Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Surrey Place St Lukes Hospital Skilled Nursing during CMS and state inspections, most recent first.
A resident with a known penicillin allergy was administered Zosyn, a penicillin antibiotic, leading to anaphylaxis and hypoxia. The resident's family had reported severe allergic reactions, but the facility staff only communicated blood clots as the reaction to the pharmacy and physician. After receiving Zosyn, the resident experienced breathing difficulties and was treated in the ER with epinephrine.
The facility failed to provide adequate infection control training and competency evaluation for staff, with only limited education on Bloodborne Pathogens and COVID-19. There was no documented training for CNAs on enhanced barrier protection or isolation precautions. The lack of a staff educator and incomplete training of the DON and ADON as Infection Preventionists contributed to this deficiency, placing all 80 residents at risk of infection.
The facility failed to ensure proper labeling, dating, and cleanliness of food storage areas, potentially leading to food-borne illnesses among 80 residents. Observations revealed unsealed and unlabeled food items in the dietary freezer and nourishment room refrigerators, with dirty shelves. The Food Service Director confirmed these issues, which contradict the facility's food safety policy.
The facility's assessment failed to include essential elements such as staffing based on resident acuity, training program evaluation, and infection control services. The absence of an Infection Preventionist (IP) and oversight of the infection control program were also noted. The Administrator confirmed these omissions, indicating a lack of comprehensive planning.
The facility failed to ensure the Infection Preventionist (IP) attended quarterly QAPI meetings, potentially affecting all 80 residents. The facility's policy did not include the IP as a required attendee, and records confirmed the IP's absence from meetings in 2024. The IP's job description required participation in QAPI meetings, which the Administrator confirmed had not occurred.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended on multiple occasions, posing a risk of medication misappropriation. Additionally, expired medical supplies were found in medication rooms, with staff unsure of responsibility for their removal. The DON confirmed the expectation for carts to be locked but noted the lack of a formal policy.
The facility failed to follow infection prevention and control standards, particularly in wound care and isolation precautions. A resident with a leg wound did not receive proper hand hygiene and equipment sanitation during treatment. Another resident with MRSA was not placed under contact precautions, and several residents with wounds and catheters were not under enhanced barrier precautions. Staff lacked awareness of EBP, and the facility's water management program was inadequate, with unclean ice machines posing a risk of waterborne pathogens.
A facility failed to assess a resident for safe self-administration of medications, despite the resident's history of choking. The resident, who was cognitively intact, had medications left at her bedside by an LPN without supervision. The DON confirmed that residents should not be unsupervised with medications unless assessed, which was not done.
A resident's wallet was misappropriated by a CNA who used the credit card for unauthorized purchases. The resident, who was cognitively intact, had asked the CNA to read the CVV on the card. Later, the resident discovered fraudulent charges and reported the incident. The DON and NS assisted in contacting the bank and police. The CNA admitted to the theft and was arrested.
The facility failed to provide adequate baseline care plans for three residents upon admission. One resident with chronic kidney disease and edema had a care plan lacking specific treatments or monitoring. Another resident with a fracture, depression, and diabetes had a care plan missing monitoring for anticoagulants and psychotropic medications. A third resident with a urinary tract infection did not have a baseline care plan provided. Interviews revealed that all specialized treatments and medications should be included in the baseline care plan, but this was not done.
The facility did not post a daily staffing report with the total hours worked by nursing staff, potentially affecting all 80 residents and visitors. The staffing documents reviewed lacked this information, and the DON was unaware of the requirement, confirming no policy on daily staff postings.
Failure to Prevent Significant Medication Error Due to Allergy
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a resident with a known allergy to penicillin was administered Zosyn, a penicillin antibiotic, intravenously to treat a urinary tract infection. The resident's family had informed the facility staff that the resident's reaction to penicillin included blood clots and that the resident was highly allergic, which could be life-threatening. However, the nurse and subsequently the pharmacy and physician were only informed that the reaction involved blood clots. After the administration of Zosyn, the resident experienced difficulty breathing, required oxygen, and was transported to the emergency room where they were diagnosed with anaphylaxis and hypoxia. The resident received two rounds of epinephrine as emergency treatment for the severe allergic reaction.
