Health inspection·March 13, 2025

F 0623 Level of Harm - Minimal harm or potential for actual harm Policy Statement: The facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless: A. The transfer just charges necessary for the residents welfare and the residence needs cannot be met in the facility; Residents Affected - Few B. The transfer discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; C. The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident; D. The health of the individuals in the facility would otherwise be endangered; E. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) and stay at the facility; or F. The first hostility ceases to operate. Policy Interpretation and Implementation: 1. Before the facility transfers or discharges a resident, the facility will notify the resident and the representative of the transfer or discharge and the reasons for the move in writing in any language and manner they understand. 5. Should the health or safety of the individuals in the facility be endangered or the health of the resident's has improved sufficiently to allow a more immediate transfer or discharge or an immediate transfer or discharge is required by the resident's urgent medical needs or the resident has not resided in the facility for 30 days, notice would be given as soon as practicable. 7. The resident, and/ or representative will be provided with the following discharge notice requirements: a. The reason for the transfer discharge; b. The effective date of the transfer discharge; c. The location to which the resident is being transferred or discharged ; d. The name, address, and telephone number of the state long term care ombudsman; e. The name, address, and telephone number of each individual or agency responsible for the protection and advocacy of mentally ill or developmentally disabled individuals (as applies); and f. Any statement that the resident has the right to appeal to the action to the state which includes the name, address, and telephone number of the state health department agency that has designated to handle appeals and transfers and discharge notices. 8. The social service director will be responsible for preparing the form(s) and for ensuring the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 2 of 14 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 03/13/2025 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident/ representative receives the forms. If it is necessary to mail the form to the representative, a self-addressed stamped envelope will be included to facilitate the return of the signed form(s). The completed forms will be filed in the residence medical record under the Social Services tab. Based on record review and interviews, the facility failed to provide notice of transfer before a facility initiated transfer to two residents (Resident #11 and #60) out of three residents sampled for hospitalization. Findings Included: 1. Review of Resident #11's admission Record revealed Resident #11 had an original admission date of 9/9/2018 and a re-admission date of 3/7/2025. Resident #11 was admitted to the facility with diagnosis to include pneumonia, pleural effusion in other conditions classified elsewhere, sepsis, acute respiratory failure with hypoxia, dysphagia, oropharyngeal phase, and muscle weakness. Review of Resident #11's Change in Condition Evaluation, dated 3/4/2025 revealed under the section 1a. List the other change: Right Upper extremity shaking on and off; 02:88 on 2L [liters of oxygen]; sound congested. The Evaluation revealed under Recommendation of Primary Clinician(s): Transfer to hospital. Review of Resident #11's Nursing Home Transfer and Discharge Notice revealed notice was given on 3/7/2025 with an effective date of 3/4/2025. The notice showed Resident #11 was transferred to an acute care facility, with a documented reason, Your needs cannot be met in this facility. The notice revealed the Social Service Director (SSD) signed the notice on 3/7/2025 and Resident #11 signed the form on 3/7/2025. During an interview on 3/13/2025 at 11:56 a.m., the Nursing Home Administrator stated if a resident leaves the facility to go to a hospital it is typically an emergency, so she's not sure how the resident would sign the Nursing Home Transfer and Discharge Notice, which is why they would wait for the resident to return or would mail the form to the resident for their signature. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 3 of 14 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 03/13/2025 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide a bed-hold notice at the time of transfer to three (#55, #60, and #11) of three residents sampled for hospitalizations. Findings included: 1. Review of Resident #55's admission Record revealed the resident was originally admitted on [DATE]. Review of Resident #55's Nursing Notes showed on 2/2/2025 at 11:28 a.m., Resident #55 was sent to the emergency room (ER) for evaluation following an incident. Review of Resident #55's uploaded clinical documents did not include a bed-hold notice for the resident's transfer to a higher level of care on 2/2/2025. The progress notes on 2/2/2025 did not show the resident or representative was notified of the facility bed-hold notice. Review of the facility provided admission and Financial Agreement signed by Resident #55's family member and the facility's representative on 12/10/2024 described the facility's bed-hold policy. 