Sun Health La Loma Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, documentation, staff interviews, and policy and procedures, the facility failed to ensure that one resident (#1) did not elope. The sample was 3. The deficient practice could result in resident harm.Findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of third lumbar vertebra, cerebral amyloid angiopathy and dementia.The admission minimum data set (MDS) dated [DATE] revealed a brief interview of mental status (BIMS) score of 03. Which indicates that the resident has severe cognition impairment.The elopement risk assessment was completed on admission with a date of June 3, 2025 and revealed that Resident #1 was a low risk with a score of 0.0.A care plan was initiated on June 17, 2025 with a focus for Resident #1 being at risk for elopement. Interventions included to engage resident in purposeful activity, provide clear, simple instructions, provide reorientation to surroundings/environment, schedule time for regular…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. On March 26, 2025 at 12:23PM a test tray was provided by Staff #103, the final temperatures of the food were obtained by Staff #103, which revealed meat was tempted at 152°F, vegetables were tempted at 140°F, starch tempted at 157°F, and a cheese steak sandwich tempted at 123°F. An interview on March 27, 2025…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. A clinical admission progress note dated March 15, 2025, revealed the presence of an intact urostomy, and urostomy stoma. The March 2025 Treatment Administration Record (TAR) revealed evidence that urostomy treatments had been provided as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Findings include: -Resident #14 was initially admitted on [DATE] and re-admitted on [DATE], with diagnoses that included parkinsonism, unspecified; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; unspecified atrial fibrillation; and essential (primary) hypertension. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident did not have a BIMS (Brief Interview for Mental Status) completed and a staff assessment of the resident's mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments for 1 of 12 sampled residents (#37) accurately reflected their status regarding falls. The deficient practice could result in suboptimal care planning and effect the quality of care provided. Findings include: Resident #37 was admitted on [DATE] with diagnoses that included Parkinson's disease, dementia, repeated falls, muscle weakness, abnormalities of gait/mobility, malignant neoplasm of prostate and skin. An admission summary progress note dated March 6, 2025, revealed that the resident's spouse stated that he was admitted due to frequent falls. A fall risk evaluation progress note dated March 6, 2025, revealed a history of three or more falls within the past three months, and a fall risk of 26, which indicated a moderate fall risk. A clinical admission progress note dated March 6, 2025, revealed safety concerns related to falls. A Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, resident and staff interviews and policy review, the facility failed to provide indwelling (Foley) catheter care in accordance with professional standards of practice for one of one sampled resident (#146). This deficient practice could lead to indwelling foley catheter complications. Findings include: Resident #146 was admitted to the facility on [DATE] with diagnoses that included peritoneal abscess, type 2 diabetes mellitus, depression, colostomy and encounter for surgical aftercare following surgery on the digestive system. An initial observation was conducted on March 25, 2025 at 9:43 AM of Resident #146, who was lying in her bed with a catheter bag hanging on the bed frame. The resident stated she had a Foley catheter. A Nursing Skilled Evaluation Progress Note, dated March 25, 2025 indicated that the resident had a Foley catheter due to urinary retention. A provider order was written on March 21, 2025, for Foley catheter care to be conducted on every shift,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record review, resident and staff interviews and policy review, the facility failed to provide ileostomy care in accordance with professional standards of practice for one of two sampled residents (#146). This deficient practice could lead to ileostomy skin complications. Findings include: Resident #146 was admitted to the facility on [DATE] with diagnoses that included peritoneal abscess, Type 2 diabetes mellitus, depression, colostomy and encounter for surgical aftercare following surgery on the digestive system. A skilled nursing note dated March 21, 2025, revealed the resident had an ileostomy, rather than a colostomy. A provider order was written on March 21, 2025, for ileostomy care to be conducted every seven days and PRN (as needed): cleanse gently the skin and stoma with a wet washcloth or wipe, pat dry, apply wafer and pouch. The Treatment Administration Record (TAR) revealed no evidence that ileostomy care had been performed on March 24, 2025, on the day shift. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews and policy review, the facility failed to that ensure that policies regarding storing opened food and leftovers were followed. The deficient practice could result in the potential of bacterial growth in susceptible conditions. Findings include: On March 25, 2025 at 8:20AM, an observation was conducted of the facility's kitchen with the Interim Director of Dining Services (Staff #102) providing guidance during this initial observation. At the end of the initial observation of the kitchen and dining services, an observation of the nourishment refrigerator revealed food items including canned beverages and a wrapped item within the freezer, with no labeled dates. An interview was conducted with Staff #102 during the observation above, where Staff #102 reported that they were unsure on whether or not closed items, such as canned beverages and yogurts, require a written date on the item itself due to the best by date on each individual item, however, stated that any leftovers or any items that are opened and then put back into the refrigerators,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and policy, the facility failed to ensure proper infection control practices were implemented to prevent development and transmission of communicable disease/infection for two of two sampled residents related to urostomy care for one resident (#145), and foley catheter care for one resident (#146). The deficient practice could result in transmission of infection. Findings Include: -Regarding Resident #145, PPE Donning/Doffing and hand hygiene: Resident #145 was admitted on [DATE] with diagnoses that included cerebral infarction, history of malignant neoplasm of bladder, and artificial openings of the urinary tract. Physician orders dated March 15, 2025, revealed an order for urostomy care two times a day. Further review of the clinical record revealed that a Brief Interview for Mental Status (BIMS) assessment had been conducted on March 19, 2025 with a score of 12, which indicated moderate cognitive impairment. An observation of Resident #145's urostomy care was conducted on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure a copy of the notice of two out of two discharges for one resident (# 47) to a representative of the Office of the State Long-Term Care Ombudsman. The failure may result in residents not having the advocacy and support from the State Long-Term Ombudsman during the discharge process. Findings include: Resident # 47 was admitted on [DATE]. Resident # 47 was readmitted on [DATE], with a diagnosis of unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing, unspecified atrial fibrillation, cerebral infarction, and Alzheimer's disease, and then discharged home with hospice December 29, 2023. The Minimum Data Set assessment (MDS) on December 19, 2023, revealed a Brief Interview of Mental Status (BIMS) score of 1. Indicating that the resident had severe cognitive impairment. A review of clinical records revealed no evidence of sent notice of discharge to a representative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.