Sun Terrace Health Care Center

In the surveyor’s words

From the most serious findings on record at Sun Terrace Health Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jun 6, 2024

  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… […]

• No harm, potential for more than minimal, isolatedF677Jul 20, 2026

  Based on observation, interview, and record review, the facility failed to follow the comprehensive care plan and physician ordered toileting schedule for one (#4) out of four sampled. As a result, Resident #4 experienced overnight incontinence without timely care, and scheduled toileting was not consistently implemented or documented. Findings Include: During an observation and interview on 7/20/26 at 7:15 a.m., Resident #4 was seated in a wheelchair, well groomed and dressed in street clothing. During the interview, the resident became tearful, appeared stressed, and reported having a bad night. Resident #4 stated she was incontinent during the night and staff did not provide incontinent care until she was assisted with getting dressed for the day. […]

• No harm, potential for more than minimal, isolatedF689Jul 20, 2026

  Based on record review, and interviews, the facility failed to ensure that effective supervision and fall prevention interventions were implemented to prevent an avoidable fall with injury for one (Resident #6) out of three residents sampled.Review of Resident #6's Resident Information Record showed she was originally admitted on [DATE] and readmitted on [DATE]. Her diagnoses included: periprosthetic fracture around an internal prosthetic left knee joint (subsequent encounter) dated 04/30/2026; unspecified fracture of the upper end of the left humerus (subsequent encounter with routine healing) dated 02/20/2026; Type 2 Diabetes Mellitus with diabetic polyneuropathy dated 02/20/2026; fracture of the left shoulder girdle (subsequent encounter with routine healing) dated 02/20/2026; need for… […]

• No harm, potential for more than minimal, isolatedF691Jul 20, 2026

  Based on record review and interviews, the facility failed to ensure ostomy care was provided and documented according to the physician's orders for one (Resident #5) out of three residents reviewed for ostomy care. This failure resulted in the inability to determine whether the resident received required ostomy care and hygiene support. Findings include:Record review showed Resident #5 was admitted in October 2021 with multiple diagnoses including partial intestinal obstruction, ileostomy status, Type 2 diabetes mellitus with chronic kidney disease, vascular dementia (moderate), muscle weakness, need for assistance with personal care, hypertensive heart and chronic kidney disease with heart failure, and obstructive sleep apnea. […]

• No harm, potential for more than minimal, isolatedF684Jun 6, 2024

  Based on observation, record review, and interview, the facility failed to ensure residents received care and services for PICC (Peripherally Inserted Central Catheter) access device in accordance with professional standards of practice for 1 of 3 reviewed residents with a PICC access device, Resident #104 (Photographic evidence obtained). Findings include: During an observation on 6/3/2024 at 9:52 AM, Resident #104's PICC line was visible in right upper arm. The transparent dressing over the gauze securing PICC and insertion site was not visible. The transparent dressing was peeling off on one side. The dressing was dated 5/28/2024. During an observation on 6/4/2024 at 10:22 AM, Resident #104's PICC line was visible in right upper arm. […]