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 Health La Loma Care Center during CMS and state inspections, most recent first.
A resident with multiple complex medical conditions had conflicting documentation regarding code status, with some records indicating DNR/DNI and others indicating full code. When the resident was found unresponsive, staff relied on a shift report and chart information that listed the resident as DNR, and CPR was not initiated. Interviews confirmed that staff were unsure of the correct code status due to inconsistent documentation and communication breakdowns.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised and remained outside for about an hour before being found by staff from a neighboring building. Although 15-minute checks were part of the care plan, the resident was not detected missing until discovered outside, demonstrating a failure to provide adequate supervision and prevent elopement.
Staff failed to ensure that prepared food was served to a resident at a safe and appetizing temperature, with a cheese steak sandwich measured at 123°F upon delivery, below the FDA-recommended hot holding temperature of 135°F. Facility policy and staff interviews confirmed this did not meet meal service expectations.
Two residents with orders for urostomy, ileostomy, and Foley catheter care did not have these treatments included in their baseline care plans or EHR care plans within 48 hours of admission, despite documentation confirming the presence of these devices and staff acknowledging the omission. Facility policy required such care to be included in baseline care plans, but this was not done.
Two residents received anti-hypertensive and pain medications outside of physician-ordered parameters, with staff administering drugs despite vital signs falling outside specified limits. MAR reviews showed multiple instances of non-compliance, and interviews with an LPN and the DON confirmed that these actions did not meet facility expectations. Facility policies requiring documentation of vital signs and adherence to medication orders were not consistently followed.
A resident with a documented history of frequent falls and multiple risk factors was inaccurately coded on the MDS assessment as having no prior falls, despite clinical records and care plans indicating otherwise. The error was identified during a surveyor review, and both the MDS Coordinator and DON confirmed the assessment did not accurately reflect the resident's status.
A resident with a Foley catheter for urinary retention did not receive required catheter care, timely bladder scans, or prompt re-insertion of the catheter as ordered. Documentation and staff interviews confirmed missed care and assessments, with facility policy and provider orders not followed.
A resident with an ileostomy experienced repeated leakage of the ostomy bag, which was not promptly addressed by nursing staff despite early notification by a CNA. The bag was not changed for several hours, and there was no documentation of required care or provider notification regarding the ongoing leakage. Facility policies for ostomy care and documentation were not followed.
Surveyors observed that staff did not consistently label and date opened food and leftovers in nourishment refrigerators, as required by facility policy. Multiple items, including a container with a pink substance and wrapped items in the freezer, were found without proper labeling or dating. Staff interviews confirmed that this practice did not meet facility expectations and that daily checks were not always performed.
Two residents experienced lapses in infection control: a nurse performed urostomy care without proper PPE use or hand hygiene, allowing her gown to fall and contaminating clean supplies with soiled gloves, while another resident's foley catheter bag outlet was left open and on the floor, cleaned only with a personal wipe and not reported to nursing, resulting in the bag not being changed as required by policy.
The facility failed to notify the State Long-Term Care Ombudsman of a resident's discharge on two occasions, despite the resident's severe cognitive impairment. Staff interviews revealed confusion over who was responsible for the notification, and the facility's policy was not followed, as the notifications were only sent on the day of the surveyor's visit.
