Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sante Of Surprise during CMS and state inspections, most recent first.
Medication Administration Outside Ordered Pain Parameters: The facility failed to administer pain medications according to provider orders for two residents. One resident received Oxycodone and Acetaminophen outside the ordered pain-scale parameters, and another resident received Dilaudid for pain ratings below the prescribed threshold. Nursing staff stated that giving medications outside ordered parameters is a medication error, and the record contained no documentation or provider authorization for the out-of-parameter doses.
An LPN left medication cart P2 unlocked and unattended in a hallway, and the cart’s lock would not engage when she tried to secure it. The LPN said she had difficulty with the lock since the start of her shift but did not report it, and there was no shift-change communication about the issue. The DON later confirmed the cart remained unlocked when the key turned, and the Administrator stated he was aware the lock was not working.
A facility failed to complete a quarterly MDS assessment for a resident within the required timeframes. The resident, admitted with a fracture, had their assessment delayed beyond the due date, potentially impacting their care. The MDS Coordinator and DON acknowledged the lapse, which was against the facility's policy of adhering to federal and state submission timeframes.
A resident with intact cognition and requiring substantial assistance with personal hygiene did not receive a shower for three weeks after admission. Despite the care plan indicating the need for 1-2 staff assistance, the resident was not offered a shower, and staff interviews revealed a lack of a fixed schedule and misunderstanding of the resident's refusal. The DON expressed concern over the situation, acknowledging the risks associated with poor hygiene.
A resident with multiple health issues, including a fracture and pressure ulcers, was not positioned according to professional standards, leading to discomfort and potential skin breakdown. Observations showed improper positioning in bed and wheelchair, with inadequate personal hygiene. Staff interviews revealed a failure to adhere to the care plan, with the CNA not repositioning the resident as required and not reporting the resident's discomfort. The DON confirmed the inappropriate positioning and the need for additional interventions.
Surveyors observed unsecured medication cards left unattended on a cart, posing a potential hazard. An LPN left the medications accessible for about two minutes while attending to a resident. Interviews with the LPN and DON confirmed this practice violated facility policy, which requires medications to be locked away when not in use.
A resident with chronic pain and other conditions received Percocet outside the prescribed pain level parameters, as documented in the MAR. Despite the physician's order specifying dosage based on pain levels, the medication was administered incorrectly multiple times. Interviews with an LPN and the DON highlighted a lack of adherence to medication administration policies, posing risks such as drowsiness and falls.
A facility failed to implement Enhanced Barrier Protection (EBP) for a resident with a gastrostomy tube (G-tube). Despite EBP signage and available PPE, a nurse administered medications and enteral feed without donning a gown, as required. The nurse was unaware of the need for EBP during G-tube care, associating it only with other treatments. The Director of Nursing confirmed EBP should be used for indwelling devices, aligning with facility policy and CMS guidelines.
A resident with moderate cognitive impairment and asthma was observed receiving oxygen therapy without a physician's order. Staff interviews and record reviews confirmed the absence of documentation for the oxygen therapy, contrary to facility policies requiring a physician's order for medication administration.
Medication Administration Outside Ordered Pain Parameters
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders for two residents. One resident had diagnoses including essential hypertension, type 2 diabetes mellitus, anxiety disorder, depression, pneumonia, and muscle weakness, and had a care plan for Oxycodone therapy for chronic pain with an intervention to administer medications as ordered. The resident’s orders specified Oxycodone 10 mg every 6 hours as needed for pain rated 6-10/10 and Acetaminophen 325 mg, 2 tablets every 6 hours as needed for pain rated 1-5/10. The MAR showed Oxycodone was administered for pain rated 5/10 on multiple occasions, and Acetaminophen was administered for pain rated 10/10. Another resident was admitted with diagnoses including a fracture of the lower end of the right tibia, displaced fracture of the lateral malleolus of the right fibula, anxiety, essential hypertension, and difficulty walking. The resident had a care plan for alteration in comfort/pain with an intervention to administer analgesics as ordered. Physician orders included Dilaudid 4 mg, 0.5 tablet every 3 hours as needed for pain rated 6-10/10 and Dilaudid 4 mg, 1 tablet every 4 hours as needed for pain rated 6-10/10. The MAR showed Dilaudid was administered for pain rated 5/10 on several occasions. Interviews with nursing staff confirmed that giving pain medication outside ordered parameters was considered a medication error, and review of the record found no documentation explaining why the medications were given outside the ordered parameters or any physician authorization for doing so.