2. Review of Resident #60's admission Record revealed the resident was originally admitted on [DATE] and readmitted on [DATE]. Review of Resident #60's Transfer Form showed on 2/21/2025 the resident was transferred to an acute care facility due to placement of a midline. Review of Resident #60's physician order, dated 2/21/25 at 2:43 p.m. showed the facility was to send the resident to ER for re-insertion of a midline by the vascular team. Review of Resident #60's uploaded documents did not reveal a copy of a bed-hold notice given to the resident's representative on 2/21/2025 and the resident's progress notes on 2/21/2025 did not reveal documentation showing the resident or representative had been notified or had received a bed-hold notice at the time of the transfer on 2/21/2025. Review of the facility provided Bed Hold Policy revealed it was part of the admission and Financial Agreement signed by Resident #60's legal representative on 2/4/2025. During an interview on 3/12/2025 at 2:27 p.m., the Social Services Director (SSD) reported making phone calls to the families and asking if they wanted a bed-hold. The SSD reported not really documenting family notifications of bed-hold notifications. 3. Review of Resident #11's admission Record revealed Resident #11 had an original admission date of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 4 of 14 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 03/13/2025 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 9/9/2018 and a re-admission date of 3/7/2025. Resident #11 was admitted to the facility with diagnosis to include pneumonia, pleural effusion in other conditions classified elsewhere, sepsis, acute respiratory failure with hypoxia, dysphagia, oropharyngeal phase, and muscle weakness. Review of Resident #11's Change in Condition Evaluation, dated 3/4/2025 revealed under the section 1a. List the other change: Right Upper extremity shaking on and off; 02:88 on 2L [liters of oxygen]; sound congested. The Evaluation also revealed under Recommendation of Primary Clinician(s): Transfer to hospital. Review of Resident #11's medical record did not reveal notice of a bed-hold related to the hospital transfer on 3/4/2025. During an interview on 3/13/2025 at 11:56 a.m., the Nursing Home Administrator stated residents get the bed-hold policy when they admit and they would call the residents and go over the policy if a transfer occurred. She stated she would have to talk to the Social Services Director to confirm what process she is following to document how the residents are being notified of the bed-hold process during a transfer. Review of the facility's undated policy titled Bed Hold Policy, found in the admission packet, revealed a summary of explanation will be given to the resident, legal representative, or responsible party on admission in a copy of the bed-hold policy each time the resident is transferred for hospitalization or leaves the facility on a therapeutic leave. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 5 of 14 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 03/13/2025 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 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 staff interviews, the facility failed to ensure Level I Preadmission Screening and Resident Review (PASRR) screenings were accurate prior to a admission to the facility and did not follow up with a Level II PASRR screen for two residents (Resident #41 and #16) of forty-one sampled residents. Residents Affected - Few Findings included: 1. On 3/10/2025 at 1:45 p.m. Resident #41 was observed in her wheelchair while therapy staff were assisting down the hallway and to the therapy gym. At 1:49 p.m. while in the gym, Resident #41 appeared anxious, but was participating in all the exercises that were presented to her. Resident #41 kept saying I just want to go home and just need to go home. On 3/12/2025 at 8:00 a.m., Resident #41 was assisted to the 300 unit nurses desk and lobby area. She was seated in her wheelchair and was awaiting a transport ride to an appointment. Resident #41 was given information that the transport van would be thirty minutes late. She then started to cry and was very anxious to get out to her doctor's appointment and then planned to return home with home health services the following day. Review of Resident #41's medical record revealed she was admitted to the facility on [DATE] for short term therapy. Review of the diagnosis sheet revealed diagnoses to include adjustment disorder with mixed anxiety and depressed mood, anxiety (added 2/12/2025), and major depression (added 2/12/2025). