Sun Health La Loma: Treatment Failure Harmed Resident - AZ
The miscommunication caused actual harm to resident #10, according to federal inspectors who investigated a complaint at the facility in October. The Director of Nursing acknowledged the breakdown, telling inspectors that the resident's code status "was misread and miscommunicated" during the incident.
The facility's own policy, implemented just months earlier in November 2024, required staff to clearly document advance directive orders in designated sections of the medical record. The policy specifically stated that "the facility will implement procedures to communicate a resident's code status to those individuals who need to know this information."
Yet that system failed when it mattered most.
The Director of Nursing told inspectors it was her expectation that staff use the hard chart to verify code status before responding to emergencies. She said that when CPR is initiated, the crash cart should be present as part of standard protocol.
But during the emergency involving resident #10, staff apparently relied on incorrect information instead of following the facility's verification procedures. The inspection report classified the incident as causing "actual harm" to the resident, though specific medical details of that harm were not disclosed in the available documentation.
The facility's Advanced Directives Policy outlined clear responsibilities for nursing staff. When a physician writes an order about a resident's advance directive status, the nurse who documents that order must record the directions "in all relevant sections of the medical record." Those designated sections are maintained at the nurses station on each unit.
The policy emphasized the facility's commitment to adhering to "residents' rights to formulate advanced directives." But the communication breakdown with resident #10 suggests a gap between written policy and actual practice during critical moments.
Code status determines whether a resident receives cardiopulmonary resuscitation during a medical emergency. Some residents choose "do not resuscitate" orders, while others want full resuscitation efforts. The distinction can mean the difference between life and death, making accurate communication essential.
The Director of Nursing's admission that "something broke down with communication" points to systemic issues beyond a single staff error. If the hard chart contained the correct code status information, multiple staff members would have needed to either ignore protocol or misinterpret the documentation for the miscommunication to occur.
The timing of the incident is particularly concerning given that the facility had recently updated its Advanced Directives Policy. The November 2024 implementation date suggests management recognized the need for clearer procedures around code status communication, yet the system still failed months later.
Federal inspectors found that few residents were affected by the violation, but the actual harm to resident #10 demonstrates the serious consequences of communication failures during medical emergencies. The inspection classified this as a significant deficiency requiring immediate attention.
The case highlights the critical importance of accurate documentation and communication in nursing homes, where split-second decisions during emergencies can determine patient outcomes. When staff misread or miscommunicate a resident's wishes about end-of-life care, they violate both federal regulations and the fundamental principle of patient autonomy.
The Director of Nursing's acknowledgment of the communication breakdown suggests the facility recognized the severity of the incident. However, the inspection report does not detail what corrective measures were implemented to prevent similar miscommunications in the future.
For resident #10, the policy failures and communication breakdown resulted in actual harm during what may have been their final moments. The family's wishes about their loved one's care were not honored because the system designed to protect those wishes broke down when it was needed most.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sun Health La Loma Care Center from 2025-10-28 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
Sun Health La Loma Care Center in LITCHFIELD PARK, AZ was cited for violations during a health inspection on October 28, 2025.
The miscommunication caused actual harm to resident #10, according to federal inspectors who investigated a complaint at the facility in October.
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.