Unlocked Medication Cart Left Unattended
Penalty
Summary
Medication carts were not kept locked when unattended, as observed with medication cart P2 in the hallway. At 8:38 A.M., the cart was found unlocked with no staff at the cart. When the LPN returned a few minutes later, she attempted to push in the lock, but it would not engage. She then used her key, which turned in the lock but still did not secure the cart, and the drawers opened when pulled. The LPN stated she had forgotten to lock the cart and had been having difficulty with the lock since the start of her shift, but she did not notify anyone that the lock was not working and there was no communication at shift change about the problem. The DON later observed the same cart and confirmed that the lock would not work, with the key turning but the cart remaining unlocked. The DON stated medication carts should be locked when the nurse steps away and said she had not been made aware that the lock on cart P2 was not working. The Administrator later stated he was aware the lock was not working and that it had been sent back to the pharmacy to be fixed. The facility policy stated that drugs and biologicals must be stored in a safe, secure manner and that carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to ensure the completion of a quarterly Minimum Data Set (MDS) assessment for a resident within the regulatory time frames. The resident, who was admitted with an unspecified fracture of the shaft of the right tibia, had their admission MDS completed on February 23, 2024. However, the quarterly assessment, which was due on May 18, 2024, was not completed until June 24, 2024, and was transmitted on June 28, 2024, and accepted on July 1, 2024. This delay in completing the assessment could lead to insufficient resident assessment and impact resident care. During an interview, the MDS Coordinator acknowledged that the quarterly MDS assessment for the resident was not completed within the required timeframes. The Director of Nursing also confirmed that the expectation is for MDS assessments to be completed timely and reflect the resident's care and needs. The facility's policy states that resident assessments should be conducted and submitted in accordance with federal and state submission timeframes, which was not adhered to in this instance.
Failure to Provide Necessary Personal Hygiene Services
Penalty
Summary
The facility failed to ensure that a resident received necessary services to maintain personal hygiene, which may lead to a decline in the resident's quality of life. The resident, who was admitted with diagnoses including cellulitis, osteoporosis, chronic pain, dementia, and anxiety, had a BIMS score indicating intact cognition and required substantial assistance with personal hygiene. Despite this, the resident did not receive a shower for three weeks after admission, as documented in the ADL shower sheet. Interviews revealed that the resident was not offered a shower during this period, contrary to the care plan that required 1-2 staff assistance for daily activities. Interviews with staff, including a CNA and the DON, highlighted a lack of a fixed schedule for showers and a misunderstanding regarding the resident's refusal of showers. The CNA stated that showers were not scheduled and residents needed to ask, and if a resident refused, they were not re-approached. The DON acknowledged the risk of poor hygiene and skin breakdown due to not receiving showers and expressed concern over the situation. The resident confirmed having her first shower only after three weeks and did not recall refusing any previous offers, contradicting the CNA's documentation.
Deficient Positioning and Care for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, specifically in terms of positioning, which did not align with professional standards of practice. The resident, who was admitted with multiple diagnoses including a fracture of the left acetabulum and muscle weakness, was at risk for developing pressure ulcers and had an existing unstageable pressure ulcer. Observations revealed that the resident was often positioned improperly, with both feet dangling off the bed and the head elevated to an extreme angle, causing discomfort and potential harm to the resident's skin integrity. The resident was observed multiple times in positions that could exacerbate their condition, such as sitting in a wheelchair for extended periods without proper repositioning, and being left in a bed with the head and legs elevated inappropriately. These positions placed additional pressure on the resident's sacrum and heels, which were not floated as per physician orders. The resident also exhibited signs of neglect in personal hygiene, with food debris and a brown substance under their fingernails, indicating a lack of adequate care. Interviews with staff revealed a lack of adherence to the care plan, with the CNA responsible for repositioning the resident every two hours failing to do so effectively. The CNA admitted to not informing the nurse of the resident's discomfort and refusal to rest. The DON acknowledged that the resident's positioning was inappropriate and that additional interventions were necessary to prevent further skin breakdown. The facility's policy on repositioning was not followed, leading to the deficiency in care provided to the resident.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely, leading to a potential accident hazard. On July 2, 2024, surveyors observed two medicine cards left unattended on top of a medicine cart. These cards contained medication and were accessible to anyone passing by. A Licensed Practical Nurse (LPN) emerged from a resident room and agreed to assist the surveyors after finishing in the room. However, the LPN re-entered the room, leaving the medication cards unattended for approximately two minutes. Upon returning, the LPN continued with the medication pass without securing the medication cards. Interviews with the LPN and the Director of Nursing (DON) revealed that the facility's policy requires medications to be stored securely in locked carts when not in use. The LPN acknowledged that medications should always be put away and the cart locked, while the DON confirmed that leaving medications unattended is not the standard of care and poses a risk of unauthorized access. The facility's policy on the storage of medications mandates that compartments containing drugs must be locked when not in use, and carts should not be left unattended if open or accessible to others.
