Health inspection·October 2, 2025

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for 1 of 2 residents reviewed for respiratory services (Resident #14) and 1 of 3 residents reviewed for behavioral health (Resident #31).Findings include:1) Review of Resident #14's physician order dated 9/22/2025 read, O2 [Oxygen] PRN [as needed] at 2 L [liter] via n/c [nasal cannula] to maintain an O2 sat [saturation] of greater than 92%.Review of Resident #14's Weights and Vital Summary documented the resident's oxygen saturation as 97% (Oxygen via nasal Cannula) on 8/29/2025 at 2:22 AM, 98% (Oxygen via nasal cannula) on 8/29/2025 at 6:30 PM, 97% (Oxygen via nasal cannula) on 8/29/2025 at 11:43 PM, 98% (Oxygen via nasal cannula) on 8/31/2025 at 1:46 AM, and 97% (Oxygen via nasal cannula) on 9/1/2025 at 12:47 AM.Review of Resident #14's Medicare 5-Day MDS assessment dated [DATE] showed no information documented for oxygen therapy under Section O. Special Treatments, Procedures, and Programs.During an interview on 10/1/2025 at 2:15 PM, the MDS Coordinator stated, [Resident #14's name] MDS Section O, the oxygen coding, needs to be corrected. The nurses were not documenting the use of oxygen, but it was being documented in the vitals oxygen saturation.2) Review of Resident #31's admission record showed the resident was admitted on [DATE] with diagnoses including but not limited to adjustment disorder with depressed mood and other specified anxiety disorders.Review of Resident #31' MDS assessment for significant change dated 8/18/2025 showed no anxiety disorder and adjustment disorder with depressed mood documented in Psychiatric/Mood Disorder or other additional active diagnoses parts of Section I. Active Diagnosis.During an interview on 10/1/2025 at 2:10 PM, the MDS Coordinator stated, [Resident #31's name] MDS did not include the diagnosis of anxiety or adjustment disorder. It will need to be corrected.Review of the facility policy and procedure titled MDS 3.0 Completion with the last review date of 4/24/2025 read, Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI [Resident Assessment Instrument] specified by the State. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents had an accurate Level I Preadmission Screening and Resident Review (PASRR) completed for 2 of 3 residents reviewed for mood and behavior (Residents #27 and #31).Findings include:1) Review of Resident #27's admission record showed the resident was admitted on [DATE] with diagnoses to include major depressive disorder with an onset date of 9/9/2025 and post-traumatic stress disorder with an onset date of 9/9/2025.Review of Resident #27's PASRR) dated 9/9//2025 showed no depressive disorder or post-traumatic stress disorder documented as mental illness under Section I: PASRR Screen Decision Making.During an interview on 10/1/2025 at 2:16, the Minimum Data Set (MDS) Coordinator stated, [Resident #27's name] PASRR does not include depressive disorder or PTSD [Post Traumatic Stress Disorder]. It will need to be updated.2) Review of Resident #31's admission record showed the resident was admitted on [DATE] with diagnoses to include other specified anxiety disorders with an onset date of 3/26/2025 and adjustment disorder with depressed mood with an onset date of 3/26/2025.Review of Resident #31's PASRR dated 9/9/2025 showed no mental illness including anxiety disorder documented as mental illness under Section I: PASRR Screen Decision Making.During an interview on 10/1/2025 at 2:17 PM, the MDS Coordinator stated, [Resident #31's name] original PASRR does not include anxiety or adjustment disorder. It will need to be updated.During an interview on 10/2/2025 at 10:15 AM, the Social Services Director stated, PASRRs are uploaded from admission. I am required to check them [PASSR] within 24 to 48 hours. Making sure that resident diagnoses are all accurate. If the diagnoses are not accurate, I will update them. Once I have completed the PASSR, I submit them to [the MDS Coordinator's name] and she will review them and submit them. I think with these two residents [Residents #27 and #31], you have to put the code twice and I think there was a mix up and the code was not input again.Review of the facility policy and procedure titled Resident Assessment- Coordination with PASARR Program with the last review date of 4/24/2025 read, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting to their needs. Policy Explanation and Compliance Guidelines: 1. a. PASARR Level I- initial pre-screening that is completed prior to admission. 6. The Social Services Director shall be responsible for keeping track of each resident's PASSAR screening status, and referring to the appropriate authority. