Above average — CMS composite of the measures below.
The next survey window likely opens around September 2026
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 Nursing Center during CMS and state inspections, most recent first.
Failure to follow EBP during direct resident care. CNAs provided peri-care, toileting assistance, linen care, bed-making, and transfers for residents with active EBP orders related to MRSA, a suprapubic catheter, and wounds while wearing gloves but no gowns, despite EBP signage posted on room doors. Staff later stated they missed the signs or forgot to don gowns, and the IP and DON confirmed gowns and gloves were required for close-contact care and linen handling.
Late Medicare Non-Coverage Notice: A resident receiving skilled PT did not receive the NOMNC within the required timeframe. The resident’s Medicare-covered skilled services were ending, but the SNF ABN was signed only one day before the last covered day. The Administrator stated business staff misunderstood the timing requirement, and the facility policy required notice at least two days before the end of the covered stay.
Inaccurate MDS coding affected two residents. One resident had an order for O2 via NC and multiple documented O2 sat readings while on oxygen, but the MDS did not include oxygen therapy in Section O. Another resident had documented anxiety and adjustment disorder diagnoses on the admission record, but the significant change MDS did not include those psychiatric diagnoses in Section I. The MDS Coordinator acknowledged both omissions and stated the assessments needed correction.
Inaccurate PASRR screenings were completed for two residents with documented mental health diagnoses. One resident’s PASRR did not include major depressive disorder or PTSD, and another resident’s PASRR did not include anxiety disorder or adjustment disorder with depressed mood. The MDS Coordinator stated the screenings needed to be updated, and the Social Services Director said PASRRs are checked after admission for diagnosis accuracy before submission.
Medications were administered outside physician-ordered parameters for two residents. One resident received metoprolol and clonidine when SBP was below the hold threshold, and another resident received PRN hydrocodone-acetaminophen multiple times when pain scores were below the ordered range. The DON and LPNs acknowledged the medications were given out of parameters.
Failure to sanitize a food thermometer probe between testing different foods. In the kitchen, the Dietary Manager checked the internal temp of pureed eggs and then used the same probe on pureed ham without cleaning or sanitizing it first. The DM later stated she should not have done that, and the facility’s temperature-taking guidance required the thermometer to be sanitized between uses in different foods.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in medication administration and restorative care. One resident received medication without the required vital signs being recorded, while another had incomplete documentation for a splint application. The DON confirmed the lapses in documentation, which were against the facility's policies.
The facility failed to follow infection control standards during medication administration and wound care. An LPN handled medications without gloves and did not sanitize a blood pressure cuff after use. Another LPN did not perform hand hygiene between steps of a wound care procedure. These actions violated the facility's policies, which require gloves for medication handling and hand hygiene during wound care.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure staff followed enhanced barrier precautions during high-contact care for residents with active orders for enhanced barrier precautions. During observation, a CNA provided peri-care to a resident with an order for enhanced barrier precautions related to MRSA while wearing gloves but no gown, despite signage posted on the room door. In interview, the CNA stated a gown should have been worn and that PPE was stored in the hallway. Additional observations showed multiple CNAs providing direct care without gowns for residents with enhanced barrier precaution orders. One resident with an active MRSA-related order was receiving bedside care, linen collection, and bed-making while staff wore gloves but no gowns, and staff later stated they had missed the signage or were unaware of the order. Another resident with a history of MRSA was receiving toileting assistance while the CNA wore gloves but no gown. A fourth resident with orders for enhanced barrier precautions related to a suprapubic catheter and wounds was being transferred from bed to chair by two CNAs, both wearing gloves but no gowns. The Infection Preventionist and DON stated staff should wear gowns and gloves during close contact care, including toileting, transferring, hygiene, dressing, bathing, and linen changes.
Late Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) to Resident #18 within the required time frame for the end of Medicare-covered skilled services. Review of the resident’s NOMNC showed that Medicare coverage for the current skilled services was to end on 6/11/2025, and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) stated that beginning on 6/12/2025 the resident may have to pay out of pocket for physical therapy if other insurance did not cover the costs. The resident acknowledged receipt of the notice and signed it on 6/10/2025. During interview, the Administrator stated that business staff were training and believed the notice had to be given two days from 6/12/2025, the day the resident would become responsible for services, instead of two days before the last covered day of services ended. The facility policy titled Advance Beneficiary Notices stated that the notice must be provided at least two days before the end of a Medicare-covered Part A stay or when all Part B therapies are ending.
Inaccurate MDS Coding for Oxygen Therapy and Behavioral Health Diagnoses
Penalty
Summary
The facility failed to ensure accurate MDS assessments for a resident receiving respiratory services and a resident with behavioral health diagnoses. For the resident reviewed for respiratory services, the physician order specified oxygen PRN at 2 L via nasal cannula to maintain oxygen saturation greater than 92%, and the resident’s vital records documented multiple oxygen saturation readings while on oxygen via nasal cannula. However, the Medicare 5-Day MDS assessment did not include any information for oxygen therapy in Section O, Special Treatments, Procedures, and Programs. During interview, the MDS Coordinator stated the oxygen coding needed to be corrected because the nurses were documenting oxygen saturation in the vitals but not documenting the use of oxygen. For the resident reviewed for behavioral health, the admission record listed diagnoses including adjustment disorder with depressed mood and other specified anxiety disorders. The significant change MDS assessment did not document anxiety disorder or adjustment disorder with depressed mood in the psychiatric/mood disorder section or in the active diagnosis section of Section I. During interview, the MDS Coordinator stated the MDS did not include the diagnosis of anxiety or adjustment disorder and would need to be corrected. The facility policy stated residents are assessed using a comprehensive assessment process to identify care needs and develop the interdisciplinary care plan.
