Sunray Healthcare Center

In the surveyor’s words

From the most serious findings on record at Sunray Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jan 8, 2026

  Based on interview and record review the facility failed to ensure Licensed Vocational Nurse1 (LVN1), Certified Nursing Assistant 1 (CNA1), and Restorative Assistant 1 (RNA1) performed cardiopulmonary resuscitation (CPR, a life-saving procedure used when someone's heart or breathing has stopped) with no delays to one of four sampled residents (Resident 1), who was found with no mobility (movement), no reaction, not responding, and lifeless, on 12/31/2025 at approximately 1:10 PM to 1:15PM by failing to: -Ensure LVN1, CNA1, and RNA1 implemented the facility's Policy and Procedure (P&P) titled Emergency Procedure - Cardiopulmonary Resuscitation dated 8/28/2025 when LVN1, CNA1, and RNA1 failed to check Resident 1's pulse, checked for breathing, and failed to begin CPR when CNA1, LVN1, and… […]

• Immediate jeopardy, isolatedF689Jan 8, 2026

  Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) reviewed for pureed diet (a pudding-like texture that is smooth, blended) diet received food consistent with the ordered diet by failing to: -Ensure staff (in general) implemented accident-prevention measures by requiring visitors to notify nursing staff when food was brought into resident care area on 12/31/2025, so staff could supervise and prevent unsafe food from creating an accident hazard.-Ensure staff provided adequate supervision and environmental safeguards to prevent visitors (Family Member 3, FAM3) from providing unsafe food (non-pureed chocolate chip cookie/unidentified size) on 12/31/2025 at approximately 1 PM to Resident 1 who had a diagnosis of dysphagia… […]

• Immediate jeopardy, isolatedF689Mar 13, 2024

  Based on observation, interview and record review, the facility failed to ensure a resident, who was at risk to leave the facility and had expressed to multiple staff that he wanted to leave, did not elope (Resident leaves the premises or a safe area without the facility's knowledge and supervision) from the facility for one of four sampled residents (Resident 1). The facility failed to: 1. Assess Resident 1's risk for elopement upon admission. 2. Implement their care plan interventions to check resident's whereabouts. 3. Communicate with the facility staff the planned intervention of every 30 minutes monitoring for Resident 1 who is at risk to leave the facility. 4. Identify Resident 1's risk for elopement behavior of repeatedly asking to leave the facility. 5. […]

• Immediate jeopardy, isolatedF684Dec 2, 2023

  Based on interview, and record review, the facility failed to identify and ensure one of three sampled residents (Resident 77), who had a diagnosis of Human Immunodeficiency Virus (HIV - a virus that attacks the body's immune system), received care, treatment, and services in accordance with professional standards of practice by failing to: - Conduct a comprehensive reassessment of Resident 77, including risk for immunocompromised (immune system's defenses are low, affecting its ability to fight off infections and diseases) status. - Conduct an Interdisciplinary Team (IDT - a group of health care professionals from different fields who coordinate resident care) meeting to address Resident 77's HIV positive status. […]

• Actual harm, isolatedF600Nov 1, 2024

  Based on observation, interview, and record review, the facility failed to ensure two of six sampled residents (Resident 48 and Resident 77), who required assistance from staff with activities of daily living (ADLs - essential and routine activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) were free from neglect (failure of the facility, its employees or service providers to provide services to a resident that were necessary to avoid pain, mental anguish or emotional distress). The facility failed to: -Provide Resident 77, who required substantial / maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs) with personal hygiene. […]