Sun Health La Loma Care Center

In the surveyor’s words

From the most serious findings on record at Sun Health La Loma Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Oct 28, 2025

  Based on clinical record review, staff and caregiver interviews, and policy and procedures, the facility failed to ensure advance directives was followed for one resident (#10).Findings include:Resident #10 was admitted on [DATE], with diagnoses of muscle weakness, bacteremia, methicillin resistant staphylococcus aureus (MRSA), acute abscess of female pelvis, acute delirium, atrial-fibrillation, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety.The facesheet of the clinical record revealed no code status documented.The hospital history and physical dated [DATE] revealed that the resident had a code status of Do Not Resuscitate (DNR) and Do Not Intubate (DNI).An undated admission report sheet included that the resident had a code status of DNR.An admission progress… […]

• No harm, potential for more than minimal, widespreadF804Mar 28, 2025

  Based on observations, staff interviews and policy review, the facility failed to ensure that prepared food were distributed to residents at a safe and appetizing temperature. The deficient practice could result in the potential of bacterial growth in susceptible conditions. Findings include: On March 26, 2025 at 11:03AM, the tray line was observed, and the initial temperatures of the meat was at 180°F, vegetables were tempted at 169°F, starch tempted at 175°F, and a sandwich to which Staff #103 (Interim Dietary Manager) stated is a cheese steak sandwich tempted at 172°F. No cold components were included in the tray line for this observation due to no cold components on the menu for that day. During this tray line, meal service and tray distribution to all units were observed. […]

• No harm, potential for more than minimal, patternF655Mar 28, 2025

  Based on clinical record review, staff interviews and policy review, the facility failed to ensure that a baseline care plan regarding urostomy care/treatment was developed for two of two sampled residents (#145, and #146). The deficient practice could result in goals and interventions not being evaluated, and available to the staff providing the care and treatment. Findings include: -Regarding Resident #145: Resident #145 was admitted on [DATE] with diagnoses that included cerebral infarction, history of malignant neoplasm of bladder, and artificial openings of urinary tract. Physician orders dated March 15, 2025, revealed an order for urostomy care two times a day. A weekly skin assessment dated [DATE], revealed the presence of a urostomy on the resident's left abdomen. […]

• No harm, potential for more than minimal, patternF757Mar 28, 2025

  Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that anti-hypertensives were administered within parameters for two residents (Residents #14 and #27); and that, pain management medication were administered within parameters for one resident (Resident #27). The deficient practice could result in further instances of inaccurate pain management with opioid medication; and, inaccurate administration of blood pressure medication. […]

• No harm, potential for more than minimal, patternF686Nov 18, 2021

  Based on an observation, clinical record review, interviews, and facility policies, the facility failed to ensure that necessary treatment and services were provided to one resident (#13) to assist in the healing of a pressure ulcer. The sample size was one resident. The deficient practice could result in delayed wound healing. Findings include: Resident #13 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an annual Minimum Data Set (MDS) dated [DATE] revealed that the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating he was cognitively intact. The assessment included that the resident had one suspected Deep Tissue Injury (DTI) that was present on admission. […]