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Complaint Investigation

Sante Of Surprise

May 28, 2026 · Surprise, AZ · 14775 West Yorkshire Drive
Citations 2
CMS Rating 4/5
Beds 70
Provider ID 035282
Healthcare Facility
Sante Of Surprise
Surprise, AZ  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Sante Of Surprise in SURPRISE, AZ — inspection on May 28, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0684
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

Federal health inspectors cited Sante Of Surprise in SURPRISE, AZ for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2026-05-28.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 2 deficiencies cited during this inspection of Sante Of Surprise.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2026-06-06.

Based on observation, interviews, and review of facility policy and procedure, the facility failed to

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.

Next, she pulled on the drawers of the medication cart (P2) and they opened.An interview was conducted with LPN (Staff #29), on May 26, 2026 at 8:41A.M. who stated she forgot to lock the medication cart (P2).

She stated she was having difficulty with the lock since she started her shift at 6:00 A.M., but did not make anyone aware that the lock was not working on the P2 medication cart.

She further stated that there was no communication during the shift change meeting that the lock was not working properly on the medication cart (P2).

The LPN (Staff #29) stated that the risk of a mediation cart being left unlocked, is anyone could grab medications out of the medication cart. An observation was conducted with the Director of Nursing (Staff #149) on May 26, 2026 at 8:50 A.M. who tried to push the lock in, but it did not work.

Next, she put the key in the lock of the medication cart (P2) and the key turned in the lock, but it did not push in to lock the medication cart (P2).

She pulled on the drawers of the medication cart and they opened.An interview was conducted with the Director of Nursing (DON/Staff # 149) on May 26, 2026 at 8:50 A.M. stated that medication carts should be locked when the nurse steps away from the medication cart.

She stated that she was not made aware that the lock of medication cart (P2) was not working.

She stated that she will notify the pharmacy to get fixed and during medication pass the nurse will need to place medication cart (P2) in the medication room that is locked at all times. DON (Staff #149) stated that the risk of leaving the medication cart unlocked anyone could come and steal medications out of the medication cart.An interview with Administrator (Staff #21) on May 28, 2026 at 1:02 P.M. revealed he was aware that the lock was not working on medication cart (P2) and he stated it was sent back to the pharmacy to be fixed.The facility policy on Storage of Medications- Revised 4/2007 revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SURPRISE, AZ, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Sante Of Surprise or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.