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 Sun City Post Acute during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of unsafe wandering and exit-seeking behaviors was able to leave a locked dementia unit undetected, despite door alarms and staff presence. The resident was found outside the facility, having tipped his wheelchair and sustained a knee injury while attempting to evade staff, resulting in hospital evaluation. Staff interviews and observations confirmed that monitoring and supervision were inadequate to prevent this avoidable accident.
The facility failed to ensure that several residents and their legal representatives were fully informed and provided proper consent before changes were made to their insurance coverage, resulting in delays in care, financial burdens, and confusion about benefits. Staff did not consistently verify decision-making authority or provide adequate information about the impact of switching from Medicare Advantage to Medicare A and B, and documentation of consent was lacking.
A resident with chronic respiratory failure and COPD was found to have medication left at their bedside, contrary to facility protocol. The resident attempted to take the medication later but found it too hard to swallow. The LPN confirmed the medication was the prescribed antibiotic and believed the resident had taken it earlier. The DON stated that medications should never be left at the bedside and must be administered under direct supervision.
A resident with multiple diagnoses, including dementia and an acquired absence of the right leg, reported missing five pairs of pants. Despite the facility's process for inventorying and labeling personal belongings, no inventory list was created for the resident. Interviews and observations revealed that the resident had been waiting for pants from the CNA, and the issue remained unresolved. The facility's policy on personal property was not followed in this case.
The facility failed to ensure expired medications were not available for resident use and that medications were not left unattended. An LPN found expired aspirin in a medication cart, and another LPN prepared and almost administered expired Bumetanide before realizing the error. The expired medication was left unattended on the cart.
The facility failed to protect two residents from abuse by other residents. One resident with severe cognitive impairment was punched by another resident, resulting in a small tear and bruise. Another resident reported being hit with a TV remote control by a resident with behavioral issues. Both incidents were not properly documented or addressed by the facility.
Failure to Prevent Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate monitoring and supervision to prevent an avoidable accident involving a resident with moderate cognitive impairment and a history of unsafe behaviors, including wandering, exit-seeking, agitation, and poor safety awareness. The resident, who was admitted with diagnoses such as Wernicke's Encephalopathy and unsteadiness on feet, was residing in a locked dementia unit. Despite the presence of door alarms and staff assigned to monitor the area, the resident was able to leave the unit undetected. Staff became aware of the resident's absence only after hearing an alarm and conducting a sweep of the unit, at which point the resident was found missing. Subsequently, the resident was located outside the facility, less than 500 feet from the driveway entrance, attempting to wheel himself away. During the attempt to evade staff, the resident tipped his wheelchair and sustained a scraped knee, necessitating hospital evaluation. Interviews with staff confirmed that the doors were equipped with alarms and that staff were expected to be present in the hallways and dining areas. However, the monitoring in place was insufficient to prevent the resident's elopement and subsequent injury. Facility policy required identification and prevention of unsafe wandering, but the measures in place did not prevent this incident.
Failure to Obtain Informed Consent for Insurance Changes
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided informed consent regarding changes to their insurance plans, specifically the switch from Medicare Advantage plans to Medicare A and B. Multiple residents, including those with varying levels of cognitive function, were affected by these changes without adequate explanation of the consequences or proper authorization from the appropriate decision-makers. In one instance, a resident's roommate was mistakenly identified and signed paperwork to switch insurance, resulting in the actual resident experiencing delays in scheduled medical procedures and incurring significant out-of-pocket medication expenses. Interviews with residents, their powers of attorney (POAs), and public fiduciaries revealed that several residents and their representatives were either not consulted or not fully informed about the insurance changes. In some cases, staff members contacted individuals who were not authorized to make decisions, such as a resident's daughter instead of the public fiduciary, or failed to provide comprehensive information about how the insurance change would impact benefits, therapy access, and post-discharge services. Documentation and interviews indicated that staff members did not consistently use or require signed forms for these insurance changes, and some staff were unaware of the full implications of switching insurance plans. The deficiency was further compounded by a lack of clear communication and documentation processes within the facility. Staff interviews indicated confusion about who was responsible for informing residents and obtaining consent, and there was no standardized form or confirmation process for insurance changes. The business office and billing staff were often unaware of the changes or complaints, and the process for verifying resident identity and decision-making authority was not consistently followed. As a result, residents experienced disruptions in care, confusion about their coverage, and financial burdens due to uncovered services and medications.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside and were not readily available for use for one resident. Resident #282, who was admitted with diagnoses including chronic respiratory failure and chronic obstructive pulmonary disease, had a physician order for amoxicillin-pot clavulanate 875-125 mg to be taken every 12 hours for a bacterial infection. During an observation, the resident stated he forgot to take his pill and retrieved it from his bedside table, indicating that the nurse had left it there earlier. The resident attempted to take the pill but found it too hard to swallow. The LPN assigned to the resident confirmed that the medication was indeed the prescribed antibiotic and stated that she had administered it earlier that morning, believing the resident had taken it immediately as instructed. An interview with the Director of Nursing (DON) revealed that the facility's protocol requires nurses to hand medications to residents and watch them take the medication as ordered by the physician. If a resident refuses medication, the nurse is expected to destroy the medication and inform the provider. The DON emphasized that medications should never be left at the resident's bedside to be taken later. This failure to follow protocol could result in residents not receiving medications as ordered and an increased risk of side effects.
