Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Surrey Place Healthcare And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to meet state-mandated staffing requirements, with CNA hours falling below the 2.0 minimum on two occasions and weekly averages below 3.6 for eight weeks. Errors in staffing records and reliance on a non-compliant corporate form contributed to the deficiency. Interviews revealed a lack of formal training for the staffing coordinator and inconsistencies in recording staffing hours.
The facility failed to ensure proper hygiene in the kitchen, with staff not washing hands or changing gloves between handling soiled and clean dishes. Additionally, a resident was found with rotten fruit on her bedside table, which staff did not remove despite facility policies requiring the disposal of perishable foods. The Dietary Manager and Director of Nursing acknowledged these issues but did not take corrective action during the observations.
The facility failed to provide bed-hold notices during transfers for three residents. A resident was sent to the ER without a documented bed-hold notice, despite the policy being in the admission agreement. Another resident transferred for a procedure also lacked a documented notice, with the Social Services Director admitting to verbal notifications without documentation. A third resident transferred due to a condition change had no bed-hold notice recorded, with the Nursing Home Administrator acknowledging the need to review the notification process.
A resident was not provided with her physician-ordered hearing aids, leading to difficulty hearing. Staff interviews revealed that a CNA did not put in the hearing aids, and an RN failed to verify their use before signing off on the treatment record. The DON emphasized the expectation for nurses to ensure orders are completed.
Two residents in an LTC facility were observed with their catheter bags and tubing improperly positioned, dragging on the floor, which posed potential risks for accidents and infections. Despite care plans and facility policies requiring proper positioning, staff failed to consistently address the issue, leading to a deficiency in providing adequate care.
The facility failed to provide timely and complete Nursing Home Transfer and Discharge Notices for residents transferred to acute care facilities. In emergencies, notices were often completed after the resident's return, lacking necessary explanations and representative information. The Social Service Director admitted to delays and incomplete documentation, contrary to facility policy requiring written notice of transfer reasons.
The facility failed to provide timely transfer notices for two residents transferred to acute care facilities. One resident was transferred due to a change in condition, and the other for a medical procedure. Notices were completed post-transfer, lacking required information and timely delivery, indicating non-compliance with federal regulations.
The facility failed to ensure accurate Level I PASRR screenings for two residents prior to admission. One resident was admitted with mental health diagnoses not reflected in the initial PASRR screen, while another resident's PASRR screen did not indicate the presence of serious mental illness, leading to a missed Level II evaluation. Interviews revealed that PASRR screenings were often inaccurate from hospitals, and the facility lacked a PASRR policy.
Two residents in an LTC facility were observed with urinary catheter bags and tubing touching the floor, creating potential safety hazards. Despite having care plans and orders for catheter use due to urinary retention, the facility failed to ensure proper positioning of the equipment. Staff, including RNs and CNAs, confirmed awareness of the issue but did not consistently address it, contrary to the facility's policy.
A facility failed to accurately document a resident's clinical record when the resident was not present. Despite being transferred to an acute care facility, a Daily Medicare Nursing Note was recorded, detailing a physical assessment. Interviews with staff revealed inconsistencies, with an LPN acknowledging a potential mistake and the ADON confirming the resident's discharge. The facility's documentation policy emphasizes accuracy, which was not met in this instance.
During a facility tour, it was observed that an exit door in the therapy gym was not latching properly, failing to meet NFPA 101 (2012 Edition) standards. This was confirmed by facility maintenance staff.
