Health inspection·July 22, 2021

F 0584 Level of Harm - Minimal harm or potential for actual harm stated the staff put any maintenance concerns in the maintenance book to be addressed. She stated the staff are aware they are supposed to follow the process. The DON stated the staff should also let her know and if they cannot reach her, she has shift supervisors on every shift. The DON stated she was not aware of the condition of the recliners. The DON further stated the solution being used to clean the recliners may be breaking down the upholstery. Residents Affected - Some On 7/21/21 at 11:18 a.m. an interview was conducted with the Maintenance Director. He stated he had spoken with the Administrator, and they purchased 25 recliners in 2017. He provided a map with a red dot in each room that currently has a recliner. The map indicated there are currently 30 recliners in the private rooms of the building. A review of the facility policy entitled 'Cleaning Carpeting and Cloth Furnishings' effective February 2006 and revised April 2015 indicated the following: Policy: Furnishings shall be maintained and cleaned regularly Procedure: 5. Stained or soiled upholstered furniture shall be cleaned in a manner consistent with the type of fabric and stain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 2 of 8 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 105629 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Healthcare and Rehabilitation 5525 21st Ave W Bradenton, FL 34209 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **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 further confirmed she receives antibiotics at this time for the UTI. During record review on 7/20/2021, the electronic medical record revealed Resident #44 was admitted to the facility on [DATE] for short term rehabilitation. A review of the advance directives revealed Resident #44 was her own responsible party. A review of the admission diagnosis sheet revealed the Resident had a diagnosis to include UTI. A review of the Minimum Data Set (MDS) 5-day admission assessment dated [DATE] revealed the following: Cognition/Brief Interview Mental Status (BIMS) score - 15 of 15, which indicates Resident #44 has very high cognition and would be interviewable related to her care and services.; Bowel and Bladder Dx [diagnosis]. UTI - checked Yes. A review of the Physician's Order Sheet (POS) dated for current month 7/2021 revealed the following orders: - UA C&S labs on time 7/23/2021 - Ampicillin 500 mg 1 PO QID for UTI for 10 days. Order date: 7/12/2021 During further review of the record for Resident #44, the nurse progress notes revealed: 1. 7/11/2021 16:30 - Notified MD of positive urine cx for UTI. New order received for Ampicillin 500 mg QID PO for 10 days and ascorbic acid 500 mg PO QD. Orders transcribe and faxed to pharmacy. 2. 7/13/2021 - Continues ABT for UTI no adverse reactions. 3. 7/14/2021 - Continues ABT for UTI with no adverse reactions. 4. 7/15/2021 - Continues ABT for UTI with no adverse reactions. 5. 7/15/2021 - Resident seen by MD and request referral to see GYN for frequent UTI. Schedule appt. Orders to D/C Roxicodone 5 mg PRN. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 3 of 8 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 105629 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Healthcare and Rehabilitation 5525 21st Ave W Bradenton, FL 34209 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 0657 6. 7/16/2021 - Continues ABT for UTI with no adverse reactions. Level of Harm - Minimal harm or potential for actual harm 5. 7/17/2021 - Continues ABT for UTI with no adverse reactions. 6. 7/18/2021 - Continues ABT for UTI with no adverse reactions. Residents Affected - Few 7. 7/19/2021 - Continues ABT for UTI with no adverse reactions. 8. 7/20/2021 01:52 - Resident continues ABT for UTI, no adverse reactions, but c/o pain after urinating. MD is aware and appt sched with gyn, resident is aware. 9. 7/20/2021 10:33 - Resident has complaint of discomfort when urinating. MD notified of resident's discomfort, new order received and Pyridium 100 mg BID. Repeat CS UA when ABT is completed. 10. 7/20/2021 13:59 - Continues ABT for UTI. 11. 7/21/2021 01:29 - Resident continues with ABT for UTI without adverse reactions. A review of the current Care Plans with next review date 10/3/2021 revealed the following areas: - Occasionally incontinent of bowel and bladder and requires extensive assist with toileting r/t deconditioning r/t recent hospitalization, pain to LLE d/t recent left foot surgical repair, NWB to LLE, diuretic use. admitted with UTI (resolved) 7/5/2021 with interventions to include to include: Administer medications per order, Monitor/document for signs and symptoms of UTI, pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, AMS, change in bx, eating patterns - initiated 7/5/2021. Further review of the care plan indicated the UTI had resolved on 7/5/2021 and did not capture Resident #44's current UTI and with current use of Antibiotics., and without interventions and approaches related to the current UTI as of 7/11/2021. On 7/21/2021 at 1:00 p.m. an interview was held with the Care Plan Coordinator related to Resident #44. She reviewed the medical record and confirmed the resident had a resolved from a UTI on 7/5/2021 but was unaware she had another UTI as of 7/11/2021. She confirmed the care plan should be reflective and revised with the current UTI and new approaches, and interventions. She also confirmed the care plan should be reflective of the medical record and updated within three to five days. A review of the Person Centered Care Plan Policy and Procedure, with a last revision date 12/2016 revealed: The Care Plans are to be revised as changes in the resident's condition warrant or when there is a change in resident preference or choice of treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 4 of 8 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 105629 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Healthcare and Rehabilitation 5525 21st Ave W Bradenton, FL 34209 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Few 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 across the bed and the nebulizer tubing and mask was observed to be placed in the top drawer of the