Failure to Follow Pain Medication Orders
Penalty
Summary
The facility failed to adhere to a resident's prescribed pain medication regimen, resulting in a deficiency. Resident #15, who was admitted with conditions including cellulitis, osteoporosis, chronic pain, dementia, and anxiety, had a physician's order for Percocet to be administered based on specific pain levels. The order specified that one tablet should be given for pain levels between 4-6 and two tablets for pain levels between 7-10. However, the Medication Administration Records (MAR) for June 2024 showed that the resident received one tablet six times when the pain level was below 4 and when it was over 6, and two tablets were administered 15 times when the pain level was below 7, both of which were outside the prescribed parameters. Interviews with staff revealed a lack of adherence to the medication administration policy. An LPN stated that medication orders include pain scale parameters and that deviations should be reported to the provider. The Director of Nursing acknowledged the risks associated with administering medication outside the prescribed parameters, such as drowsiness and increased fall risk. The facility's policies on opioid use, medication orders, and documentation emphasize the necessity of following prescribed orders and documenting reasons for any deviations, which were not followed in this case.
Failure to Implement Enhanced Barrier Protection for G-tube Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Protection (EBP) for a resident with a gastrostomy tube (G-tube), as observed by surveyors. The resident, who was admitted with diagnoses including metabolic encephalopathy, dysphagia, and severe protein-calorie malnutrition, was receiving enteral feeding and medications through the G-tube. Despite EBP signage on the resident's door and the presence of personal protective equipment (PPE) in the room, a registered nurse (RN) was observed administering medications and enteral feed without donning a gown, which is required under EBP guidelines. The RN, when interviewed, was unaware of the specific instances requiring EBP, incorrectly associating the need for gown and gloves only with breathing treatments and certain other conditions, but not with G-tube care. The Director of Nursing confirmed that EBP should be used for residents with indwelling devices, such as feeding tubes, and that staff had been educated on these precautions. The facility's policy and CMS guidelines both indicate that EBP is necessary for high-contact activities involving indwelling medical devices, including feeding tubes, regardless of infection status.
Lack of Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident had a physician's order for oxygen use, which is considered a medication. The resident, who had a history of moderate cognitive impairment, asthma, and other medical conditions, was observed receiving oxygen therapy at various times without a documented order. Observations noted the resident receiving oxygen at different flow rates via nasal cannula, but there was no corresponding physician's order or documentation in the clinical records, Medication and Treatment Administration Record (MAR/TAR), or the Baseline Care Plan. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed the absence of a physician's order for the oxygen therapy. The DON acknowledged that oxygen is a medication and requires a physician's order, along with documentation of the resident's vitals and oxygen saturation. The facility's policies on oxygen administration and medication orders emphasize the necessity of a physician's order for safe administration, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Surprise
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sun Health Grandview Care Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Surprise Health And Rehabilitation Center | 0.8 mi | ★★★★★ | 4 | 0 |
| Sun West Choice Healthcare & Rehab | 1.2 mi | ★★★★★ | 1 | 0 |
| Sun City Post Acute | 5.8 mi | ★★★★★ | 1 | 0 |
| Lake Pleasant Post Acute Rehabilitation Center | 5.8 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.