Surrey Place Healthcare and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Surrey Place Healthcare and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Mar 13, 2025

  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. […]

• No harm, potential for more than minimal, patternF625Mar 13, 2025

  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. […]

• No harm, potential for more than minimal, patternF584Jul 22, 2021

  Based on observations, interviews, and record reviews the facility failed to ensure recliners furnished in resident rooms were maintained in ten of thirty rooms sampled with recliners. Findings included: On 7/20/21 at 3:30 p.m. a tour of the facility revealed recliners, located in resident rooms 318, 315, 316, 313, 311, 329, 113, and 159 with peeling upholstery on the backrest and arms of the chairs. Photographic evidence was obtained. On 7/21/21 at 10:00 a.m. room 320 and 322 were observed to have a recliner with peeling upholstery on the backrest. Photographic evidence was obtained. On 7/21/21 at 10:07 a.m. an interview was conducted with Staff C, housekeeper. […]

• No harm, potential for more than minimal, isolatedF623Mar 13, 2025

  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 2/21/2025 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 Nursing Home Transfer and Discharge Notice showed the notice was given on 2/21/2025 and effective on 3/21/2025. The form showed the resident was transferred or discharged to an acute care facility due to Your needs cannot be met in this facility, and did not include a Brief explanation to support this action. […]

• No harm, potential for more than minimal, isolatedF645Mar 13, 2025

  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. 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. […]