Inspection Reports for Suring Health and Rehabilitation Center

The complaint investigation found that on 8/26/25, resident R1 complained of increased pain and difficulty breathing. The Nurse Practitioner was notified and gave orders that were not transcribed timely. Staff failed to complete thorough assessments or notify the physician of worsening condition. R1 was transferred to the hospital with serious diagnoses including sepsis and acute renal failure. Immediate jeopardy was identified and later removed on 9/5/25, but deficient practices continued at a lower severity level.

The facility failed to ensure timely recognition and response to a change in condition for resident R1, resulting in immediate jeopardy due to inadequate pain management, delayed transcription of physician orders, incomplete assessments, and failure to notify the physician timely. R1 was ultimately hospitalized with sepsis, pleural effusion, and acute renal failure. The immediate jeopardy was removed after corrective actions, but deficiencies remain at a lower severity level.

The complaint investigation focused on the incident where resident R1 was injured during a Hoyer lift transfer on 11/14/24. The facility delayed notification to the Hospice agency until 11/19/24 and to the physician until 11/21/24. Interviews with staff and the Hospice nurse confirmed these delays. The investigation revealed inadequate post-incident assessments, lack of staff interviews, and insufficient education following the incident.

The facility failed to notify the Hospice agency until five days after the incident and the physician until seven days after the incident. The resident sustained a head injury when a Hoyer lift tipped over due to the catheter bag not being disconnected, causing the lift to fall on the resident's head. The facility did not offer the resident an opportunity for hospital evaluation and failed to complete adequate post-incident assessments, staff interviews, and education.

The facility failed to maintain an effective infection prevention and control program for one resident (R4) with an indwelling Foley catheter. Enhanced Barrier Precautions were not initiated, and staff did not use gowns and gloves during high-contact care. The resident's uncovered catheter drainage bag was placed on the floor and footrest, contrary to policy.

The visit was complaint-related, triggered by concerns about resident rights, pressure ulcer care, range of motion care, nutrition, menu adherence, food safety, infection control, and vaccination practices. Substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including failure to obtain court-ordered protective placement for a resident, inadequate pressure ulcer care and repositioning, failure to implement cervical collar orders, insufficient nutritional care and diet management, improper food handling and sanitation practices, lapses in infection prevention hand hygiene during medication administration, and failure to offer pneumococcal vaccination as per guidelines.

The complaint involved a missing checkbook belonging to Resident 5 (R5). Staff searched for the checkbook but did not report the missing item to the Nursing Home Administrator or the State Agency as required. The Nursing Home Administrator was unaware of the missing checkbook until the survey. RN-D contacted the resident's family but did not document the missing checkbook in the medical record. The resident's bank confirmed no transactions had occurred since July.

The facility did not ensure timely reporting of a potential misappropriation allegation to the State Agency for one resident. Staff were aware of the missing checkbook but failed to report it to administration, and the Nursing Home Administrator was unaware of the issue until the surveyor's inquiry.

The visit was complaint-related, triggered by allegations including failure to notify physicians timely, incomplete employee background checks, lack of written transfer notices, medication errors, and infection control issues. Substantiation status is not explicitly stated.

The facility failed to notify a physician timely about blood in a resident's urine, did not complete required background checks for some employees, failed to provide written transfer notices for multiple residents, had multiple medication administration errors including expired medications and improper self-administration, left medication carts unlocked, and staff did not consistently perform proper hand hygiene.

The complaint involved Resident R198 reporting concerns about a caregiver, which led to the caregiver being removed from caring for R198. The facility did not complete a grievance form or properly document the grievance. Additionally, the facility failed to receive or maintain hospice notes and care plans for R198, resulting in medication errors.

The facility failed to document, investigate, and resolve a grievance expressed by Resident R198 regarding a caregiver, and did not ensure proper coordination of hospice services, resulting in medication adjustments not being made per hospice requests.

The facility did not ensure food was served at a palatable temperature for 3 of 5 residents observed. Food items served to residents were lukewarm rather than hot, as confirmed by temperature measurements and resident interviews.

The visit was complaint-related, focusing on medication self-administration, care planning, feeding tube care, medication storage, food temperature, and infection control. Specific substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including failure to document self-administration medication assessments, incomplete care plans for specialized services, incorrect feeding tube orders and care, unsafe medication storage practices, serving food at inappropriate temperatures, and inadequate infection prevention and control practices including improper PPE use and hand hygiene.