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed under Section C Cognitive Patterns a Brief Interview Mental Status (BIMS) score 15 out of 15, which indicated Resident #41 was cognitively intact. Review of Resident #41's electronic medical record revealed a Level I PASRR screen dated 2/10/2025, completed prior to the resident's admission to the facility, and was signed by a Licensed Clinical Social Worker (LCSW) at a hospital. The screen did not identify Mental Illness/Suspected Mental Illness (MI/SMI) diagnoses to include major depression and anxiety. Further review of the electronic medical record revealed a second Level I PASRR screen dated 2/14/2025 for Resident #41. Review of the screen revealed it was completed by a Registered Nurse at the admitted facility. Review of Section I of the PASRR screen under MI/SMI diagnoses indicated diagnosis of major depression. The screen did not identify anxiety, per Resident #41's admission diagnosis. On 3/12/2025 at 1:50 p.m., an interview with the Minimum Data Set (MDS) Coordinator, who confirmed she, along with several other staff, are responsible for the assurance of Level I PASRR completion in a timely and accurate manner. The MDS Coordinator confirmed Resident #41 was admitted to the facility on [DATE] and there were two Level I PASRR screens that were scanned into the electronic record to include one on 2/10/2025, which was incorrect, and one on 2/14/2025, which was a corrected version. The MDS Coordinator confirmed Resident #41 had diagnoses of major depression and anxiety upon her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 6 of 14 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 03/13/2025 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admission, and the Level I PASRR screen that came from the hospital did not reflect MI/SMI diagnoses of either major depression or anxiety. She revealed this Level I PASRR was incorrect and the facility had to complete a new one. She verified the new and revised Level I PASRR screen now only reflected major depression as an MI/SMI diagnosis, but they failed to include anxiety. She revealed the corrected Level I was not correct to reflect all appropriate MI/SMI diagnoses. The Director of Nursing (DON), who was present for this interview, also confirmed the current corrected Level I PASRR screen for Resident #41 was not correct. 2. Review of an admission Record showed Resident #16 was admitted to the facility on [DATE] with diagnoses to include but not limited to major depressive disorder, recurrent, severe with psychotic symptoms, and anxiety disorder, unspecified Review of the State of Resident #16's Level I PASRR screen dated 1/9/2023 showed Mental Illness diagnoses listed as anxiety disorder and depressive disorder. Review of Section IV: PASRR Screen Completion revealed: Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. On 3/12/2025 at 10:00 am, an interview was conducted with the facility's MDS Coordinator, who stated the PASRRs are reviewed on admission and at the Quality-of-Care meetings to see if there was a change with a resident diagnosis. The MDS Coordinator also stated she received training on how to complete the Level II PASRR last Monday and during the training she learned a PASRR Level II is required if a resident has a serious mental illness with dementia or if the resident has an intellectual disability, or depression with behaviors that are interfering with the resident daily life. The MDS Coordinator stated she has a list of residents who's PASRR has to be redone and submitted for a Level II review and Resident # 16 is one of the residents who is on her list that require a Level II PASRR review. The MDS Coordinator stated the facility does not have a PASRR policy. On 3/12/2025 at 10:30 am, an interview was conducted with the DON. The DON stated her expectations are for the PASRR to be accurate and most of the time the PASRR is inaccurate coming in from the hospital. If the PASRR's are inaccurate, her expectations are that they correct them so the PASRR's reflect the resident accurately. The DON stated she depends on her MDS Coordinator to accurately complete the PASRR's. