Surprise Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Surprise Health and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF554Dec 23, 2022

  Based on observations, resident interviews, clinical record review, staff interviews, and policy review, the facility failed to ensure staff did not leave medications with two residents (#351 and #354) who were not assessed and determined to be clinically appropriate for self-administration of medication. The deficient practice could result in medication not being taken as ordered by the physician. The findings include: -Resident #351 was admitted on [DATE] with diagnoses of periprosthetic fracture around internal prosthetic left hip joint, overactive bladder, and unspecified dementia. A nursing note dated December 9, 2022 revealed the resident was alert and oriented x 2 and had a history of Alzheimer's disease. […]

• No harm, potential for more than minimal, patternF641Nov 4, 2021

  Based on clinical record reviews, staff interviews, facility policy and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure the MDS (Minimum Data Set) assessments for 3 residents (#12, #79 and #81) were accurate. The sample size was 21. The deficient practice could result in the assessment not reflecting the resident's status. Findings include: -Resident #81 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the case manager progress note dated September 30, 2021 revealed that the resident was scheduled to be discharged to home on October 6, 2021. A physician order dated October 6, 2021 revealed an order to discharge to home with home health services. […]

• No harm, potential for more than minimal, patternF658Nov 4, 2021

  Based on clinical record reviews, observation, staff interviews, and policy review, the facility failed to ensure medications were administered as ordered for two of five sampled residents (#13 and #31). The deficient practice could result in residents not receiving medications as ordered by the physician. Findings include: -Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on August 8, 2021 revealed the resident had anti-anxiety medication use related to anxiety disorder as evidenced by restlessness. Interventions included to give anti-anxiety medications ordered by physician. […]

• No harm, potential for more than minimal, isolatedF684Mar 27, 2026

  Based on a clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure that Specialized Durable Medical Equipment (DME) services were provided to one resident (#100). The census was 98. The deficient practice could result in immobility and isolation. Findings include: Resident #100 was re-admitted to the facility on [DATE], with diagnoses that included heart failure, anoxic brain damage, and chronic kidney disease. A comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had several impairments in cognitive skills related to daily description-making. The MDS further revealed no use of a mobility device. […]

• No harm, potential for more than minimal, isolatedF761Mar 27, 2026

  Based on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure one medication cart was secured when left unattended. The deficient practice could result in residents, visitors and/or staff members having unrestricted access to medications. The census was 98.Findings include:An observation was conducted on March 26, 2026 at 11:10 a.m. on the C Wing on the first floor, a staff member was preparing medications at the medication cart. The staff member ( Registered Nurse (RN), Staff #165) collected the medication cup with the prepared medications and walked around the cart and into the resident room that was located next to the medication cart. […]