Failure to Maintain Minimum Staffing Requirements
Penalty
Summary
The facility failed to maintain the minimum staffing requirements as mandated by state regulations. Specifically, the facility did not meet the required 2.0 direct care hours by certified nursing assistants (CNAs) on two occasions out of ninety-two days. Additionally, the facility failed to maintain a weekly average of 3.6 direct care hours per resident for eight out of fourteen weeks during the survey period. The discrepancies were identified through a review of the facility's staffing records, which showed incorrect calculations and inconsistencies in the reported staffing hours. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) provided multiple copies of staffing records, which contained errors and corrections. The initial records did not include weekly averages, and subsequent records showed incorrect calculations of CNA and nursing hours. Interviews with the staffing coordinator revealed that the facility did not use the state form for recording staffing hours but relied on a corporate Key Factor form, which did not accurately reflect the weekly averages required by state regulations. The staffing coordinator admitted to learning the role without formal training and acknowledged issues with call-offs affecting staffing levels. Further interviews with the Assistant Business Office Manager (ABOM) and the staffing coordinator highlighted a lack of clarity and consistency in recording and reporting staffing hours. The ABOM, new to payroll, relied on instructions from the NHA and the staffing coordinator to adjust hours to meet state requirements. The facility's assessment indicated a reliance on a formula to determine staffing needs, but the actual staffing levels fluctuated and occasionally fell below the state minimum requirements. The facility's failure to maintain accurate and compliant staffing records contributed to the deficiency identified during the survey.
Plan Of Correction
The Certified Nursing Assistant's (CNA) Per Patient Day for the specific dates were reviewed. No actions warranted due to the time has passed. The weekly direct care staffing hours for the specific weeks of /24, /24, /24 and for the quarter of through for meeting the weekly direct care average of 3.6 per patient day staffing requirement were reviewed. No actions are warranted due to the time has passed. An audit was conducted on the other 6 weeks which are /24, and for the Quarter through for meeting the minimum staffing requirements of 2.0 per patient day daily for Certified Nursing Assistants and the weekly average of direct care staffing of 3.60 per patient day. The results of the audit found that there were no other days during that specific quarter that the daily Certified Nursing Assistant staffing or the weekly average of direct care staffing did not meet the minimum staffing requirement of 2.0 per patient day and 3.6 per patient day respectively. On the Administrator initiated education for the Director of Nursing, Staffing Coordinator, Business Office Manager, Assistant Business Office Manager/Payroll, Rehab Director and the Activity Director related to meeting the daily minimum staffing for Certified Nursing Assistants of 2.0 per patient day and the definition of direct care staffing and meeting the required minimum weekly average of the 3.6 per patient day for direct care staff. Education was completed by The Director of Nursing/designee will audit the Certified Nursing Assistant staffing and direct care staffing 5 times per week for 12 weeks to ensure that the facility is meeting the Certified Nursing Assistant and direct care staffing requirements. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement Committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Deficiencies in Kitchen Hygiene and Food Storage Practices
Penalty
Summary
The facility failed to ensure proper hygiene practices were followed by staff working in the kitchen, specifically in the dishwashing area. Observations revealed that staff members handling soiled dishes did not wash their hands or change gloves before handling clean and sanitized dishes. This was observed on multiple occasions over several days, with staff members moving directly from handling soiled items to clean items without appropriate hand hygiene. The Dietary Manager was present during some of these observations but did not intervene to correct the staff's actions. Additionally, the facility did not adhere to proper food safety and storage procedures for a resident. The resident was observed with rotten fruit on her bedside table for two days, which she intended to eat later. The Director of Nursing acknowledged that the resident was difficult and did not allow staff to remove the food, but stated that the staff should have reported the situation to a nurse or to her. The facility's policy requires nursing staff to discard perishable foods within three days or before the expiration date, and to discard any food showing signs of potential foodborne danger. The facility's policies on dishwashing and handwashing were not followed, as evidenced by the lack of handwashing between handling soiled and clean dishes. The Dietary Manager provided policies that outlined the need for maintaining dishwashing machines in a clean condition and for staff to practice good handwashing to minimize the risk of foodborne illness. However, these policies were not adhered to during the observed incidents, contributing to the deficiencies noted in the report.