Failure to Follow Advance Directives Due to Code Status Documentation Errors
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately followed, resulting in a discrepancy regarding the resident's code status at the time of a critical event. The resident was admitted with multiple diagnoses, including muscle weakness, MRSA, acute abscess, delirium, atrial fibrillation, dementia, and mood disturbances. Documentation in the clinical record was inconsistent: while the hospital history and some admission documents indicated a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, other records, including a signed advance directive and physician orders, indicated a full code status. The care plan did not specify a code status, and there was no evidence that the code status was clarified with the resident, their power of attorney, or the physician. Shift reports and staff recollections further conflicted, with some indicating DNR and others full code. On the day of the incident, the resident was found unresponsive in bed. Staff interviews revealed that upon discovery, the CNA called for a nurse, and two nurses responded. One nurse checked the resident's vital signs, while another checked the chart for code status and reported the resident as DNR. As a result, CPR was not initiated. There was no documentation in the clinical record that CPR was started, and the facility's self-report confirmed that CPR was not performed when the resident was found unresponsive and without signs of life. The staff relied on conflicting information from shift reports and the physical chart, leading to the decision not to initiate resuscitation. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was to verify code status in the physical chart and follow the documented orders. However, the DON acknowledged a breakdown in communication and misreading of the resident's code status. Facility policy required clear documentation and communication of advance directives, but this was not consistently implemented, resulting in the failure to honor the resident's documented wishes regarding resuscitation.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a BIMS score of 03 and diagnoses including dementia and cerebral amyloid angiopathy, was admitted to the facility and initially assessed as low risk for elopement. Despite this, a care plan was developed that included interventions such as engaging the resident in purposeful activity, providing reorientation, and conducting 15-minute checks. However, the resident was able to leave the care center building and was found sitting on a bench approximately 700 feet away, outside the facility and not visible from the care center. The resident had been unsupervised for about an hour before being discovered by staff from the independent living building next door. Staff interviews confirmed that 15-minute checks were supposed to be in place for residents at risk of wandering or elopement, but the resident was able to leave the premises without detection. The facility's policy defines elopement as a resident leaving the premises or a safe area without authorization or necessary supervision. Documentation and staff statements revealed that the resident was found hot and sweaty, and required assistance from emergency services upon return. The incident demonstrated a failure to provide adequate supervision and to ensure the area was free from accident hazards, resulting in the resident's elopement.
Failure to Maintain Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure that prepared food was distributed to residents at a safe and appetizing temperature. On March 26, 2025, observations of the tray line revealed that initial food temperatures were within safe ranges, with meat at 180°F, vegetables at 169°F, starch at 175°F, and a cheese steak sandwich at 172°F. However, by the time a test tray was provided to a resident, the final temperatures had dropped, with the meat at 152°F, vegetables at 140°F, starch at 157°F, and the cheese steak sandwich at 123°F. No cold components were present on the tray line that day due to the menu selection. Interviews with the Interim Director of Dining Services and the Part-Time Registered Dietician confirmed that the facility's policy is to follow FDA recommendations, which require hot foods to be held at 135°F or higher and cold foods at 41°F or lower. The staff acknowledged that serving hot food below 135°F, such as the cheese steak sandwich at 123°F, did not meet the facility's meal service expectations. Review of the facility's kitchen policy and FDA guidelines further emphasized the importance of maintaining proper food temperatures to prevent bacterial growth.
Failure to Include Ostomy and Catheter Care in Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans addressing urostomy, ileostomy, and Foley catheter care for two residents within 48 hours of admission, as required by policy. For one resident with a history of cerebral infarction, malignant neoplasm of the bladder, and an artificial urinary tract opening, physician orders specified urostomy care twice daily. Documentation confirmed the presence of a urostomy and that care was being provided per orders, but neither the baseline care plan nor the electronic health record (EHR) care plan included any focus or interventions for urostomy care. Multiple staff interviews confirmed that urostomy care should have been included in the baseline care plan and EHR, but was omitted. Another resident was admitted with diagnoses including peritoneal abscess, type 2 diabetes, depression, colostomy, and recent digestive system surgery. Physician orders required ostomy care every seven days and as needed, as well as Foley catheter care every shift. Observations and progress notes confirmed the presence of an ileostomy and Foley catheter. However, the baseline care plan and EHR care plan did not include any nursing care instructions for either the ileostomy or Foley catheter. Staff interviews confirmed that these care needs should have been included in the baseline care plan within 48 hours of admission, but were not. Policy review indicated that baseline care plans must include instructions for all services and treatments to be provided, and that ostomy care plans should reflect the resident's goals and preferences, including frequency of care and required products. Despite these requirements, the facility did not ensure that baseline care plans for the two residents included the necessary information for urostomy, ileostomy, or Foley catheter care, as confirmed by staff and documentation review.