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure medications were administered as per the parameters ordered by physician for 2 of 7 residents reviewed for medication management (Residents #7 and #27).Findings include:1) Review of Resident #27's physician order dated 9/10/2025 read, Metoprolol Tartrate Oral Tablet 25 MG [milligram] (Metoprolol Tartrate), Give 1 tablet by mouth two times a day for afib [atrial fibrillation] Hold for SBP [Systolic Blood Pressure] less than 110, hold for heart rate less than 60.Review of Resident #27's Medication Administration Record (MAR) for September 2025 for administration of Metoprolol Tartrate 25 mg showed the resident was administered the medication on 9/18/2025 at 9:00 PM for the blood pressure (BP) of 107/68, and on 9/23/2025 at 9:00 PM for the BP of 109/68.Review of Resident #27's physician order dated 9/11/2025 read, Clonidine HCl Oral Tablet 0.1 mg (Clonidine HCl), Give 1 tablet by mouth two times a day for HTN [Hypertension] Hold for SBP < [less than] 110.Review of Resident #27's MAR for September 2025 for administration of Clonidine HCl 0.1 mg showed the resident was administered the medication on 9/18/2025 at 9:00 PM for the blood pressure (BP) of 107/68, and on 9/23/2025 at 9:00 PM for the BP of 109/68.During an interview on 10/1/2025 at 2:26 PM, Staff I, Licensed Practical Nurse (LPN), stated, If there is a check documented, it means I gave the medication. I document the blood pressure, and the parameters are listed. I should have not given the medication.2) Review of Resident #7's physician order dated 9/17/2025 read, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen), Give 1 tablet by mouth every 6 hours as needed for non acute pain, pain level 6-10.Review of Resident #7's MAR for September 2025 for administration of Hydrocodone-Acetaminophen 5-325 mg showed the resident was administered the medication on 9/17/2025 at 10:00 PM for the pain level of 0, 9/18/2025 at 6:24 AM for the pain level of 0, 9/19/2025 at 12:01 AM for the pain level of 0, at 6:34 AM for the pain level of 0, and at 11:19 PM for the pain level of 4, 9/20/2025 at 6:31 AM for the pain level 0 and at 10:59 PM for the pain level of 4, 9/21/2025 at 6:44 AM for the pain level of 4 and at 11:08 PM for the pain level of 4, 9/22/2025 at 6:52 AM for the pain level of 4 and at 11:44 PM for the pain level of 1, 9/23/2025 at 11:11 PM for the pain level of 5, 9/24/2025 at 11:12 PM for the pain level of 4, 9/25/2025 at 6:49 AM for the pain level of 4 and at 11:12 PM for the pain level of 4, 9/26/2025 at 6:24 AM for the pain level of 4, 9/28/2025 at 11:41 PM for the pain level of 1, 9/29/2025 at 10:57 PM for the pain level of 4, 9/30/2025 at 6:32 AM for the pain level of 4, and at 11:17 PM for the pain level of 4.During an interview on 10/2/2025 at 8:07 AM, the Director of Nursing (DON) sated, After reviewing [Resident #7's name and Resident #27's name] medication record, the medications were administered out of parameters. Nurses should check parameters and physician orders and follow the doctors' orders.During an interview on 10/2/2025 at 8:08 AM, Staff G, LPN, stated, I do not recall [Resident #7's name] medication order. I do not have the record in front of me. I don't recall.During an interview on 10/2/2025 at 8:12 AM, Staff H, LPN, stated, It was an oversight on my part. I gave him [Resident #7] the medication and did not follow the parameters.Review of the facility policy and procedure titled Medication Administration with the last review date of 4/24/2025 read, Policy: Medications are administered by licensed nurse, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 staff cleaned and sanitized the thermometer probe between testing temperatures of different food items.Findings include:During an observation on 9/30/2025 at 7:40 AM in the main kitchen, the Dietary Manager tested the internal temperature of pureed eggs by a food temperature probe. The Dietary Manager used the same probe to test the pureed ham without cleaning or sanitizing between uses.During an interview on 9/30/2025 at 7:41 AM, the Dietary Manager stated she should not have tested the pureed ham without cleaning the probe first.Review of the document provided by the facility for taking food temperature read, Taking Accurate Temperatures using Metal Stem Thermometers. 3. The thermometer must be sanitized between uses in different foods. 