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 7 of 14 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 03/13/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to 1. Ensure staff who worked in the kitchen initiated proper hand hygiene in between and after touching soiled dishes and before touching clean dishes in the dish machine room, during two of four days observed (3/10/2025 and 3/12/2025), and 2. failed to follow proper food safety and storage procedures for one resident (Resident # 14) of eight residents sampled. Findings included: 1. On 3/10/2025 at 9:29 a.m., the facility's kitchen was entered and toured with Staff A, Dietary Manager. Staff A, Dietary Manager confirmed they operate a low temperature dish washing machine and pointed out the machine in the front right corner of the kitchen. The dish machine area appeared with a large mechanical dish washing machine with a metal table and table chute on the right side, which was used for soiled dishes and prerinse prior to dishes going into the dish washing machine. The left side of the machine was observed with a metal table and metal chute where clean crates of dishes went after coming out of the dish washing machine. Staff B, Dietary Aide (DA) and Staff C, DA were operating the dish washing machine. Staff B, DA and Staff C, DA were both on the right side/soiled side of the machine and were placing soiled breakfast trays, dishes, cups, bowls, or eating/dining ware that came from tray carts onto the metal table chute to be pushed over to the prerinse area. Staff B, DA was observed at the prerinse station area wearing blue plastic gloves. She was observed handling soiled eating/dining ware with her hands and was using a rinse hose to rinse off large debris from the various eating/dining ware. Staff C, DA continued to take soiled eating/dining ware from tray carts and pushed them down the metal chute towards Staff B, DA for prerinsing. At 9:31 a.m. Staff B, DA, after prerinsing soiled eating and dining ware, immediately placed the eating/dining ware into plastic crates and pushed the crate of soiled eating/dining ware into the soiled side of the machine and closed the door with her gloved hands. Staff B, DA continued to receive soiled eating/dining ware from the metal table chute and prerinsed with the hose. After the dish washing machine ran its wash and rinse cycle, Staff B, DA walked over to the left side/clean side of the machine, opened the door, and pulled out the crate full of clean and sanitized eating/dining ware with her gloved hands. Staff B, DA did not remove her gloves or wash/sanitize her hands after handling soiled eating/dining ware and before handling clean and sanitized eating/dining ware. At 9:33 a.m. Staff B, DA stated the type of dish washing machine the facility used was a high temperature dish washing machine, but she was not able to state what temperatures the wash and rinse cycles get to. She then stated, I think the wash needs to get to 150 degrees [Fahrenheit] She was unsure what the rinse cycle temperature should reach. Staff B, DA confirmed there was a chemical sanitizer and they test the clean dishes with a test strip to see if there is enough sanitizer getting through the machine and onto the eating/dining ware. She was asked if she was sure the machine was a high temperature dish washing machine. Staff B, DA could not answer and then got a verbal cue from the Staff A, Dietary Manager that the machine was a low temperature, chemical sanitizing dish washing machine. Staff B, DA demonstrated the use and operation of the low temperature dish washing machine at 9:35 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 8 of 14 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 03/13/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many a.m. Staff C, DA stood back in the right side/soiled side of the machine and continued to place soiled eating/dining ware from the tray carts and on to the metal table chute. Staff B, DA immediately put on blue plastic gloves, was not observed to wash her hands prior to, and started to prerinse soiled plastic trays with the hose. She placed prerinsed trays into a plastic crate and ran the crate of soiled eating/dining ware into the soiled side of the dish washing machine. After the machine ran its wash and rinse cycle, Staff B, DA opened the door to the dish washing machine and pushed the crate of cleaned and sanitized dishes through to the left side/clean side of the machine with her gloved hands. She walked over to the left side/clean side of the machine and retrieved the crate of cleaned and sanitized eating/dining ware with her gloved hands and began to take a new chemical sanitizer test strip and placed it on one of the trays in the crate. Staff B, DA never removed her gloves or washed her hands after handling the soiled eating/dining ware and prior to handling the clean and sanitized eating/dining ware. Staff B, DA could not get a reading from the test strip, so she walked over to the right side/soiled side of the dish washing machine area and pushed through another crate of soiled eating/dining ware into the machine. While the dish washing machine was running its cycle, Staff B, DA stood near the machine to wait for the cycle to be finished. Once the wash and sanitize cycle was completed, Staff B, DA was observed walking over to the left side/clean side of the machine and retrieved the clean crate of eating/dining ware with her gloved hands and began to conduct another chemical sanitizer test with a new test strip. Staff B, DA did