Health inspection·June 1, 2023

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, interviews, and record review, the facility failed to update and revise a care plan to reflect a significant weight loss for one (Resident #38) of twenty-one sampled residents. Findings Included: On 5/30/2023 at 10:00 a.m., and 1: 20 p.m., 5/31/2023 at 1:00 p.m., and 6/1/2023 at 12:00 p.m., Resident # 38, was observed lying down in her bed with her head elevated and her call light within her reach. She presented without behaviors, pain, or discomfort. The room appeared clean and well lit. A review of Resident #38's admission record showed she was admitted to the facility on [DATE], with diagnoses to include but not limited to Parkinson's Disease, Unspecified, Gastro-Esophageal, Ileus Unspecified, and Reflux Disease Without Esophagitis. A review of the most current Minimum Data Set (MDS), dated [DATE], show in Section C, a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of the electronic health record weights and vital record showed, on 4/3/2023 Resident #38 weighed 129.6 Lbs., on 4/18/2023 111.8 Lbs., and on 5/3/2023 110.0 Lbs. A review of the Registered Dietitian (RD) weight loss follow-up note, dated 4/19/2023, showed, Current Body Weight, CBW 111.8 lbs. (4/18/23), ht 60, Body Mass Index, BMI 21.8. Reweigh for verification, CBW represents a 13.7 % loss x 30d (4/3/23 129.6 lbs). Current diet order is clear liquid due to constipation/ KUB. Resident # 38 was previously on a regular diet, regular texture thin liquid, magic cups every day, QD, mighty shakes every day and Medpass 2.0 every day. A recommendation was made to allow nutrition supplements on Clear Liquid Diet (CLD). A review of the physician order summary sheet dated 6/1/2023, showed a diet order for thin consistency, clear liquid diet, that started on 4/17/2023 to 5/5/2023. Further review showed clear liquid diet order currently discontinued. A review of the current care plan with an initial date of 9/25/2020 and a revision date of 5/8/2023, indicated the following areas: Resident is at risk for altered nutritional status related to (r/t) Parkinson's, convulsions, HTN (hypertension), hypothyroidism, occlusion/stenosis of carotid arteries, pacemaker presence, MDD (major depressive disorder), anxiety, insomnia, GERD (Gastroesophageal reflux disease), constipation, ileus, dysphagia, recent hx clear liquid diet. A review of the care plan interventions with an initial date of 9/25/2020 and a revision date of 11/24/2020, showed to honor (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105629 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 06/01/2023 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)