Surrey Place Healthcare And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to 1. Ensure staff who worked in the kitchen initiated proper hand hygiene in between and after touching soiled dishes and before touching clean dishes in the dish machine room, during two of four days observed (3/10/2025 and 3/12/2025), and 2. failed to follow proper food safety and storage procedures for one resident (Resident # 14) of eight residents sampled. Findings included: 1. On 3/10/2025 at 9:29 a.m., the facility's kitchen was entered and toured with Staff A, Dietary Manager. Staff A, Dietary Manager confirmed they operate a low temperature dish washing machine and pointed out the machine in the front right corner of the kitchen. The dish machine area appeared with a large mechanical dish washing machine with a metal table and table chute on the right side, which was used for soiled dishes and prerinse prior to dishes going into the dish washing machine. The left side of the machine was observed with a metal table and metal chute…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to provide a bed-hold notice at the time of transfer to three (#55, #60, and #11) of three residents sampled for hospitalizations. Findings included: 1. Review of Resident #55's admission Record revealed the resident was originally admitted on [DATE]. Review of Resident #55's Nursing Notes showed on 2/2/2025 at 11:28 a.m., Resident #55 was sent to the emergency room (ER) for evaluation following an incident. Review of Resident #55's uploaded clinical documents did not include a bed-hold notice for the resident's transfer to a higher level of care on 2/2/2025. The progress notes on 2/2/2025 did not show the resident or representative was notified of the facility bed-hold notice. Review of the facility provided admission and Financial Agreement signed by Resident #55's family member and the facility's representative on 12/10/2024 described the facility's bed-hold policy. 2. Review of Resident #60's admission Record revealed the resident was originally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide notice of transfer before a facility initiated transfer to two residents (Resident #11 and #60) out of three residents sampled for hospitalization. Findings Included: 1. Review of Resident #11's admission Record revealed Resident #11 had an original admission date of 9/9/2018 and a re-admission date of 3/7/2025. Resident #11 was admitted to the facility with diagnosis to include pneumonia, pleural effusion in other conditions classified elsewhere, sepsis, acute respiratory failure with hypoxia, dysphagia, oropharyngeal phase, and muscle weakness. Review of Resident #11's Change in Condition Evaluation, dated 3/4/2025 revealed under the section 1a. List the other change: Right Upper extremity shaking on and off; 02:88 on 2L [liters of oxygen]; sound congested. The Evaluation revealed under Recommendation of Primary Clinician(s): Transfer to hospital. Review of Resident #11's Nursing Home Transfer and Discharge Notice revealed notice was given…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure Level I Preadmission Screening and Resident Review (PASRR) screenings were accurate prior to a admission to the facility and did not follow up with a Level II PASRR screen for two residents (Resident #41 and #16) of forty-one sampled residents. Findings included: 1. On 3/10/2025 at 1:45 p.m. Resident #41 was observed in her wheelchair while therapy staff were assisting down the hallway and to the therapy gym. At 1:49 p.m. while in the gym, Resident #41 appeared anxious, but was participating in all the exercises that were presented to her. Resident #41 kept saying I just want to go home and just need to go home. On 3/12/2025 at 8:00 a.m., Resident #41 was assisted to the 300 unit nurses desk and lobby area. She was seated in her wheelchair and was awaiting a transport ride to an appointment. Resident #41 was given information that the transport van would be thirty minutes late. She then started to cry and was very anxious to get out to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, and interviews, the facility failed to accurately document in the clinical record for one resident (Resident #60) of forty-one sampled residents related to a physical assessment completed during a time the resident was not in the facility. Findings included: An observation on 3/11/25 at 8:31 a.m. revealed Resident #60 was sitting up in bed with a meal in front of her. The resident did not appear to be in visible distress. Review of a Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer form showed the resident was transferred to an acute care facility on 2/21/25 for a midline placement by the vascular team. Review of a physician order written on 2/21/25 at 2:43 p.m. instructed staff to send Resident #60 to the emergency room (ER) for re-insertion of midline by vascular team. Review of Resident #60's payor source information showed the facility stop billing on 2/21/25 and the resident became active on 2/27/25. Review of Resident #60's Daily Medicare A/Managed Care Nursing Note dated 2/22/25 at 7:07 p.m. revealed a temperature…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide catheter care and services to prevent injuries and infections for two residents (#123 and #124) of nine sampled residents who utilized indwelling catheters, during two of four days observed (3/10/2025 and 3/12/2025). Findings included: 1. On 3/10/2025 at 10:25 a.m., Resident #123's room door was observed open from the main hallway. She was observed