not remove her soiled gloves or wash her hands after handling soiled eating/dining ware. Staff B, DA was observed retrieving soiled eating/dining ware from the soiled side of the dish machine, prerinsed the eating/dining ware, placed the soiled eating/dining ware in empty crates, sent the soiled eating/dining ware through the machine to be clean and sanitized, received the clean eating/dining ware from the clean side of the machine, and handled the clean and sanitized eating/dining ware with her unchanged and unwashed hands four more times before the surveyor left the area. During most of the observation from 9:31 a.m. through to approximately 9:42 a.m., the Staff A, Dietary Manager was in the kitchen's dish washing machine room observing the operation from both Staff B, DA and Staff C, DA. Staff A, Dietary Manager did not intervene to ensure Staff B, DA washed her hands after handling soiled eating/dining ware and prior to handling clean and sanitized eating/dining ware. On 3/12/2025 at 1:43 p.m. an observation was conducted in the facility kitchen with Staff D, DA and Staff B, DA, who were observed in the dish washing machine area and were both on the right side/soiled side of the dish machine. Staff B, DA was observed taking soiled dishes, trays, cups, bowls, or eating/dining ware from received tray carts and placed the eating/dining ware on the metal table chute. She was observed pushing the eating/dining ware down the metal chute to the prerinse station where Staff D, DA was. Staff D, DA was observed with her bare hands taking a rinsing hose and was prerinsing the soiled eating/dining ware and placed the eating/dining ware in empty plastic crates to be ran through the dish washing machine. At 1:45 p.m., Staff D, DA was observed pushing a full plastic crate of eating/dining ware into the soiled side of the dish machine with her bare hands and closed the dish washing machine door for it to run its clean and sanitizer cycle. Once the machine finished its cycle, Staff D, DA walked over to the left side of the dish washing machine, opened the door, and pulled the clean and sanitized crate of eating/dining ware out and to the clean table area. Staff D, DA did not wash her hands or don gloves after handing soiled eating/dining ware and prior to handling clean and sanitized eating/dining ware. At 1:47 p.m., Staff B, DA continued to place soiled eating/dining ware on the soiled side of the dish machine table chute and Staff D, DA continued to retrieve the soiled eating ware, prerinse them, and set them in a plastic crate to be ran through the dish washing machine. Staff D, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 9 of 14 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 03/13/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many DA walked over to the left side/clean side of the dish washing machine and retrieved clean and sanitized crates of eating/dining ware with her bare hands. She was not observed to donning gloves or washing her hands after handling soiled eating/dining ware or prior to receiving and handling clean and sanitized crates of eating/dining ware. Staff D, DA continued to handle and feed crates of soiled eating/dining ware through the soiled side of the machine and received and handled crates of clean and sanitized eating/dining ware with her bare unwashed hands for four more dishwashing cycles. In between and while the dish washing machine was in cycle, Staff D, DA took plates from an already clean and sanitized crate and stacked them in her hands and arms and brought them to a metal plate holder. She did this process three times and without washing her hands after touching and handling soiled eating/dining ware and prior to touching the clean and sanitized plates. The plates were stored in a manner as if ready to use for residents at the next meal/dining service. On 3/13/2025 at 10:45 a.m., and while in the facility's kitchen, the Staff A, Dietary Manager was interviewed with relation to the dish washing process. Staff A, Dietary Manager revealed the dish machine area is composed of two sides, one soiled side on the right and one clean side on the left. Staff A, Dietary Manager revealed typically there are two staff members in the dish washing machine area. One staff member handles the soiled dishes and runs the eating/dining ware through the soiled side of the machine while another staff member works on the clean side of the machine and receives/handles only clean and sanitized eating/dining ware that came through the machine. Staff A, Dietary Manager explained there are times when she is in the dish washing machine area assisting with cleaning dishes and she will usually be on the clean side, not the soiled side. She revealed she would only be handling clean and sanitized eating/dining ware. She also confirmed if she touches or handles soiled eating/dining ware with her bare hands or gloved hands, she would remove her gloves and wash her hands, or wash her hands if she is not gloved, prior to handling clean and sanitized eating/dining ware after they come out from the dish washing machine. Staff A revealed that she saw a lack of handwashing when handling soiled eating/dining ware and during the handling of clean and sanitized eating/dining ware during the observation of Staff B, DA and Staff C, DA on 3/10/2025. On 3/13/2025 the Dietary Manager provided an undated policy titled Dishwashing Machine, which revealed: Policy: The facility will maintain dishwashing machine in a clean condition to minimize the risk of food hazards. Dish washing machines will be cleaned three times a day after each meal. Procedure: 1. Turn the dishwashing machine on. 2. Open drain valves. 