Plan Of Correction
On the Certified Dietary Manager (CDM) provided education to the identified dietary staff on proper hygiene when working in the dish room with dirty/soiled and clean dishes. This included proper glove use and washing before putting gloves on or after taking gloves off. The Certified Dietary Manager (CDM) initiated education on hygiene and proper glove use with the other dietary staff. In addition, dietary staff were provided information about the dish machine that included the facility has a low temperature, chemical sanitizing dish machine. The education was completed by The Registered Dietician reviewed and provided input for updates related to the facility policy for Handwashing for Dietary Staff. The Certified Dietary Manager/designee is doing a minimum of 3 observations per week for 12 weeks related to dietary staff hygiene compliance when they are working with dirty/soiled dishes and clean dishes while in the dish room. The Certified Dietary Manager/designee will review the observations with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee. On , Resident #14 was assessed for any potentially hazardous food at bedside. No adverse effects noted. On , all resident rooms were assessed to ensure that there was no potentially hazardous food at bedside. No additional areas of concern identified. On , the current policy related to Storage of Foods Brought to Residents by Family/visitors was reviewed and updated. The Director of Nursing (DON)/designee initiated education for Department Heads, nursing, and housekeeping staff related to food storage at bedside/in the resident room. The education was completed by The Director of Nursing/designee will complete 10 observations each week for 12 weeks to ensure that there is no potentially hazardous food being stored at bedside in a resident's room. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Failure to Provide Bed-Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to provide a bed-hold notice at the time of transfer for three residents who were hospitalized. For Resident #55, the nursing notes indicated a transfer to the Emergency Room for evaluation following an incident, but there was no documentation of a bed-hold notice being provided to the resident or their representative. Although the facility's Admission and Financial Agreement, signed by the resident's family member, described the bed-hold policy, there was no evidence of notification at the time of transfer. Similarly, Resident #60 was transferred to an acute care facility for a medical procedure, but the facility's records did not include a bed-hold notice given to the resident's representative. The Social Services Director admitted to making phone calls to families regarding bed-hold options but did not document these notifications. For Resident #11, who was transferred to a hospital due to a change in condition, there was also no record of a bed-hold notice. The Nursing Home Administrator acknowledged that residents receive the bed-hold policy upon admission and stated that they would review the process with the Social Services Director to ensure proper documentation.
Plan Of Correction
The facility is unable to provide residents #55, #60 and #11 the bed hold notice at the time of their transfer to the hospital since the date of their discharge has passed. Residents #55, #60 and #11 were re-admitted and/or returned to the facility after their emergency discharge to the hospital. Other residents discharged after with a need for an unplanned/emergent transfer/discharge will receive a bed hold form as noted in the facility Bed Hold policy. The facility policy for Bed Hold has been reviewed. On [date], the Director of Nursing/designee initiated education for the nurses, Assistant Director of Nursing, Social Service Director, and Medical Records related to the Bed Hold policy. This education was completed by [date]. The Social Service Director/designee will do a weekly audit for 12 weeks on a minimum of 3 unplanned/emergent transferred residents and/or residents on a therapeutic leave each week. Otherwise, if the facility doesn't have at least 3 unplanned/emergent transferred residents and/or residents on a therapeutic leave for that week, the Social Service Director/designee will complete the weekly audit on the number of transferred/on leave residents that the facility has for that week. This weekly audit will be done to ensure that the facility provided transferred residents written notice on the facility Bed Hold policy for residents who were transferred for hospitalization or those on a therapeutic leave. The Social Services Director/designee will review the audits with the monthly Quality Assurance Performance Improvement Committee for three months. The Quality Assurance Performance Improvement Committee will evaluate the outcome of the audits and, if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Failure to Follow Physician Orders for Hearing Aids
Penalty
Summary
The facility failed to follow physician orders for a resident who required an assistive hearing device. Observations and interviews revealed that the resident was not provided with her hearing aids when she was assisted out of bed, despite having a physician's order to wear them during the day. The resident expressed difficulty hearing because the staff did not put in her hearing aids as required. Interviews with staff members, including a CNA and an RN, indicated a lack of adherence to the physician's order. The CNA admitted to not putting in the resident's hearing aids, while the RN assumed the CNA had done so without verifying. The Director of Nurses stated that nurses are expected to ensure orders are completed before signing off on treatment records, which was not done in this case.
