Sante Of Surprise

In the surveyor’s words

From the most serious findings on record at Sante Of Surprise, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF684May 28, 2026

  Based on clinical record review, interviews and facility policy review, the facility failed to ensure medications were administered according to physician instructions for two residents sampled out of five (#24 and #58). The deficient practice could result in medication errors that could harm residents. The universe was 62.Findings include:-Regarding Resident #58:Resident #58 was admitted to the facility on [DATE] with diagnoses that included: essential primary hypertension, type 2 diabetes mellitus, anxiety disorder, depression, pneumonia and muscle weakness.A care plan for resident #58 included for pain medication Oxycodone therapy related to chronic pain with a date of initiation of April 10, 2026. […]

• No harm, potential for more than minimal, patternF885Jan 27, 2022

  Based on clinical record review, facility documentation, resident and resident family and staff interviews, and policy review, the facility failed to ensure that residents, including residents #251 and #37, and family/representatives (including resident #348 family) were notified that two residents had tested positive for COVID-19, within the required timeframe. The deficient practice could result in residents and their families/representatives not being aware of new COVID-19 cases in the facility and the actions implemented to reduce the risk of transmission. […]

• No harm, potential for more than minimal, isolatedF580Jul 27, 2026

  Based on clinical record review, interviews, and the facility's policies and procedures, the facility failed to ensure that one resident's (#7) representative was notified of a change in condition. The sample size was three. The deficient practice could lead to the responsible party not being informed and not being able to participate in the resident's care. Findings include:Resident #7 was admitted to the facility on [DATE] with diagnoses that included radiculopathy in the lumbar region, chronic diastolic heart failure, and acute kidney failure.The discharge Minimum Data Set (MDS), dated [DATE], indicated that Resident #7 did not participate in a Brief Interview for Mental Status (BIMS). […]

• No harm, potential for more than minimal, isolatedF761May 28, 2026

  Based on observation, interviews, and review of facility policy and procedure, the facility failed to ensure medications were locked in 1 medication cart while left unattended. The deficient practice could lead to unauthorized persons gaining access to medications.An observation conducted on May 26, 2026 at 8:38 A.M. of the facility hallway revealed that a medication cart labeled P2 was not locked. There was no staff observed at the medication cart. The Licensed Practical Nurse (LPN/Staff#29) returned to the cart a few minutes later and tried to push in the lock, but it did not push in. She then used her key and put it in the lock of the medication cart and the key moved but it did not lock the medication cart. […]

• No harm, potential for more than minimal, isolatedF638Jul 3, 2024

  Based on clinical record review, the CMS (Centers for Medicare and Medicaid Services) system for MDS (Minimum Data Set) data, staff interviews, the Resident Assessment Instrument (RAI) 3.0 User's manual, and facility policy, the facility failed to ensure completion of a quarterly MDS assessments for one resident (#43) within the regulatory time frames. The deficient practice could lead to insufficient resident assessment and impact resident care. Findings Include: Resident #43 was admitted to the facility on [DATE] with the diagnosis that included unspecified fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing. The admission MDS (Minimum Data Set) for resident #43 revealed that it was completed on February 23, 2024. […]