3. Remove scrap trays. 4. Spray scrap trays over garbage. 5. Spray down the inside of the dishwashing machine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 10 of 14 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 03/13/2025 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 0812 6. Scrub stains inside dishwashing machine and on outside drains using an abrasive pad soaked in warm water and detergent and de-staining solution. Level of Harm - Minimal harm or potential for actual harm 7. Wash the outside of the dishwashing machine and hood with a clean cloth soaked in detergent solution. Residents Affected - Many 8. Wipe down with an approved sanitizing solution. 9. Wipe with clean dampened cloth. The Dietary Manager also provided an undated policy titled Hand Washing, which revealed: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Dietary employees will practice good hand washing practices in order to minimize the risk of infection and food borne illness. Procedure: 1. Hand-washing Stations a. Make sure hand washing stations are located in food preparation areas to encourage employees to wash their hands frequently. c. Make sure all hand-washing stations are equipped with the following: i. Hot and cold running water. ii. Hand cleaning liquid, powder or bar soap. iii. Individual, disposable towels, a continuous towel system that supplies the use with a clean towel or a heated - air hand-drying device. iv. A receptacle for disposable towels. v. A sign that indicates employees must wash hands before returning to work. 2. Hands should be washed after the following occurrences: a. Using the Restroom. b. Handling raw food (before and after). c. Touching the hair, face, or body. d. Sneezing or coughing. e. Smoking. f. Eating or drinking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 11 of 14 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 03/13/2025 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 0812 g. Handling chemicals. Level of Harm - Minimal harm or potential for actual harm h. Taking out garbage. i. Clearing tables. Residents Affected - Many j. Touching clothing or aprons. k. Touching un-sanitized equipment, work surfaces, or wash cloths. 2. On 3/10/2025 at 9:24 AM and on 3/11/2025 at 3:00 PM, Resident # 14 was observed lying down on her bed dressed in her night gown. She was observed with rotten fruit left on her bedside table for two days. An interview was conducted following the observation with Resident # 14, who stated she was going to eat the fruit later. Review of an admission Record showed Resident # 14 was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia in other diseases classified elsewhere, mild, with other behavioral disturbance and anxiety disorder, unspecified Review of a Quarterly [NAME] Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. During an interview on 3/13/2025 at 10:00 AM with the Director of Nursing (DON), the DON stated Resident #14 is difficult and she doesn't let the staff take away her food. The DON also stated the resident's husband brings her food from time to time. The DON stated Resident # 14 has had a recent decline and she's assuming the resident did not want the staff to remove the fruit from her room. The DON stated if the resident refused to discard the rotten fruit, they should have reported the behaviors to the nurse or to her. The DON stated her expectations are residents' bedside tables should be cleaned off and old food should be discarded. Review of the facility policy titled Storage of Foods Brought to Residents by Family/Visitors showed: Policy Statement: Staff must be aware of and approve, food(s) brought to a resident by family/visitors to ensure safe and sanitary storage, handling and consumption of foods. Interpretation and Implementation 7. The Nursing staff is responsible for discarding perishable foods within 3 days or before the use by/expiration date, whichever comes first. 