Plan Of Correction
On the were provided to resident #16 and placed in her. On for resident #16, the Director of Nursing (DON) completed a Medication error Reporting Form. On, all other resident records were checked; there were no other residents with a physician ordered assistive device for hearing. On the Director of Nursing/designee provided education to the direct care nurse for resident #16 on adherence and documentation related to physician ordered assistive devices for hearing. On, the Director of Nursing/designee provided education to the other nurses on adherence and documentation related to physician ordered assistive devices for hearing. The education was completed by. The Director of Nursing/designee will complete 3 audits each week for 12 weeks to ensure physician ordered assistive devices for hearing are placed in the resident's prior to the nurse signing the administration record. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Improper Positioning of Catheter Bags and Tubing
Penalty
Summary
The facility failed to provide adequate care and services to prevent injuries for two residents who were observed with their catheter bags and tubing improperly positioned. Resident #123 was seen with her catheter bag and tubing dragging on the floor while she was seated in her wheelchair, posing a potential risk for accidents and infection. The resident's medical records indicated she had a history of retention and was using a catheter, which was supposed to be positioned off the floor according to her care plan. However, the nursing staff, including Staff E, RN, were unaware of the improper positioning of the catheter bag and tubing. Similarly, Resident #124 was observed with her catheter bag and tubing touching the floor on multiple occasions. The tubing was seen in excess tension and was even run over by the wheelchair tires when a visitor repositioned the resident. Resident #124's medical records showed a history of retention and the use of a catheter, with care plans specifying the need for proper positioning of the catheter bag and tubing. Despite these care plans, the staff, including CNAs Staff F and G, confirmed they had observed the improper positioning but did not consistently address it. Interviews with the Director and the Director of Nursing revealed that they were not aware of the issues with the catheter bags and tubing touching the floor. The facility's policy on catheter care emphasized the importance of securing the tubing and positioning the drainage bag off the floor, yet this was not adhered to in practice. The failure to follow these procedures led to the deficiency in providing adequate and appropriate health care to the residents involved.
Plan Of Correction
On the for resident #123 was positioned and secured properly so the bag nor the tubing touched the floor. On the for resident #124 was positioned and secured properly so the bag nor the tubing touched the floor. On , all other residents identified with were checked for proper positioning and securing so the bag nor the tubing of the touched the floor. For these other residents, no area of concern identified. On the Director of Nursing (DON)/designee initiated education for nurses, certified nursing assistants and staff related to proper positioning and securing of bags/tubing. Education completed by The Director of Nursing/designee for all residents with will do an audit 2 times a week for 12 weeks to ensure proper positioning and securing the tubing for those residents with so no bag or tubing for are touching the floor. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Deficiencies in Transfer and Discharge Notice Procedures
Penalty
Summary
The report identifies deficiencies in the handling of Nursing Home Transfer and Discharge Notices for residents being transferred to acute care facilities. Specifically, the facility failed to provide timely and complete discharge notices to residents and their representatives. In the case of Resident #11, the notice was signed by the Social Service Director (SSD) and the resident, but the Nursing Home Administrator expressed uncertainty about how residents could sign the notice during emergency transfers. Similarly, for Resident #60, the notice lacked a brief explanation to support the transfer action and did not include resident representative information. The SSD admitted that notices were often completed after the resident returned from the hospital, due to the emergency nature of the transfers. The facility's policy on transfer and discharge requires that residents and their representatives be notified in writing of the reasons for transfer or discharge. However, the SSD acknowledged that in 9 out of 10 cases, the transfer was an emergency, and the resident or family was not present to sign the notice. The SSD also mentioned that the notices were typically uploaded into resident records but might still be in the office. The facility's policy allows for immediate notice in cases where the resident's urgent medical needs require a transfer, but the report indicates that the facility did not consistently adhere to this policy, resulting in incomplete and delayed notifications.
