Inspection Reports for
Surrey Place St Luke’s Hospital Skilled Nursing

The complaint investigation found the medication error substantiated, involving a resident with a known penicillin allergy who suffered an anaphylactic reaction after receiving Zosyn IV.

The facility failed to ensure residents were free from significant medication errors after administering Zosyn to a resident allergic to penicillin, resulting in an anaphylactic reaction requiring emergency treatment.

The facility was found not in substantial compliance with multiple deficiencies including failure to assess residents for safe self-administration of medications, failure to protect residents from misappropriation of property, insufficient nursing staff competencies, inadequate infection control training, improper labeling and storage of drugs and biologics, food safety violations, and incomplete facility-wide assessments.

The facility was found to be noncompliant with several Life Safety Code requirements including means of egress, illumination of exit discharge areas, hazardous area enclosures, sprinkler system installation, corridor door functionality, and HVAC smoke damper maintenance.

The complaint investigation included allegations of resident property misappropriation by a staff member, a medication error involving administration of a penicillin antibiotic to an allergic resident causing anaphylaxis, and infection control failures including improper isolation precautions and hygiene practices.

The facility failed to protect a resident from misappropriation of property by a staff member, failed to prevent a significant medication error involving administration of a penicillin antibiotic to an allergic resident resulting in anaphylaxis, and failed to implement proper infection prevention and control practices including inadequate isolation precautions, improper wound care hygiene, and poor cleaning of equipment and ice machines.

The facility failed to assess a resident for safe self-administration of medications, protect a resident from misappropriation of property, ensure staff competency in infection control, prevent significant medication errors, secure medication and treatment carts, maintain food safety standards, conduct a comprehensive facility-wide assessment including infection control, and implement an effective infection prevention and control program. Multiple residents were not placed on appropriate isolation or enhanced barrier precautions, and infection control practices were inconsistently followed.

The facility failed to maintain portable fire extinguishers at the proper height and did not maintain smoke barrier walls with the required fire resistance rating. These deficiencies had the potential to affect residents in multiple smoke compartments.

The complaint was substantiated as the facility failed to provide necessary assistance with shaving to Resident #100, confirmed by observations and interviews with staff and the resident.

The facility was found not in substantial compliance due to failure to regularly offer or assist a resident with removal of facial hair to maintain good grooming and hygiene. Observations, interviews, and record reviews confirmed the deficiency.

The complaint was substantiated as the facility failed to provide shaving assistance to Resident #100 despite the resident's inability to shave independently and repeated requests for help.

The facility failed to provide regular shaving assistance to Resident #100, who required help with shaving but was not offered assistance by staff. The Director of Nursing and Administrator acknowledged the lack of a formal policy for shaving residents and confirmed that personal hygiene care should be offered and provided to dependent residents.

The facility failed to provide adequate protective oversight for one resident who attempted to elope multiple times, resulting in a deficiency related to accident hazards and supervision. The facility's policies and procedures for elopement risk and resident condition changes were reviewed and found lacking in implementation.

The complaint investigation included allegations of abuse and injury of unknown origin for residents #13 and #7. The facility failed to properly investigate these allegations per policy. The Director of Nursing was not aware of the allegations prior to the investigation.

The facility failed to obtain consistent, accurate weights necessary for assessing residents' nutritional status for four of eleven residents reviewed. The facility also failed to properly investigate allegations of abuse and injury of unknown origin for two of three sampled residents. The census was 44 residents in certified beds at the time of inspection.

The facility failed to complete the Skilled Nursing Facility Advanced Beneficiary Notice for one resident whose payer source changed from Medicare Part A to Medicaid. The facility also failed to provide timely written notification to residents or their representatives upon hospital transfers for four residents. Additionally, the facility did not maintain proper functioning of bathroom exhaust ventilation systems on the C hallway.

The facility was found deficient in issuing Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN) for residents transitioning from Medicare to Medicaid, failure to provide timely written transfer/discharge notices to residents or their representatives, and inadequate ventilation in resident bathrooms on the C hallway.

The facility failed to meet requirements for the storage and use of liquid oxygen containers, including improper placement of a light switch in the oxygen storage room. No other deficiencies were cited in the licensure inspection.

The facility failed to meet professional standards of care related to medication administration and wound care for multiple residents. The facility also failed to provide sufficient nursing staff to meet resident needs on several days.

The facility failed to notify the State Long-Term Care Ombudsman of resident transfers and discharges, failed to provide written bed hold policy notices to residents, and did not follow professional standards for medication administration and care plans for several residents.

The facility failed to maintain the fire alarm system, sprinkler system, corridor doors, smoke barriers, oxygen storage, and dryer vents in compliance with applicable fire safety codes. Deficiencies had the potential to affect residents in multiple smoke compartments, with issues such as non-communicating fire alarm signals, sprinkler heads covered in insulation, doors not resisting smoke passage, improper oxygen storage, and lint buildup in dryer vents.