Inadequate Infection Control Training and Competency Evaluation
Penalty
Summary
The facility failed to ensure that staff were adequately trained in infection control practices, specifically enhanced barrier protection (EBP) and isolation precautions. The review of educational records revealed that the only infection control-related training provided was on Bloodborne Pathogens and Targeted COVID-19 Training. Registered Nurses and Licensed Practical Nurses had completed limited infection control education, and there was no documented training or competency testing for Certified Nursing Assistants related to infection control. The New Employee Orientation checklist indicated Hand Hygiene & Infection Control education, but detailed information was missing from the files. Interviews with facility staff revealed that there was no staff educator, and the responsibility for disseminating training from the main hospital fell on facility management. The Administrator admitted to receiving CMS guidance on EBP but could not provide documentation of staff training. Additionally, the Director of Nursing and Assistant Director of Nursing were not fully trained as Infection Preventionists, which contributed to the lack of proper infection control training and competency evaluation. This deficiency placed all 80 residents at risk of infection.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, dating, and cleanliness of food storage areas, which could potentially lead to food-borne illnesses among the 80 residents. During observations and interviews, it was found that the dietary department's walk-in freezer contained unsealed bags of frozen fish, hashbrowns, and potato wedges. The Food Service Director (FSD) acknowledged that these bags should not be left open and should be labeled with the date they were opened. Further observations in the nourishment room refrigerators on the Alpine Park, Canyon Creek, and Dakota units revealed multiple food items that were not labeled, dated, or were expired. These included various to-go containers of meals, fruits, and other food items. Additionally, the refrigerators had dirty and sticky shelves. The FSD confirmed these observations and stated that the food should be labeled, dated, and expired items should be discarded. The facility's policy on food safety and the FSD's job description emphasize the importance of proper food storage and handling to prevent foodborne illnesses.
Facility-Wide Assessment Lacks Critical Components
Penalty
Summary
The facility failed to conduct and document a comprehensive Facility-wide Assessment necessary for competent resident care during both day-to-day operations and emergencies. The assessment did not include critical components such as staffing requirements based on resident acuity levels, an evaluation of the training program, and infection control services. Specifically, the assessment lacked details on surveillance and antibiotic use, and it did not mention the employment of an Infection Preventionist (IP) responsible for overseeing the infection control program. During interviews, the Administrator confirmed the omissions in the Facility Assessment, acknowledging that it did not address staffing requirements, training program evaluations, or infection control services. The Administrator also admitted to not having seen other examples of Facility Assessments that included infection control surveillance and the employment of an IP, indicating a lack of awareness or understanding of the necessary components for a comprehensive assessment.
Infection Preventionist Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure the Infection Preventionist (IP) attended the quarterly Quality Assurance and Performance Improvement (QAPI) meetings, which had the potential to affect all 80 residents in the facility. The facility's policy on QAPI, dated January 2019, outlined the required attendees for the meetings but did not include the IP. Review of the QAPI meeting attendance records for January, April, and July 2024 confirmed the absence of the IP. Additionally, the job description for the IP indicated a requirement to participate in QAPI meetings. During an interview, the Administrator confirmed that the current IP had not attended any of the recent quarterly QAPI meetings.