Plan Of Correction
Do a weekly audit for 12 weeks on a minimum of 3 discharged residents each week. Otherwise, if the facility doesn't have at least 3 discharges per week, the Social Service Director/designee will complete the weekly audit on the number of discharges the facility has for that week. This weekly audit will be done to ensure that the facility provided discharged residents the Nursing Home Transfer and Discharge Notice form per the facility policy. The Social Service Director or designee will review the audits with the monthly Quality Assurance Performance Improvement Committee for three months. The Quality Assurance and Performance Improvement Committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Failure to Provide Timely Transfer Notices
Penalty
Summary
The facility failed to provide proper notice of transfer before initiating a transfer for two residents, which is a violation of the regulatory requirements. Resident #11 was admitted with multiple diagnoses, including acute failure, and experienced a change in condition that led to a recommendation for hospital transfer. The facility issued a Nursing Home Transfer and Discharge Notice after the transfer, which was signed by the Social Service Director and the resident post-transfer, indicating a lack of timely notification. Resident #60 was transferred to an acute care facility for a medical procedure, but the Nursing Home Transfer and Discharge Notice was not completed with all required information. The notice lacked a brief explanation to support the transfer action and did not include the resident representative's information. The notice was signed by the resident after the transfer, which suggests that the facility did not provide the notice in advance as required. Interviews with facility staff, including the Nursing Home Administrator and the Social Services Director, revealed a misunderstanding or misapplication of the notice requirements, particularly in emergency situations. The facility's policy on transfer and discharge notice was not followed, as evidenced by the delayed completion and signing of the notices. This deficiency highlights the facility's failure to adhere to federal regulations regarding timely and complete notification of transfers or discharges.
Plan Of Correction
The facility is unable to have residents #55, #60 and #11 sign the Nursing Home Transfer and Discharge Notice at the time of discharge to the hospital since the date of their discharge has passed. Residents #55, #60 and #11 were re-admitted and/or returned to the facility after their emergency discharge to the hospital. Other residents discharged after will receive the Nursing Home Transfer and Discharge Notice based on the facility policies. The facility policy for Notice of Transfer and/or Discharge was reviewed. On the Director of Nursing/designee initiated education for the nurses, Assistant Director of Nursing, Social Service Director and Medical records related to the facility Notice of Transfer and Discharge policy and Making an Emergency Transfer or Discharge policy. The education included the Nursing Home Transfer and Discharge Notice form. This education was completed by The Social Service Director/designee will do a weekly audit for 12 weeks on a minimum of 3 discharged residents each week. Otherwise, if the facility doesn't have at least 3 discharges per week, the Social Service Director/designee will complete the weekly audit on the number of discharges the facility has for that week. This weekly audit will be done to ensure that the facility provided discharged residents the Nursing Home Transfer and Discharge Notice form per the facility policy. The Social Service Director or designee will review the audits with the monthly Quality Assurance Performance Improvement Committee for three months. The Quality Assurance and Performance Improvement Committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Inaccurate PASRR Screenings for Two Residents
Penalty
Summary
The facility failed to ensure accurate Level I Preadmission Screening and Resident Review (PASRR) screenings for two residents prior to their admission. Resident #41 was admitted with diagnoses including adjustment disorder with mixed anxiety and depressed mood, and major depressive disorder. However, the initial Level I PASRR screen completed by a Licensed Clinical Social Worker at a hospital did not identify these mental illness diagnoses. A subsequent PASRR screen completed by a Registered Nurse at the facility also failed to include all necessary diagnoses, leading to an incomplete and inaccurate assessment. Resident #16 was admitted with diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms, and unspecified anxiety disorder. The Level I PASRR screen for this resident did not accurately reflect the presence of serious mental illness, as it marked that no diagnosis or suspicion of serious mental illness was indicated. This oversight resulted in the resident not being flagged for a Level II PASRR evaluation, which is required for individuals with serious mental illness or intellectual disabilities. Interviews with the facility's MDS Coordinator and Director of Nursing (DON) revealed that the PASRR screenings were often inaccurate when received from hospitals, and there was no existing PASRR policy at the facility. The MDS Coordinator acknowledged the need for a Level II PASRR review for Resident #16 and confirmed that the facility's PASRR processes were not being conducted accurately, as evidenced by the incorrect screenings for both residents.