4. Thermometers should be sanitized according to manufacture's instructions. In between uses at one meal, an alcohol swab may be used to sanitize. (Use a new swab for each sanitizing.) Event ID: Facility ID: 105597 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 followed enhanced barrier precautions while providing high-contact care to residents in 2 of 3 units reviewed for infection control to prevent the possible spread of infection and communicable diseases.Findings include: 1) During an observation on 9/29/2025 at 9:51 AM, there was an enhanced barrier precautions signage posted on Resident #31's room door. Resident #31 was lying in bed. Staff A, Certified Nursing Assistant (CNA), entered Resident #31's room with a clear plastic bag that contained towels. Staff A provided peri-care to Resident #31. Staff A was wearing gloves, but no gown.Review of Resident #31's physician order dated 6/30/2025 read, Enhanced Barrier Precautions R/T MRSA [related to Methicillin-resistant Staphylococcus aureus] every shift.During an interview on 10/1/2025 at 2:02 PM, Staff A, CNA, stated, For residents that are on enhanced barrier precautions, we need to wear gloves and gown when providing care. The personal protective equipment is only stored in the hallway. I should have worn a gown when providing care for [Resident #31's name].2) During an observation on 9/29/2025 at 1:43 PM, there was an enhanced barrier precautions signage posted on Resident #4's room door. Staff B, CNA, and Staff C, CNA, were providing care to Resident #4 at bedside, wearing gloves but no gown. Staff D, CNA, was collecting linen in Resident #4's room. Staff D was wearing gloves but no gown. Staff C was making Resident #4's bed, wearing gloves but no gown.Review of Resident #4's physician order dated 7/8/2024 read, Enhanced Barrier Precautions R/T MRSA. Order Status: Active.During an interview on 10/1/2025 at 12:54 PM, Staff B, CNA, stated, I was not aware [Resident #4's name] had orders for enhanced barrier precautions. I did not see a sign posted on the door. I might have missed it. When a resident has enhanced barrier precautions, you are to wear gloves and gown when providing care.During an interview on 10/1/2025 at 1:39 PM, Staff D, CNA, stated, I must have missed it [enhanced barrier precautions signage on the door]. I should have donned a gown.3) During an observation on 9/29/2025 at 1:55 PM, there was an enhanced barrier precautions signage posted on Resident #19's room door. Resident #19's call light was on. Resident #19 was sitting in the toilet seat in his room. Resident #19 verbalized he needed assistance with putting his brief and pants up. Staff E, CNA, entered Resident #19's room and donned gloves. Staff E provided toileting assistance to Resident #19. Staff E did not wear a gown.Review of Resident #19's physician order dated 9/26/2025 read, Enhanced Barrier Precautions R/T Hx [History of] MRS [Sic.] every shift.During an interview on 10/1/2025 at 1:26 PM, Staff E, CNA, stated, I only put up his pants, He [Resident #19] does everything else by himself. I cannot recall if I saw the sign [enhanced barrier precautions] posted outside his [Resident #19] room.4) During an observation on 9/30/2025 at 8:35 AM, Staff E, CNA, and Staff F, CNA, were transferring Resident #61 out of bed. Staff E and Staff F had gloves but no gown. There was an enhanced barrier precautions signage posted on Resident #61's room door.Review of Resident #61's physician order dated 9/29/2025 read, Enhanced Barrier Precautions R/T Suprapubic catheter, wounds every shift.During an interview on 10/1/2025 at 1:26 PM, Staff E, CNA, stated, I was assisting [Staff F's name] get [Resident #61's name] out of bed to his chair. We forgot to put a gown on.During an interview on 10/1/2025 at 1:30 PM, Staff F, CNA, stated, We were getting [Resident #61's name] out of bed into his wheelchair. I forgot to wear the gown. We always have signs on the door. The personal protective equipment is stored outside in the hallways.During an interview on 10/1/2025 at 3:09 PM, the Infection Preventionist stated, Staff should wear gowns and gloves during any close contact with the resident or any close contact with their linens for any residents on enhanced barrier precautions. The staff have to read the signs posted on the resident's doors and follow them.During an interview on 10/1/2025 at 3:38 PM, the Director of Nursing stated, Staff should follow enhanced barrier precautions, which mean they are Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105597 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 105597 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Nursing Center 110 SE Lee Ave Live Oak, FL 32064 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete expected to wear gown and gloves when providing direct care to any resident that have enhance barrier orders. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 4/24/2025 read, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines. 4. High-contact resident care activities include: a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting. Event ID: Facility ID: 105597 If continuation sheet Page 7 of 7