8. The nursing and/or food service staff must discard any food prepared for the residents that shows obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates) Photographic Evidence Obtained FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 12 of 14 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 03/13/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observations, record review, and interviews, the facility failed to accurately document in the clinical record for one resident (Resident #60) of forty-one sampled residents related to a physical assessment completed during a time the resident was not in the facility. Findings included: An observation on 3/11/25 at 8:31 a.m. revealed Resident #60 was sitting up in bed with a meal in front of her. The resident did not appear to be in visible distress. Review of a Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer form showed the resident was transferred to an acute care facility on 2/21/25 for a midline placement by the vascular team. Review of a physician order written on 2/21/25 at 2:43 p.m. instructed staff to send Resident #60 to the emergency room (ER) for re-insertion of midline by vascular team. Review of Resident #60's payor source information showed the facility stop billing on 2/21/25 and the resident became active on 2/27/25. Review of Resident #60's Daily Medicare A/Managed Care Nursing Note dated 2/22/25 at 7:07 p.m. revealed a temperature reading from 2/19/25, a pulse from 2/2/25, and blood pressure and respiration readings from 2/20/25. The note showed the resident was alert & oriented to person, there were no changes in the resident's mood and behavior patterns, the resident was incontinent of bladder, and the urine was clear with a normal odor. The resident was incontinent of bowel with an ileostomy. The resident's lung sounds were Within Normal Limits (WNL) and respiratory effort was normal. The resident had a regular heart rate and peripheral pulses were palpable. The residents' pupils were equal, round and reactive to light and accommodation (PERRLA), the hearing was adequate, and speech was clear and appropriate. The resident's pain measurement was shown as a smiling face revealing the scale of No Hurt. The resident was noted to have no new changes to skin integrity and no wound infection. The note did not reveal if the resident was on any isolation/precautions. The note showed the resident was receiving physical and occupational therapy. An interview was conducted on 3/13/25 at 9:38 a.m. with Staff H, Licensed Practical Nurse (LPN). The staff member reported if a resident was discharged , the facility discharged them from the electronic system. Staff H, LPN reviewed the assessment completed on Resident #60 on 2/22/25 and stated the nurse may have made a mistake and did not think any nurse would document on a discharged resident. The staff member stated at times and if needed they may go in and make a late entry on the resident but would not document an assessment on them. An interview was conducted on 3/13/25 at 9:47 a.m. with Staff I, LPN/Assistant Director of Nursing (ADON). Staff I, LPN ADON reported staff document on Daily Medicare with daily notes, for 3 days. She would expect a narrative note for new admissions and any long-term care residents on antibiotics should be documented on every shift. She reported a resident who had been discharged would not typically be documented on, except for a hospital follow up note, but would not document an assessment or a daily Medicare note on a discharged resident. The ADON reviewed Resident #60's chart and confirmed the resident left the faciity on 2/21/25 and thought the resident had been gone 5-6 days, thinking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 13 of 14 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 03/13/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the resident came back on the 2/27/25. Staff I, LPN ADON stated the expectation was to assess and lay eyes on a resident when documenting and the note on 2/22/25 was not correct documentation. Review of the undated policy titled Documentation, Clinical, revealed: Policy: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical care and other services provided to the resident and ensure that the appropriate information is available to all industry interdisciplinary team members. Documentation in the medical record of each resident should provide: 1. A complete account of the residents care treatment and response to the care. 2. Information for the physician when prescribing medications and managing care and treatments. 3. A description of care and services that can be used for measuring the quality of care provided to a resident. 4. An ongoing record of the physical and mental status of the resident. 5. Information for the development of a plan of care for each resident. 6. Elements to support quality medical care. 7. A legal record that protects the resident, physician, nurse, and the facility. 8. Documentation as recorded to support reimbursement. Documentation Guidelines: 1. All entries in the medical record should be accurate, legible, dated, and timed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105629 If continuation sheet Page 14 of 14