Plan Of Correction
A new Preadmission Screening and Resident Review (PASRR) was completed on 3/14/25 for resident #41 to include anxiety. On Resident #16, Preadmission Screening and Resident Review (PASRR) was re-evaluated by the Minimum Data Set (MDS) Coordinator, and a Level II Preadmission Screening and Resident Review (PASRR) was requested and submitted to the Florida Preadmission Screening and Resident Review Portal. The Minimum Data Set (MDS) Coordinator received a response from the Florida Preadmission Screening and Resident Review Portal on the outcome of the Level II request for resident #16, and it was denied. The Minimum Data Set (MDS) Coordinator initiated an audit of the Level I Preadmission Screening and Resident Reviews (PASRRs) for all current residents to ensure the Level I Preadmission Screening and Resident Reviews are correct based on each individual resident. Identified corrections were addressed, and the appropriate corrections were made. In addition, as noted in the Statement of Deficiency, the Minimum Data Set (MDS) Coordinator recently participated in a Webinar by the Florida Preadmission Screening and Resident Review Portal. This educational Webinar addressed proper completion for Level II Preadmission Screening and Resident Reviews (PASRRs). The education included the need for a Level II Preadmission Screening and Resident Review (PASRR) to be submitted for a resident. Education was provided by the Minimum Data Set (MDS) Coordinator to the Admissions team and RN Management staff related to Level I and Level II Preadmission Screening and Resident Reviews. The education was completed by the Minimum Data Set Coordinator/designee. The Minimum Data Set (MDS) Coordinator/designee is auditing a minimum of three Preadmission Screening and Resident Reviews (PASRRs) each week for 12 weeks to ensure that the admission Preadmission Screening and Resident Reviews are accurate and the follow-up related to Level II Preadmission Screening and Resident Reviews (PASRRs) are completed. The Minimum Data Set (MDS) Coordinator/designee will review the audits with the monthly Quality Assurance Performance Improvement Committee for three months. The Quality Assurance Performance Improvement Committee will evaluate the outcome of the audits and, if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Inadequate Catheter Care Leads to Safety Hazards
Penalty
Summary
The facility failed to provide adequate care and services to prevent injuries for two residents who utilized urinary catheters. Observations revealed that Resident #123 had a catheter bag and tubing hanging below the seat of her wheelchair, with portions touching the floor. This was observed while she was scooting back and forth in her wheelchair, creating a potential hazard. The resident's medical records indicated a diagnosis of urinary retention, and she had orders for a catheter. However, the care plan did not ensure the catheter bag and tubing were kept off the floor, as confirmed by the resident's nurse, Staff E, RN. Similarly, Resident #124 was observed with a catheter bag and tubing touching the floor while seated in her wheelchair. The tubing was in excess tension and was observed touching the front wheel of the wheelchair. The resident's medical records showed a history of urinary retention and orders for a catheter. Despite this, the care plan failed to ensure the catheter bag and tubing were properly positioned, as confirmed by Staff E, RN, and CNAs Staff F and Staff G. Both CNAs acknowledged observing the catheter equipment on the floor and stated that they could reposition it or report it to a nurse. The facility's Director of Nursing provided a policy for catheter care, which stated that the drainage bag should be secured in a manner that prevents it from touching the floor. However, the policy was not effectively implemented, as evidenced by the observations of the catheter bags and tubing on the floor for both residents. The Director of Rehabilitation also confirmed that her staff should ensure proper positioning of the catheter equipment but was unaware of the deficiencies observed with Residents #123 and #124.
Plan Of Correction
On the for resident #123 was positioned and secured properly so the bag nor the tubing touched the floor. On the for resident #124 was positioned and secured properly so the bag nor the tubing touched the floor. On all other residents identified with were checked for proper positioning and securing so the bag nor the tubing of the touched the floor. For these other residents, no area of concern identified. On the Director of Nursing (DON)/designee initiated education for nurses, certified nursing assistants and staff related to proper positioning and securing of bags/tubing. Education completed by The Director of Nursing/designee for all residents with will do an audit 2 times a week for 12 weeks to ensure proper positioning and securing the tubing for those residents with so no bag or tubing for are touching the floor. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Inaccurate Documentation of Resident Assessment
Penalty
Summary
The facility failed to accurately document in the clinical record for one resident, identified as Resident #60, during a time when the resident was not present in the facility. An observation noted that Resident #60 was sitting up in bed with a meal and did not appear to be in visible distress. However, a review of the Skilled Nursing Facility/Nursing Facility to Hospital Transfer form indicated that the resident had been transferred to an acute care facility for a procedure. Despite this, a Daily Medicare A/Managed Care Nursing Note was documented, detailing a physical assessment of the resident, which included various health metrics and observations, even though the resident was not in the facility at the time. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON), revealed inconsistencies in the documentation process. The LPN acknowledged that a mistake might have been made, as it was not typical to document on a discharged resident. The ADON confirmed that the resident had been discharged and should not have been documented on, except for a hospital follow-up note. The ADON also noted that the expectation was to assess and document accurately, indicating that the note in question was incorrect. The facility's policy on clinical documentation emphasized the need for accurate and timely entries that reflect the care and services provided to residents. The policy outlined the importance of maintaining a complete account of the resident's care, treatment, and response, as well as supporting quality medical care and legal records. However, the documentation for Resident #60 did not adhere to these standards, as it included an assessment for a resident who was not present in the facility, highlighting a lapse in the facility's documentation practices.