Failure to Administer Medications Within Ordered Parameters
Penalty
Summary
The facility failed to ensure that medications, specifically anti-hypertensives and pain management drugs, were administered within the parameters set by physician orders for two residents. For one resident with diagnoses including parkinsonism, dementia, atrial fibrillation, and hypertension, there were physician orders for Amlodipine and Metoprolol Succinate to be held if the pulse was less than 60 or systolic blood pressure was less than 110. However, the Medication Administration Record (MAR) showed that these medications were administered outside of the ordered parameters on multiple occasions. Additionally, the care plan did not include interventions related to the use of anti-hypertensives, though it did address pain management. Another resident with metabolic encephalopathy had orders for Oxycodone for pain and Metoprolol Succinate for hypertension, both with specific administration parameters. The MAR indicated that Oxycodone and Metoprolol were administered outside of the prescribed parameters on several dates. Interviews with an LPN and the Director of Nursing confirmed that the facility's expectation is for staff to follow medication orders, document vital signs as required, and provide reasons when medications are held. Both staff members acknowledged that the administration of medications outside of ordered parameters did not meet facility expectations. Facility policies reviewed stated that staff are required to document the execution of physician orders, obtain and record vital signs prior to administering certain medications, and hold medications per orders when indicated. The policies also require that vital signs be recorded on the MAR when necessary. The findings showed that these policies were not consistently followed, resulting in the administration of medications outside of the prescribed parameters for the residents involved.
Inaccurate MDS Assessment of Fall History
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for one resident accurately reflected their history of falls. The resident was admitted with multiple diagnoses, including Parkinson's disease, dementia, repeated falls, muscle weakness, and gait abnormalities. Clinical documentation, including progress notes and care plans, consistently indicated a history of frequent falls and a moderate fall risk. However, the admission 5-Day Medicare MDS assessment incorrectly documented that the resident had no falls prior to admission, despite clear evidence to the contrary in the clinical record. The MDS Coordinator, upon review, acknowledged that the fall section of the MDS was inaccurately coded and should have indicated a history of previous falls. The Director of Nursing confirmed that the MDS should be accurate and that the error was only identified after being brought to the staff's attention by the surveyor. Facility policy and the RAI manual both require that MDS assessments accurately reflect the resident's status, and the inaccurate coding in this case resulted in the submission of incorrect data regarding the resident's fall history.
Failure to Provide Timely Catheter Care and Monitoring
Penalty
Summary
A deficiency occurred when a resident with a history of peritoneal abscess, type 2 diabetes mellitus, depression, and a colostomy did not receive Foley catheter care and monitoring in accordance with provider orders and facility policy. The resident had a Foley catheter for urinary retention, with orders for catheter care every shift and specific instructions for removal, bladder scans, and re-insertion as needed. Documentation revealed that catheter care was not performed on a scheduled shift, and after the catheter was removed, there was no evidence that the required bladder scan was performed at the scheduled time. Following the removal of the Foley catheter, the resident reported not having urinated, and staff interviews confirmed that no bladder scan or assessment was conducted as ordered. When a bladder scan was eventually performed, it showed a small amount of urine in the bladder, and the resident remained unable to urinate. Despite a provider order to re-insert the Foley catheter on a specific night, documentation indicated that the catheter was not re-inserted until the following morning, with staff unable to confirm the exact timing of the procedure. Policy reviews showed that the facility was required to provide ongoing assessments, timely interventions, and thorough documentation for residents with indwelling catheters. However, the medical record lacked evidence of required catheter care, timely bladder scans, and prompt re-insertion of the catheter per provider orders. Staff interviews corroborated these documentation gaps and lapses in following established protocols.
Failure to Provide Timely and Documented Ileostomy Care
Penalty
Summary
The facility failed to provide appropriate ileostomy care in accordance with professional standards for a resident who required such services. The resident, admitted with multiple diagnoses including an ileostomy, had a provider order for ileostomy care every seven days and as needed, which included cleansing the skin and stoma, drying, and applying a wafer and pouch. Documentation on the Treatment Administration Record (TAR) showed no evidence that ileostomy care was performed as ordered on a specific day shift. Additionally, there was no documentation that the provider was notified about the resident's ongoing ileostomy leakage, despite repeated incidents of the bag leaking and requiring multiple changes within a single shift. Observations and interviews revealed that the resident's ileostomy bag was leaking for several hours before it was changed, with both the resident and her daughter noting the delay. Staff interviews confirmed that the leaking was observed early in the morning and reported to a nurse, but the bag was not changed until several hours later. The LPN was not informed about the leakage during shift report, and the Director of Nursing confirmed the lack of provider notification and documentation of care. Facility policies required prompt response to ostomy issues and meticulous documentation, which were not followed in this case.