nightstand next to the resident's bed. Photographic evidence was obtained. A record review revealed Resident #158 was admitted to the facility on [DATE] with a diagnosis of hypertension, atrial fibrillation, and congestive heart failure as per the admission face sheet. A review of the orders for Resident #158 indicated respiratory treatments with oxygen at 2 liters per minute via nasal cannula as needed. On 7/19/21 at 10:26 a.m. an observation of Resident #158's room revealed the oxygen tubing was observed hanging freely from the concentrator. On 7/19/21 at 11:19 a.m. an observation of Resident #158's room revealed the oxygen tubing connected to a tank on the resident wheelchair was observed hanging from the tank and touching the floor. Photographic evidence was obtained. On 7/22/21 at 10:47 a.m. an observation of Resident #158's room revealed the oxygen tubing was rolled up and stuck into the handle of the oxygen concentrator. An empty plastic bag was hooked to the concentrator. Photographic evidence was obtained. A record review revealed Resident #41 was admitted to the facility on [DATE] with a diagnosis of sepsis, atrial fibrillation, cardiomegaly, congestive heart failure, and obstructive sleep apnea as per the admission face sheet. A review of the orders for Resident #41 indicated respiratory treatments with oxygen 1-3 liters per minute via nasal cannula, and CPAP at home settings with humidification. On 7/20/21 at 4:16 p.m. an observation of Resident #41's room revealed the CPAP tubing and mask sitting on the bedside table open to air. Photographic evidence was obtained. On 7/19/21 at 11:30 a.m. an interview was conducted with the Director of Nursing (DON). The DON stated all respiratory care supplies should be stored in a clean plastic bag with a date on the bag. She stated the respiratory supplies are to be cleaned and changed every week. She indicated oxygen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 5 of 8 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 105629 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Healthcare and Rehabilitation 5525 21st Ave W Bradenton, FL 34209 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tubing, nebulizer tubing and masks, and CPAP machines and supplies are to be cleaned for each resident use and then stored back into the plastic bags. A review of the facility policy entitled Policy and procedure for storage of Respiratory Equipment-Departmental Respiratory Therapy Prevention of Infection revised November 2011 indicated the following: Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Steps in the Procedure: Infection control considerations related to oxygen administration 7. Change the oxygen cannula and tubing every seven days, or as needed 8. Keep the oxygen cannula and tubing used prn in a plastic bag when not in use Infection control considerations related to Medication Nebulizer's/continuous aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name between uses 9. Discard the administration set up every seven days FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 6 of 8 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 105629 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Healthcare and Rehabilitation 5525 21st Ave W Bradenton, FL 34209 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **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 it came to food items on her tray. She said, I can't have orange juice as I am diabetic. She pointed to her meal ticket and stated, Even my meal ticket says no juices. A review of the resident's meal ticket for the breakfast meal indicated the following: Diet - Regular, No Added Salt, Low Concentrated Sweets; Beverages - Coffee, Water. The meal ticket further revealed: Food Dislikes - Juices. Resident #44 revealed that this happens often and confirmed she would not like to have the juice brought to her and knows better not to drink it but would rather staff follow her meal choices. On 7/20/2021 at 12:20 p.m. during lunch observation, Resident #44 was served her meal. A review of the meal ticket revealed - Food Dislikes - Juices. The resident received one plastic cup of what appeared to be red juice. An interview was conducted with Resident #44 at this time, and she revealed she does not like to receive juice and has been receiving it on and off. A review of Resident #44's electronic medical record revealed she was admitted to the facility on [DATE] for short term rehabilitation services. A review of the advance directives revealed the resident was her own responsible party. The Minimum Data Set (MDS) 5-day admission assessment dated [DATE] revealed the following: Cognition/Brief Interview Mental Status (BIMS) score - 15 of 15, which indicates Resident #44 has very high cognition and would be interviewable related to her care and services. The Physician's Order Sheet (POS), dated for the month 7/2021 revealed Resident #44 had a diet order to include: No Added Salt, Low Concentrated Sweets diet, with regular texture and thin consistency liquids. A review of the Care Plans with next review date 10/3/2021 revealed the following areas: - Resident at risk for altered nutrition status per MNA with interventions to include but not limited to: Diet as ordered, honor food preferences as able, offer alternative entrees as needed On 7/21/2021 at 1:45 p.m. an interview with the Kitchen Dietary Manager revealed staff plate food on the tray line in the kitchen, and the meal tickets have the diet order, and likes and dislikes. She revealed staff are to read each ticket and comply with the diet order and resident choices. She further revealed it is her responsibility to audit tickets and trays to ensure accuracy. She stated she was unaware residents were receiving food items of dislikes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 7 of 8 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 105629 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Surrey Place Healthcare and Rehabilitation 5525 21st Ave W Bradenton, FL 34209 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 0807 On 7/22/2021 at 11:08 a.m. the Director of Nursing and the Dietary Manager confirmed the facility did not have a specific policy related to food preferences. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 8 of 8