including month, day, and year. 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 06/06/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 of 3 reviewed residents with PICC (Peripherally Inserted Central Catheter) line, Resident #104. Findings include: Review of Resident #104's physician order dated 5/14/2024 read, Dressing change every week and PRN [as needed]. RUA [Right Upper Arm] Measure length of line and circumference of arm upon admission/insertion then weekly. To measure length start from hub of PICC line to insertion site on forearm, to measure arm circumference measure at the insertion site around the forearm. Continue weekly until line discontinued. Document the length of line & circumference of arm upon admission/insertion below. PICC Line Length [blank] cm [centimeter]. Arm Circumference: [blank] cm, every day shift every 7 day(s) for IV [Intravenous] maintenance, Report s/s [sign and symptom] of infections/infiltration/dislodgement to MD [Medical Doctor]. Change dressing weekly and document measurement of line. Review of Resident #104's Medication Administration Record (MAR) for May 2024 and June 2024 revealed no documentation for PICC line length or arm circumference for 5/14/2024, 5/21/2024, 5/28/2024 and 6/4/2024. During an interview on 6/5/2024 at 11:50 AM, the Director of Nursing stated, I've spoken with those nurses and the measurements were done but not documented. During an interview on 6/5/2024 at 12:00 PM, Staff C, Registered Nurse (RN), stated, I did the dressing changes on 5/14, 5/28 and 6/4 and measured the length of the line and the circumference. I did not document the measurements. During an interview on 6/5/2024 at 12:20 PM, Staff B, RN, stated, I did the dressing change on 5/21/2024 and measured the length of the line and the circumference, but did not document the measurements. During an interview on 6/5/2024 at 12:50 PM, the Director of Nursing stated, PICC lines are to be measured for length and circumference of insertion site are to be measured and documented on the TAR with weekly dressing changes. Review of the facility policy and procedure titled Catheter Insertion and Care with the last review date of 2/22/2024 read, Documentation: 1. The following information should be recorded in the resident's medical record . c. Any complications, interventions that were done. 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 06/06/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff used proper PPE (Personal Protective Equipment) while providing high-contact care for 1 of 3 residents reviewed for transmission-based precautions, Resident #341, and failed to ensure staff performed hand hygiene between residents during meal tray delivery to help prevent the possible development and transmission of communicable disease and infections. Residents Affected - Few Findings include: Review of Resident #341's physician order dated 6/4/2024 showed that it read, Enhanced Barrier Precautions for Dx [diagnosis] Wound every shift nurse to verify correct door signage and equipment present. During an observation on 6/5/2024 at 8:01 AM, Resident #341's door had a sign posted for Enhanced Barrier Precaution (EBP) use. Staff D, Certified Nursing Assistant (CNA), wore gloves, but no gown, opened Resident #341's shared bathroom door from inside the bathroom and pushed Resident #341 in her wheelchair into the resident's room. After exiting Resident #341's bathroom with the resident, Staff D doffed her gloves and threw them in the trashcan. Without performing hand hygiene or wearing a gown and gloves, Staff D proceeded to wheel the resident to her bedside, helped her adjust positions in the wheelchair and pulled the resident's bedside stand, containing the resident's breakfast tray, to the resident. Without performing hand hygiene or wearing a gown and gloves, Staff D removed the covers from the breakfast item containers and juice drinks and placed the resident's eating utensils on the plate containing the food items. Staff D exited the resident's room, proceeded down the hallway and performed hand hygiene in the dirty utility room sink. Review of the Enhanced Barrier Precautions Sign by the CDC (Centers for Disease Control and Prevention) visibly posted on Resident #341's room door showed that it read, STOP: Enhanced Barrier Precautions. Everyone Must: Clean their hands, including before entering and when leaving a room. Providers and Staff Must Also: Wear gloves and a gown for the following high-contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound care: any skin opening requiring a dressing. During an observation from 8:01 AM through 8:17 AM, Staff D, CNA, returned from Resident #341's room to the breakfast tray cart and grabbed the breakfast tray for Resident #119 and entered the resident's room. Staff D placed the breakfast tray on the resident's bedside table, removed the food item and drink container covers, opened, and placed the condiments in the resident's coffee cup for Resident #119 and placed the resident's eating utensils onto the plate of food for the resident. Without performing hand hygiene, Staff D proceeded to Resident #339's bed in the same room and touched Resident #339 on the right shoulder, adjusted her top covers, and spoke to her before exiting the room. Without performing hand hygiene before or after direct contact with Resident #339, Staff D then returned to the breakfast tray cart and grabbed the breakfast tray for Resident #342. Staff D proceeded to Resident #342's room and assisted Resident #342 with setting up his tray, moved his food containers and drink containers to within reach of the resident, adjusted his bed height with the remote and moved his bedside table in front of the resident in bed. Staff D exited Resident #342's room without performing hand hygiene, proceeded to the breakfast tray cart, grabbed the dining tray for Resident #339 and entered the resident's room and placed the tray on Resident #339's bedside table. Staff D, without performing hand hygiene, donned a pair of gloves, adjusted Resident #339's pillow, assisted (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 06/06/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her with repositioning up in bed, elevated the head of the bed, adjusted the resident's covers, removed the lids from the food and drink containers and assisted the resident with her utensils. Without doffing her gloves, Staff D returned to Resident #119's bedside, picked up her tray cover off the floor and set it on Resident #119's bed. Staff D then doffed her gloves in the trashcan and exited the room. During an interview on 6/5/2024 at 8:18 AM, Staff D, CNA, stated, I didn't wash my hands before or after resident care or between moving between residents while delivering their meals or helping with tray set up and care. I should have sanitized my hands before and after each tray delivery before moving on to the next resident. For the resident on Enhanced Barrier Precautions [Resident #341], I should have worn a gown and gloves when I helped her in the bathroom. I only wore gloves. I did not wash my hands after I removed the gloves. I should wear a gown and gloves as soon as I enter the room for a resident on EBP, especially when helping them with toileting or personal care. During an interview on 6/5/2024 at 8:35 AM, the Director of Nursing (DON) stated, The staff should be performing hand hygiene before and after care with each resident, including tray delivery between every resident. The nursing staff should be wearing a gown and gloves when performing her [Resident #341] peri-care and toileting. Review of the facility policy and procedure titled Isolation- Precautions Overview; SNF & ALF with the last review date of 2/22/2024 showed that it read, Purpose: To provide a system of isolation precautions to prevent the transmission of infection. To prevent the transmission of infectious diseases. Procedure: 1. The guidelines contain two tiers of precautions, Standard Precautions and Transmission Based Precautions (Airborne, Enhanced Barrier, Droplet and Contact Precautions) . Enhanced Barrier Precautions- refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs [Multidrug Resistant Microorganisms] to staff hands and clothing. Review of the facility policy and procedure titled Infection Prevention- Hand Hygiene with the last review date of 2/22/2024 showed that it read, Overview: The facility will follow the Center for Disease Control (CDC) Guidelines for handwashing/hand hygiene. Handwashing/hand hygiene is the single most important procedure for preventing nosocomial infections. The facility requires personnel to wash hands thoroughly to remove dirt, organic material, and transient microorganisms. Handwashing is mandated between resident contact in an effort to prevent the spread of infection. Hands must be washed after the following, including, but not limited to . Contact with contaminated items or surfaces . Contact with resident . Removal of gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105319 If continuation sheet Page 7 of 7