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Inspection visit

Health inspection

SURREY PLACE ST LUKES HOSPITAL SKILLED NURSINGCMS #2654148 citations on this visit
8 citations recorded

Citations

8 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0554GeneralS&S Dpotential for harm

    F554 - The right to self-administer medications if the interdisciplinary team, as

    Allow residents to self-administer drugs if determined clinically appropriate.

  • 0602GeneralS&S Dpotential for harm

    F602 - The resident has the right to be free from abuse, neglect, misappropriation of re

    Protect each resident from the wrongful use of the resident's belongings or money.

  • 0726GeneralS&S Fpotential for harm

    F726 - Nursing Services

    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

  • 0760GeneralS&S Dpotential for harm

    F760 - Residents are free of any significant medication errors

    Ensure that residents are free from significant medication errors.

  • 0761GeneralS&S Epotential for harm

    F761 - Labeling of Drugs and Biologicals

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0838GeneralS&S Fpotential for harm

    F838 - Facility assessment

    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

  • 0880GeneralS&S Epotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the August 1, 2024 survey of SURREY PLACE ST LUKES HOSPITAL SKILLED NURSING?

This was a inspection survey of SURREY PLACE ST LUKES HOSPITAL SKILLED NURSING on August 1, 2024. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SURREY PLACE ST LUKES HOSPITAL SKILLED NURSING on August 1, 2024?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Allow residents to self-administer drugs if determined clinically appropriate."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.