Sunray Healthcare: Medication Errors Hit 25% Rate - CA
The April 21 medication pass at Sunray Healthcare Center on West Pico Boulevard resulted in a 25% error rate for the resident — seven mistakes out of 28 opportunities during federal inspection. The nurse administered the resident's 9 AM blood pressure medication at 12:19 PM, more than three hours late.
"I have not notified my supervisor that I was running behind, and I have not called or informed the doctor yet," Licensed Vocational Nurse 2 told inspectors at 12:20 PM. The facility's nurse practitioner was on site but hadn't been told about the delays.
The resident's physician had ordered that blood pressure be checked before each dose of Amlodipine, with instructions to hold the medication if systolic pressure dropped below 110 or heart rate fell under 60 beats per minute. The nurse had last checked the resident's blood pressure at 8:04 AM — four hours before giving the medication.
Records show this wasn't an isolated incident. Between April 7 and April 21, the same resident received his daily Amlodipine late on six separate occasions, including doses given at 12:58 PM and 12:04 PM when they were scheduled for 9 AM.
The timing created a dangerous overlap with the resident's second blood pressure medication, Metoprolol, scheduled for 2 PM administration. Director of Nursing staff told inspectors the combined effect of both medications given close together "could have a greater effect on the residents that could lead to confusion, lethargy, or a stroke."
Nurse Practitioner 1 explained why the timing mattered: "Administering Resident 80's Amlodipine too close to the next scheduled BP medication, Metoprolol, scheduled for administration at 2 PM, could cause a drop in the resident HR and cause bradycardia." That's why the medications were deliberately scheduled hours apart.
The facility's Medical Director confirmed that physicians should be notified when medications can't be given as scheduled. "The reason for checking the resident's BP before giving the BP medication was to ensure the licensed nurse followed the parameters that were listed on the physician's order," he said.
But medication timing wasn't the only problem inspectors found.
Controlled substance tracking broke down completely for some residents. A registry nurse removed one tablet of Oxycodone from Resident 80's medication card on March 28 at 8:20 PM but never documented giving it to the resident on his medication administration record. The controlled drug record showed the pill was taken, but there was no proof the resident actually received it.
"Not documenting on the MAR increased the risk for medication errors and drug diversion," Quality Assurance Nurse 5 told inspectors. The registry nurse also failed to assess the resident's pain level before or after giving the narcotic, despite physician orders requiring pain evaluation.
For Resident 18, a patient in a persistent vegetative state with epilepsy, seizure medication protocols fell apart entirely. The resident's Ativan prescription label from August 2024 showed instructions to give 1 ml (2 mg) every 10 minutes for seizures. But the current physician's order had reduced the dose to 0.5 ml (1 mg) — and nobody had updated the prescription bottle.
Licensed Vocational Nurse 4 couldn't explain why 3 ml of the controlled seizure medication was missing from a 10 ml vial. The controlled drug record showed a starting quantity of 7 ml, but the original prescription bottle contained 10 ml.
Worse, when Resident 18 received Ativan for seizure activity on April 12, nurses waited 15 hours to document whether the medication was effective — not the required 30 minutes. "Part of the documentation within 30 minutes is to monitor the effectiveness of the medication administered to Resident 18 for seizure control," LVN 4 explained.
The physician's order for Ativan was incomplete, missing crucial information about maximum doses and when to call 911. "If the medication was not effective for the seizures the resident would need to be sent out by calling 911 and transfer to the hospital for uncontrolled seizures," LVN 4 said. "There was nothing on the order to indicated when to call the physician."
Insulin injection practices created additional safety concerns. Residents 6 and 73, both diabetics, received multiple insulin shots in identical body locations on the same days. Resident 6 got injections in the same abdominal quadrant twice on April 2, and again in the same spot on April 19. Resident 73 received shots in the right arm twice on April 13, then the same abdominal area on consecutive days.
"The nurses should be rotating injection sites each time an injection was given," the Director of Nursing told inspectors. Repeated injections in the same location can cause skin discoloration and hardening, making future injections more difficult and painful.
The medication problems extended beyond individual doses to systemic pharmacy oversight failures.
The facility's consultant pharmacist had recommended in January that staff discontinue or add a stop date to Resident 49's hydrocortisone cream prescription. The cream had been ordered in September 2024 without an end date, meaning it could be used indefinitely. The pharmacist warned that topical steroids should be used "no more than four weeks at a time" to prevent adverse effects like skin thinning and irritation.
Three months after the recommendation, the prescription remained unchanged. The Director of Nursing couldn't explain why staff hadn't followed through on the pharmacist's advice, despite facility policy requiring that "recommendations are acted upon and documented by the facility staff."
Food service violations compounded the medication safety issues. Kitchen staff served garlic bread to 13 residents on reduced-sugar diets, directly contradicting the facility's portion control guidelines. The dietary aide confirmed that "serving garlic bread could affect blood sugar levels" for diabetic residents already struggling with medication timing issues.
In the dishwashing area, staff stored dirty trays and bowls alongside clean ones after removing them from the dishwasher. Food particles covered the counter where clean dishes were supposed to be placed. Breakfast grits stuck to bowls that were stacked for reuse. Some trays still had tape attached when they went through the wash cycle.
"The dirty dishes were contaminated and could cause problems in residents," Dietary Aide 1 acknowledged after inspectors pointed out the food residue.
The facility's policies promised medications would be "administered in a safe and timely manner" within one hour of scheduled times. Staff schedules were supposed to "ensure that medications were administered without unnecessary interruptions." Vital signs were to be checked "if necessary" before giving medications.
But for residents like the ventilator-dependent patient whose blood pressure medication was consistently hours late, those policies proved meaningless. The 25% error rate during a single medication pass revealed a system where basic safety protocols had broken down completely.
The resident remains dependent on machines to breathe and a feeding tube for nutrition, relying entirely on nursing staff to manage medications that control his blood pressure and prevent complications. Each delayed dose and each missed vital sign check represents another opportunity for the kind of medical crisis that could prove fatal for someone in his condition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunray Healthcare Center from 2025-04-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SUNRAY HEALTHCARE CENTER in LOS ANGELES, CA was cited for violations during a health inspection on April 24, 2025.
The nurse administered the resident's 9 AM blood pressure medication at 12:19 PM, more than three hours late.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.