Inaccurate PASRR Screenings for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure accurate Level I PASRR screenings were completed for 2 of 3 residents reviewed for mood and behavior. Resident #27 was admitted with diagnoses of major depressive disorder and post-traumatic stress disorder, but the PASRR dated 9/9/2025 did not document either condition as a mental illness under Section I: PASRR Screen Decision Making. During interview, the MDS Coordinator stated the PASRR did not include depressive disorder or PTSD and needed to be updated. Resident #31 was admitted with diagnoses of other specified anxiety disorders and adjustment disorder with depressed mood, but the PASRR dated 9/9/2025 did not document anxiety disorder as a mental illness under Section I: PASRR Screen Decision Making. During interview, the MDS Coordinator stated the original PASRR did not include anxiety or adjustment disorder and needed to be updated. The Social Services Director stated PASRRs are uploaded from admission and that diagnoses are checked within 24 to 48 hours for accuracy; if diagnoses are not accurate, they are updated before submission.
Medications Given Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure medications were administered according to physician-ordered parameters for 2 of 7 residents reviewed for medication management. For one resident with atrial fibrillation and hypertension, the physician ordered Metoprolol Tartrate 25 mg twice daily with instructions to hold for systolic blood pressure less than 110 and heart rate less than 60, and Clonidine HCl 0.1 mg twice daily with instructions to hold for systolic blood pressure less than 110. The MAR showed both medications were administered when the resident's blood pressure was 107/68 and 109/68, which was below the ordered hold parameter. An LPN stated that if a check was documented, the medication was given, and that the medications should not have been administered. For another resident, the physician ordered Hydrocodone-Acetaminophen 5-325 mg every 6 hours as needed for non-acute pain with a pain level of 6-10. The MAR showed the medication was administered multiple times when the documented pain level was 0, 1, 4, or 5, including repeated administrations across several days. The DON stated after reviewing the records that the medications were administered out of parameters and that nurses should check parameters and physician orders and follow the doctor's orders. An LPN stated the medication order was not recalled, and another LPN stated it was an oversight and the medication was given without following the parameters.
Failure to Sanitize Food Thermometer Probe Between Foods
Penalty
Summary
The facility failed to ensure staff cleaned and sanitized the thermometer probe between testing temperatures of different food items. During an observation in the main kitchen, the Dietary Manager tested the internal temperature of pureed eggs with a food temperature probe and then used the same probe to test pureed ham without cleaning or sanitizing it between uses. During an interview immediately afterward, the Dietary Manager stated she should not have tested the pureed ham without cleaning the probe first. Review of the facility’s document for taking food temperatures stated that the thermometer must be sanitized between uses in different foods and that, between uses at one meal, an alcohol swab may be used to sanitize, with a new swab used for each sanitizing.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to ensure accurate medical records for two residents, leading to deficiencies in medication administration and restorative nursing care. For one resident, the physician's order required the administration of Cardizem Oral Tablet 30 mg every 8 hours for hypertension, with specific parameters to hold the medication if the heart rate was less than 60 or systolic blood pressure was less than 100 or 110, depending on the date. However, the Medication Administration Record (MAR) showed instances where the medication was administered without recording the necessary vital signs, marked as 'not applicable' or 'out of parameter.' The Director of Nursing (DON) confirmed that the staff did not input the required parameters into the electronic record, and attempts to locate the missing vitals were unsuccessful. Another resident's physician order required the application of a left-hand splint daily as part of a Restorative Nursing Program. The task sheet for this resident showed multiple instances where the splint application was documented as 'not applicable,' rather than recording the time applied or noting if the resident refused. The DON acknowledged that the staff should not have recorded the splint application as 'not applicable.' The facility's policies on charting and drug administration emphasized the importance of recording medications given and services performed in the resident's chart, which was not adhered to in these cases.
Infection Control Deficiencies in Medication Administration and Wound Care
Penalty
Summary
The facility failed to adhere to infection control standards during medication administration and wound care, as well as in the disinfection of reusable medical equipment. During medication administration, an LPN was observed handling medications without gloves and failing to discard a capsule that fell onto the medication cart, instead placing it back into the medication cup for a resident. Additionally, the LPN did not sanitize a manual blood pressure cuff after use, placing it back into the basket without cleaning it. These actions were contrary to the facility's policies, which require gloves to be worn when handling medications and medical equipment to be sanitized between uses. In a separate incident, another LPN, who was also a Unit Manager, did not perform hand hygiene between steps of a wound care procedure for a resident. The LPN removed gloves after taking off a dressing but failed to wash hands before donning a new pair of gloves and continuing with the wound care. This was in violation of the facility's policy, which mandates hand hygiene after glove removal and between different steps of wound care to prevent contamination. These deficiencies were acknowledged by the staff involved and the Director of Nursing, who confirmed the expected procedures.
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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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Nursing homes near Live Oak
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Live Oak Healthcare And Rehabilitation Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Suwannee Valley Nursing Center | 15.8 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Center | 16 mi | ★★★★★ | 11 | 0 |
| Lafayette Nursing And Rehabilitation Center | 20.3 mi | ★★★★★ | 11 | 0 |
| Solaris Healthcare Lake City | 20.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.