Failure to Protect Resident's Personal Property
Penalty
Summary
The facility failed to ensure reasonable care for the protection of a resident's personal property from loss or theft. Resident #64, who was admitted with multiple diagnoses including peripheral vascular disease, major depressive disorder, unspecified dementia, and an acquired absence of the right leg below the knee, reported missing five pairs of pants. The resident had moderate cognitive impairment, as indicated by a BIMS score of 9. During interviews and observations, it was noted that the resident had been waiting for pants or shorts from the CNA and had spoken to laundry and nursing staff about the issue, but it remained unresolved. An inspection of the resident's closet revealed no pants or shorts, only a couple of soiled shirts at the bottom of the closet. Interviews with staff members, including a CNA, an LPN, and the Director of Social Services (SSD), revealed that the facility had a process for inventorying and labeling residents' personal belongings upon admission and when new items were brought in. However, it was discovered that no personal inventory list had been created for Resident #64 since their admission. The CNA mentioned a new system involving laundry bags labeled with residents' names to manage personal clothing, but this system did not prevent the loss of Resident #64's pants. The SSD confirmed that grievances regarding missing personal items were to be submitted to social services and discussed in morning meetings, but no inventory list was found for Resident #64. An observation conducted with the SSD later revealed that clean clothes with the resident's name were found in the closet, and the resident expressed satisfaction with having their clothes returned. However, the SSD acknowledged that a personal inventory list had still not been created to reflect the clothing items in the resident's closet. The facility's policy on personal property stated that residents' belongings should be inventoried and documented upon admission and as items are replenished, but this was not followed in the case of Resident #64.
Expired Medications and Unattended Medications Found
Penalty
Summary
The facility failed to ensure that expired medications were not readily available for resident use and that medications were not left unattended. During a medication cart observation on the A-hall, an LPN found an expired enteric-coated aspirin in the top drawer of the medication cart. Despite the LPN's claim of having checked the cart multiple times for outdated medications, the expired aspirin was still present. Another LPN stated that if an expired medication was given to a resident, she would notify the unit manager and the doctor and make a notation in the resident's clinical record. However, this procedure was not followed in the observed instances. During a medication pass observation, another LPN was found preparing medications, including Bumetanide 1 mg, from a blister package that had expired on January 30, 2024. The LPN initially placed the expired medication in a cup and started to walk away from the cart before realizing the expiration date and replacing it with an unexpired blister pack. The expired Bumetanide blister pack was left on top of the medication cart unattended. The DON confirmed that there should be no expired medications in the carts and that staff should not leave medications unattended, indicating a lapse in adherence to these protocols.
Failure to Protect Residents from Abuse by Other Residents
Penalty
Summary
The facility failed to ensure that two residents were free from abuse by other residents. Resident #620, who has severe cognitive impairment, was punched in the face by Resident #725, who is moderately impaired, after being found in Resident #725's bed. The incident resulted in a small tear on Resident #620's left cheek and a bruise on his left hand. Staff interviews revealed that Resident #620 often wanders the halls at night, and the altercation was witnessed by a CNA. Despite the visible injury, Resident #620's son expressed no major concerns about his father's safety at the facility. In another incident, Resident #600, who is cognitively intact, reported being hit with a TV remote control by Resident #705. The CNA heard banging from the room but did not witness the altercation. Resident #705, who has a history of behavioral issues, was observed trying to enter another resident's room and exhibited aggressive behavior towards staff. During the investigation, Resident #600 mentioned that he had asked Resident #705 to use the call light instead of slamming, which led to the altercation. Both residents were subsequently separated and moved to different hallways. The facility's policy on Freedom from Abuse, Neglect, and Exploitation, revised in October 2022, states that each resident has the right to be free from abuse and neglect. However, the facility failed to adhere to this policy, resulting in physical and psychosocial harm to the residents involved. Interviews with staff and the Director of Nursing revealed a lack of awareness and proper documentation of the incidents, further highlighting the deficiency in ensuring resident safety.
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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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Nursing homes near Sun City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Pleasant Post Acute Rehabilitation Center | 1.3 mi | ★★★★★ | 7 | 0 |
| Sierra Winds | 1.9 mi | — | 0 | 0 |
| Freedom Plaza Care Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Boswell Transitional Care Of Cascadia | 3.4 mi | ★★★★★ | 0 | 0 |
| Peoria Post Acute And Rehabilitation | 3.5 mi | ★★★★★ | 5 | 0 |
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