Medication and Treatment Cart Security and Expired Supplies Issues
Penalty
Summary
The facility failed to ensure that medication and treatment carts were consistently locked and secured, as observed on multiple occasions across different units. On the Alpine unit, a treatment cart was found unlocked and unattended, with LPN 4 acknowledging she was the last to use it and had mistakenly left it unlocked. Similarly, the medication cart on the same unit was left unlocked by a Certified Medication Technician while administering medication, and RN2 on the Canyon Creek Hall also left a medication cart unlocked. These lapses in securing medication and treatment carts posed a risk of misappropriation or tampering with medications and supplies. Additionally, the facility did not remove expired medical supplies from medication rooms, as evidenced by the presence of expired blood collection tubes and syringes in the Alpine and Dakota Bluffs units. LPN 4 and LPN 3 both expressed uncertainty about who was responsible for removing expired items, indicating a lack of clear protocol or accountability. The Director of Nursing confirmed that there was an expectation for carts to be locked but acknowledged the absence of a formal policy regarding this practice.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection prevention and control standards, particularly in the care of residents with wounds and those requiring isolation precautions. For instance, during a wound care procedure for a resident with a right leg wound, the registered nurse did not follow proper hand hygiene protocols, failed to sanitize equipment, and did not use a barrier on the treatment cart. This negligence in infection control practices had the potential to contaminate clean dressings and spread infections. Additionally, the facility did not implement appropriate contact precautions for a resident diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA). Despite the resident's positive cultures for MRSA, there was no signage or personal protective equipment (PPE) setup outside the resident's room, and staff were observed not wearing the necessary protective gear. This oversight increased the risk of MRSA transmission to staff and other residents. The facility also neglected to place several residents with wounds and catheters under enhanced barrier precautions (EBP), as required. Staff interviews revealed a lack of awareness and training regarding EBP, and there was no PPE available for use with these residents. Furthermore, the facility's water management program was inadequate, lacking a diagram of the water system, and ice machines were not cleaned regularly, posing a risk of waterborne pathogens.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for the safe self-administration of medications, as required by their policy. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had a history of choking during meals or when swallowing medications. Despite this, there was no evidence in the resident's care plan or electronic medical record that an assessment for safe self-administration of medications had been conducted by the interdisciplinary team. During an interview, the resident stated that an LPN left a Tylenol and a vitamin at her bedside for her to take by herself, without supervision. The LPN confirmed this action, and the Director of Nursing acknowledged that the facility was honoring the resident's choice to have medications left at her bedside. However, the DON also stated that residents should not be unsupervised with medications unless they have been assessed for safe self-administration, which had not been done in this case.
Misappropriation of Resident's Property by CNA
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a Certified Nurse Aide (CNA) took the resident's wallet and used the credit card to make unauthorized purchases. The resident, who was cognitively intact and had no behavioral issues, had asked the CNA to help read the card verification value (CVV) on the back of the credit card. The CNA returned the card, but later the resident discovered fraudulent charges on the credit card and realized the wallet was missing. The resident reported the incident to the facility staff after being contacted by the bank's fraud department. The Director of Nursing (DON) and Nurse Supervisor (NS) were informed of the missing wallet and fraudulent charges. They assisted the resident in contacting the credit card company and the local police department. The CNA was identified as the perpetrator after arriving at the facility with a bag of food items and admitting to the theft and unauthorized purchases. The police were involved, and the CNA was arrested for stealing and fraudulent use of a credit/debit device. The stolen items included a driver's license, credit cards, cash, and blank checks.
Failure to Provide Adequate Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to ensure that a baseline care plan addressing specific needs was provided for three residents upon admission. Resident 7 was admitted with chronic kidney disease and chronic lower extremity edema, but the baseline care plan only listed medications without specifying treatments or monitoring for edema. Additionally, concerns related to skin integrity were noted, but there was no specificity related to edema. Resident 294 was admitted with a left distal femur periprosthetic fracture, depression, and diabetes mellitus. The baseline care plan included orders for warfarin but lacked monitoring for adverse effects. It also failed to address concerns or interventions related to the use of anticoagulants and psychotropic medications, such as monitoring for bleeding or psychosocial issues. Resident 297, admitted with a urinary tract infection, had an antibiotic prescribed, but the facility did not provide a baseline care plan before the survey team exited. Interviews with the Director of Nursing and the MDS Coordinator revealed that all specialized treatments and medications should be included in the baseline care plan, but this was not done.
Failure to Post Complete Daily Staffing Information
Penalty
Summary
The facility failed to post a daily staffing report that included the total number of hours worked by nursing staff, which could potentially affect all 80 residents and visitors. The review of the staffing document dated 07/31/24, located on the receptionist counter, showed it included the facility's name, resident census, total number of licensed/unlicensed staff, and the shift they were working. However, it did not indicate the total number of hours worked by nurses and CNAs per shift/day. Further review of documents from 07/01/24 to 07/31/24 revealed the same omission. During an interview on 08/01/24, the DON stated she was unaware that the total number of hours worked by staff was required on the form and confirmed there was no policy on daily staff postings.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Westchester House, The | 0.7 mi | ★★★★★ | 0 | 0 |
| Friendship Village Chesterfield | 1 mi | ★★★★★ | 1 | 0 |
| Delmar Gardens Of Chesterfield | 2 mi | ★★★★★ | 0 | 0 |
| Mason Pointe Care Center | 2 mi | ★★★★★ | 0 | 0 |
| Delmar Gardens West | 2 mi | ★★★★★ | 0 | 0 |
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