Failure to Label and Date Opened Food Items in Refrigerators
Penalty
Summary
Staff failed to follow facility policies regarding the labeling and dating of opened food and leftovers in nourishment refrigerators. During multiple observations, surveyors found food items, including canned beverages, a wrapped item in the freezer, and a container with a thick pink substance, that were not labeled or dated. Staff interviews confirmed that facility policy requires all opened or leftover items to be labeled and dated, and that the observed items did not meet this expectation. Staff also stated that refrigerators are to be checked at the end of each shift to dispose of improperly labeled items, but this was not consistently done. Policy reviews revealed that the facility requires all refrigerated food to be labeled and dated, with daily inspections of refrigerators, coolers, and freezers. Despite these policies, the lack of labeling and dating on certain food items was observed on more than one occasion, indicating a failure to adhere to established food safety protocols. No information about specific residents or their medical conditions was provided in the report.
Deficient Infection Control Practices in Urostomy and Foley Catheter Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for two residents, resulting in deficiencies related to urostomy and foley catheter care. For one resident with a urostomy, a registered nurse was observed performing care without properly securing her gown, which repeatedly fell off her shoulders and chest during the procedure. The nurse also failed to perform hand hygiene before donning gloves and entered the resident's room after gathering supplies from other areas without sanitizing her hands. During the care, the nurse touched clean supplies in the resident's closet with gloves that had been used for the urostomy treatment, potentially contaminating those supplies. The nurse admitted to not following facility policy regarding PPE donning and hand hygiene, stating she was in a hurry and did not secure the gown or sanitize her hands as required. For another resident with a foley catheter, the catheter bag outlet spout was observed unclipped, open, and lying on the floor without a privacy bag in place. The CNA responsible for the resident stated she had emptied the catheter bag and noticed the spout on the floor, cleaning it with a personal care wipe instead of an alcohol wipe, and did not notify the nurse of the incident. Facility policy required that if a catheter bag or tubing touches the floor, it is considered contaminated and should be replaced as soon as possible, or at minimum disinfected with an approved wipe. The nurse was not informed of the contamination and the catheter bag was not changed, as confirmed by a review of the treatment administration record and progress notes. Interviews with facility leadership, including the Infection Preventionist and Director of Nursing, confirmed that the observed practices did not meet facility expectations or policy. Both leaders stated that gowns should be secured to prevent exposure, hand hygiene should be performed before donning gloves, and contaminated catheter equipment should be properly disinfected or replaced. The failure to follow these protocols was acknowledged by the staff involved and confirmed by facility policy documentation.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure that a copy of the notice of discharge was sent to a representative of the Office of the State Long-Term Care Ombudsman for a resident who was discharged on two separate occasions. The resident, who had severe cognitive impairment as indicated by a BIMS score of 1, was discharged home with hospice care. The clinical records did not show evidence of the required notice being sent for the discharges that occurred on December 16 and December 29, 2023. Interviews with facility staff revealed a lack of clarity regarding the responsibility for notifying the Ombudsman. Staff members, including the admissions coordinator and social worker, each believed the other was responsible for the notification. The facility's policy, reviewed in October 2023, required that the transfer/discharge notice be provided to the resident and the Ombudsman, with evidence maintained of the notice being sent. However, the Administrator admitted that the notifications were only sent on the day of the surveyor's visit, indicating a lapse in following the established procedure.
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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 Litchfield Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palm Valley Post Acute | 3.3 mi | ★★★★★ | 4 | 0 |
| Estrella Health And Rehabilitation Center | 4.5 mi | ★★★★★ | 8 | 0 |
| Az - Rio Vista Post Acute And Rehabilitation | 6 mi | ★★★★★ | 0 | 0 |
| Diamondback Healthcare Center | 6.1 mi | ★★★★★ | 6 | 0 |
| Northpark Health And Rehabilitation Of Cascadia | 6.5 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.