Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Surprise Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and major mobility limitations was ordered a customized wheelchair, but the DME process was not completed and follow-up was poorly documented. Staff and the resident’s daughter reported confusion about whether the order had been sent, and the DME company stated it had not received the needed documentation or proper coordination from the facility. Interviews showed the resident remained without the wheelchair despite repeated evaluations and attempts to clarify the order.
Unsecured Medication Cart Left Unattended: An RN left a medication cart unattended and unlocked while stepping into a resident room after preparing meds. The ADON later locked the cart. The ADON, RN, and DON all stated the cart must be locked when a nurse walks away, and the facility policy requires all drugs and biologicals to be stored in locked compartments.
Opened salsa was found in dry storage instead of being refrigerated after opening, with two different dates on the container and no clear explanation for the labeling. The KDM and another staff member stated the salsa should have been dated and placed in the walk-in refrigerator after opening, and the facility policy required TCS foods to be kept at or below 41 degrees F.
A resident with end stage renal disease and on hemodialysis did not have weights recorded before scheduled dialysis treatments as ordered by the physician. Despite established facility procedures and staff awareness of the process, required weights were not documented on the MAR or in the clinical record for multiple treatment dates, as confirmed by the DON and review of facility records.
The facility provided bedside hemodialysis to three residents with end stage renal disease without obtaining the required state approval or modified license for in-house dialysis services. Staff interviews confirmed awareness of the ongoing treatments, and documentation requests revealed the absence of necessary licensing for both the facility and the contracted dialysis provider.
A resident with a C2 cervical fracture was not provided with appropriate care related to a cervical collar, which was ill-fitting and often not worn. Despite the collar's poor fit and the resident's discomfort, no corrective actions were taken. The resident was found unresponsive without the collar, highlighting a deficiency in care and adherence to facility policies.
Failure to Provide and Track Customized Wheelchair DME Services
Penalty
Summary
The facility failed to ensure that specialized DME services were provided for a resident with significant mobility limitations and cognitive impairment. The resident was re-admitted with diagnoses including heart failure, anoxic brain damage, and chronic kidney disease. MDS assessments documented severe impairment in cognitive skills related to daily decision-making, and the resident was not using a mobility device or wheelchair. A physician order dated May 07, 2025 included a PT/OT evaluation for a wheelchair, and an NP/PA progress note dated November 06, 2025 stated that the resident would be a full-time wheelchair user and would require individualized fittings and adjustments. The record showed that a facsimile transmittal sheet dated November 07, 2025 indicated documentation was sent to the DME company, and a care plan dated November 24, 2025 included an RNA intervention to transfer the resident to a wheelchair twice a week for posture and positioning, but the care plan did not reference DME. Subsequent records and interviews showed that the wheelchair process was not completed as expected and that documentation of follow-up was lacking. A therapy progress note dated March 26, 2026 stated that the DME company had been contacted about the wheelchair order placed in November, and that the company had attempted to contact the resident in January and March even though the resident was residing at the facility and was unable to communicate independently. The note also stated that the facility and family attempted to obtain information, but due to HIPAA constraints no information was provided. Interviews with staff and the resident’s daughter showed conflicting and incomplete communication regarding the wheelchair order. The daughter stated that she had been told the wheelchair would take a long time, later learned no order had been placed, and was told again that there were no orders when she contacted the DME company. Staff stated that the resident’s current facility wheelchairs were not suitable, that a customized wheelchair was needed, and that the process had to be restarted after a leadership transition. Staff also acknowledged that there was no documentation of follow-up calls to the DME company after November 2025, that some calls had occurred without being documented, and that the resident’s family should have been kept informed about the wheelchair process. The DME company stated that only one order was on file and that additional therapist evaluation, a signed written order, and related documentation were needed.
Unsecured Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure one medication cart was secured when left unattended. During an observation on the C Wing first floor, a registered nurse was preparing medications at the medication cart, then took a medication cup and walked into a resident room next to the cart, leaving the cart facing the hallway, unattended, and unlocked. The assistant director of nursing was then observed walking up to the cart and locking it. During interviews, the ADON stated the policy is to lock medication carts when walking away because patients or anyone can get into the medications. The RN stated she thought she had locked the cart but it must not have happened, and acknowledged the policy is to lock the medication cart. The DON also stated the cart must be locked when a nurse walks away and that the cart can only be open when a nurse is present. A review of the facility policy titled Medication Access and Storage, E kit access, revised July 2023 and reviewed July 2025, stated that all drugs and biologicals are to be stored in locked compartments.