in her room seated in her wheelchair and being visited by a family member. Resident #123 was utilizing an indwelling catheter. From the hallway, the resident was observed with the catheter bag and tubing hanging directly below the seat of the wheelchair and with the bag and approximately two inches of catheter tubing on the floor. Resident #123 was observed scooting back and forth slowly while seated in her wheelchair with the catheter tubing and bag dragging on the floor. Review of Resident #123's medical record revealed she was admitted to the facility on [DATE] and readmitted from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to update and revise a care plan to reflect a significant weight loss for one (Resident #38) of twenty-one sampled residents. Findings Included: On 5/30/2023 at 10:00 a.m., and 1: 20 p.m., 5/31/2023 at 1:00 p.m., and 6/1/2023 at 12:00 p.m., Resident # 38, was observed lying down in her bed with her head elevated and her call light within her reach. She presented without behaviors, pain, or discomfort. The room appeared clean and well lit. A review of Resident #38's admission record showed she was admitted to the facility on [DATE], with diagnoses to include but not limited to Parkinson's Disease, Unspecified, Gastro-Esophageal, Ileus Unspecified, and Reflux Disease Without Esophagitis. A review of the most current Minimum Data Set (MDS), dated [DATE], show in Section C, a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of the electronic health record weights and vital…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure recliners furnished in resident rooms were maintained in ten of thirty rooms sampled with recliners. Findings included: On 7/20/21 at 3:30 p.m. a tour of the facility revealed recliners, located in resident rooms 318, 315, 316, 313, 311, 329, 113, and 159 with peeling upholstery on the backrest and arms of the chairs. Photographic evidence was obtained. On 7/21/21 at 10:00 a.m. room [ROOM NUMBER] and 322 were observed to have a recliner with peeling upholstery on the backrest. Photographic evidence was obtained. On 7/21/21 at 10:07 a.m. an interview was conducted with Staff C, housekeeper. Staff C stated she had been employed by the facility for six years, and she is responsible for cleaning all the resident rooms daily. Staff C stated she noticed the peeling on the recliners in the resident rooms, and some are worse than others. Staff C stated the recliners would peel 'fairly soon' after they were replaced. She stated the chairs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, medical record review, the facility failed to ensure one of thirty-six sampled resident's (#44) care plans related to Urinary Tract Infection (UTI) was updated to reflect the resident had a current UTI and was receiving Antibiotics. Findings included: On 7/19/2021 at 9:40 a.m. Resident #44's room was approached, and the door was open. The resident was seated in her wheelchair by the foot of the bed and was conversing with a family/visitor. At 9:55 a.m. the visitor had left the room and Resident #44 allowed this surveyor to come in the room for an interview. During interview, Resident #44 revealed that she is currently being treated and takes medications for a Urinary Tract Infection (UTI). She revealed that this was not the first time she has had a UTI. On 7/20/2021 at 8:00 a.m. an interview with a Licensed Practical Nurse, Employee A, who had Resident #44 on his assignment, confirmed Resident #44 is currently being treated for a UTI, and has had a history of UTI. He…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to provide necessary respiratory care and services, related to storage of oxygen, nebulizer, and continuous positive airway pressure (CPAP) tubing's and supplies, consistent with professional standards of practice for three (Resident #159, Resident #158, and Resident #41) of ten residents receiving respiratory treatments. Findings included: A record review revealed Resident #159 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) as per the admission face sheet. A review of the orders for Resident #159 indicated respiratory treatments with oxygen at 2 liters per minute via nasal cannula as needed and nebulizer treatments with Ipratropium-Albuterol solution 0.5-2.5 milligrams (mg) in 3 milliliters (ml) to inhale orally every six hours for shortness of breath. On 7/19/21 at 10:21 a.m. an observation of Resident #159's room revealed the oxygen tubing draped…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews and medical record review, the facility failed to ensure resident food/drink preferences were honored during two meal services, and during one of four days observed (7/20/2021), for one of thirty-six sampled residents (#44). Findings included: On 7/20/2021 at 8:40 a.m. during an interview Resident #44 was served her breakfast meal tray. The Resident indicated it was OK to stay as she was going to therapy after breakfast and wanted to complete the interview while she was eating. When the tray was placed on the over-the-bed table, the resident stated, Oh good, OK, let me see what's under the lid. The resident then said, OK this is good. The resident looked at the rest of the tray and then told Employee B, Certified Nursing Assistant (CNA), Oh we have orange juice again on my tray, and I can't have orange juice, please take it away. Employee B took the juice and left the room. The Resident interview continued related to related to choices and likes/dislikes when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.