Plan Of Correction
The Director of Nursing (DON) interviewed the nurse who entered the incorrect documentation into the medical record for Resident #60 on [date], and then followed the facility policy for incorrect documentation and struck out the incorrect documentation for Resident #60 on [date]. On [date], the Director of Nursing/designee initiated an audit on other residents discharged from [date] to [date] and there were no other residents that had documentation after discharge. On [date], the Director of Nursing provided education to the facility per diem nurse that incorrectly documented on discharged resident #60. On [date], the Director of Nursing/designee initiated education for the other nurses related to accurate and complete resident documentation on current residents only. The education was completed by [date]. The Director of Nursing/designee will complete an audit a minimum of one time per week for 12 weeks. This weekly audit will be to review discharged residents for the week to ensure that there is no incorrect documentation entered after a resident has discharged. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.
Failure to Maintain Exit Door Latching in Therapy Gym
Penalty
Summary
The facility failed to maintain exit doors in accordance with NFPA 101 (2012 Edition) during a facility tour conducted on March 12, 2025, between 9:00 a.m. and 3:00 p.m. An exit door in the therapy gym was observed to be not latching properly. This observation was confirmed through an interview with facility maintenance staff who were present during the tour. The deficiency is cited under NFPA 101 (2012 Edition) sections 19.2.2.2.1, 7.2.1, 7.2.1.5.10, and 4.6.
Plan Of Correction
On 3/12/25 the Maintenance Director/Maintenance Assistance evaluated the Exit Door in the therapy gym and made adjustments to the door so it could latch properly. ATTACHMENT #55 See corresponding email sent to area office dated 4/4/25 with attachments. On 3/12/25 the Maintenance Director inspected the other Exit Doors to ensure that the exit doors close and latch properly. During this inspection, there were no other exit doors that did not close and latch properly. ATTACHMENT #56 See corresponding email sent to area office dated 4/4/25 with attachments. On 3/12/25, the Administrator provided an inservice for the Maintenance and Therapy staff on the importance for exit doors to close and latch properly. The inservice included notifying the administrator/designee of any exit doors that do not close and latch properly and a plan to correct as indicated. ATTACHMENT #57 See corresponding email sent to area office dated 4/4/25 with attachments. The facility Maintenance Director/designee will audit facility exit doors weekly to help monitor and maintain proper latching for the facility exit doors. The monthly audit of exit doors will be recorded on a log. ATTACHMENT #58 See corresponding email sent to area office dated 4/4/25 with attachments. The Maintenance Director/designee will provide the monthly QAPI Committee a summary report on the findings from the audits of the facility exit doors for three (3) months. The QAPI committee will evaluate the outcome of the audits and if necessary amend the improvement plan and continue to monitor until sustained improvement has been determined by the committee. ATTACHMENT #59 See corresponding email sent to area office dated 4/4/25 with attachments.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Casa Mora Rehabilitation And Extended Care | 0.2 mi | ★★★★★ | 8 | 3 |
| Heritage Park Health Center By Harborview | 0.3 mi | ★★★★★ | 6 | 0 |
| Inn At Freedom Village, The | 0.5 mi | ★★★★★ | 2 | 0 |
| Aviata At Palma Sola Bay | 1.4 mi | ★★★★★ | 0 | 0 |
| Westminster Point Pleasant | 2.7 mi | ★★★★★ | 6 | 0 |
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