Opened Salsa Stored Improperly
Penalty
Summary
The facility failed to ensure that an opened gallon-sized container of Pace Chunky Salsa was stored in accordance with professional food service standards. During an initial walk-through of the kitchen dry storage on March 24, 2026, surveyors observed the container with approximately 1/10 of its contents used and stored in non-refrigerated dry storage with two different labels dated February 2, 2026 and March 2, 2026. When the Kitchen Dietary Manager opened the lid, he noted that the safety seal had been opened and a portion of the salsa had been used. During interviews, the Kitchen Dietary Manager stated the opened salsa should have been in the walk-in refrigerator by the salad dressing area on the top shelf and said he did not know what the differing dates indicated. A staff member stated he opened a new gallon-sized container of Pace Chunky Salsa to fill two small cups for a resident and then returned to the line, stating he should have refrigerated it after opening. The facility's policy stated food should be stored at appropriate temperatures and that TCS foods must be maintained at or below 41 degrees Fahrenheit.
Failure to Monitor and Document Dialysis Weights per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident requiring hemodialysis received weight monitoring as ordered by the physician. The resident, who had diagnoses including end stage renal disease and was dependent on renal dialysis, had physician orders and care plan interventions specifying that weights should be obtained before each scheduled bedside dialysis treatment. However, review of the Medication and Treatment Administration Records and Weight Summary logs for January and February revealed that weights were not recorded on any of the dialysis treatment dates. Interviews with staff confirmed that the process for obtaining weights involved communication between nurses and CNAs, but the required weights were not documented as expected. The Director of Nursing confirmed that the weight monitoring was not recorded in the clinical record or on the MAR for the relevant months, which did not meet facility expectations. Facility policy required weights to be recorded as ordered by the physician, and if unable to obtain, the reason should be documented. The lack of documentation and monitoring occurred despite clear physician orders and established facility procedures for weight monitoring in residents receiving dialysis.
Unlicensed In-House Dialysis Services Provided Without State Approval
Penalty
Summary
The facility failed to obtain approval from the state agency for a modification of its health care institution license prior to establishing and providing in-house dialysis services. Despite this, bedside hemodialysis treatments were administered to three residents with end stage renal disease over a period of several months. Documentation requests during the survey revealed that the facility could not provide a modified license for in-house dialysis services or a license for the contracted dialysis provider. The facility assessment did not specify the number of residents with end stage renal disease or those receiving bedside hemodialysis. Staff interviews confirmed awareness of the ongoing bedside dialysis treatments, with both a CNA and an LPN acknowledging that residents were receiving hemodialysis in their rooms. The Executive Director stated that the facility was unable to obtain the required license to provide dialysis services. The deficiency was identified through clinical record review, staff interviews, and policy review, and it was noted that the facility did not comply with Arizona Administrative Code requirements for providing dialysis services on the premises.
Failure to Ensure Proper Use of Cervical Collar
Penalty
Summary
The facility failed to ensure proper care and services related to a cervical collar for a resident with a C2 cervical fracture. The resident was admitted with a diagnosis of an unspecified displaced fracture of the second cervical vertebra, among other conditions, and was supposed to wear a cervical collar at all times except during showers and meals. However, there was no care plan with goals and interventions in place to address the use of the cervical collar, and no physician order for its use was found in the clinical record. The resident was observed without the cervical collar on multiple occasions, and there was no documentation of the reason for its absence or notification to the physician. The clinical records and staff interviews revealed that the cervical collar was ill-fitting, causing discomfort and chin tucking, which likely led to the resident's refusal to wear it. Despite these issues, no action was taken to address the poor fit of the collar. The Occupational Therapy and Physical Therapy notes indicated that the collar was not safe for wearing, yet the resident continued to be left without it. The staff, including therapists and nursing staff, were aware of the collar's poor fit but did not take steps to rectify the situation or ensure the resident's safety. On the day of the resident's passing, the resident was left in the common room without the cervical collar and was later found unresponsive and without a pulse. Video footage confirmed that the resident was not wearing the collar when wheeled to his room by a family member. Interviews with various staff members, including the Director of Nursing, confirmed that the collar should have been worn regardless of its fit. The facility's policies on rehabilitative services and physician orders were not followed, contributing to the deficiency in care.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Sante Of Surprise | 0.8 mi | ★★★★★ | 3 | 0 |
| Sun Health Grandview Care Center | 1 mi | ★★★★★ | 0 | 0 |
| Sun West Choice Healthcare & Rehab | 1.3 mi | ★★★★★ | 1 | 0 |
| Sun City Post Acute | 5.8 mi | ★★★★★ | 1 | 0 |
| Sunview Respiratory And Rehabilitation | 5.9 mi | ★★★★★ | 6 | 2 |
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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.