Cycle 1
Health 2025-03-28 · Fire 2025-03-28
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Litchfield Park, AZ
Sun Health La Loma Care Center
2-star overall rating with 2-star inspections with $12,735 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
14260 South Denny Boulevard, Litchfield Park, AZ
(623) 537-7400
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
43
Certified beds
Average residents
40
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2006-02-13
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.95
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.43
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.77
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
5.15
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
2.38
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
4.72
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.74
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
5.12
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
4,203
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9938
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.83% · Performance 23.13% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.99
Baseline 9.60% · Performance 5.69% · Measure score 7.99 · Achievement 7.18 · Improvement 7.99
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
4.29
Baseline 5.45 hours · Performance 4.30 hours · Measure score 4.29 · Achievement 4.29 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.93% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 293 · Observed rate 9.22% · Lower 95% interval 8.2% |
| Discharge to community | 59.46% |
50.57%
8.9 pts better
|
Better than the National Rate · Eligible stays 286 · Observed rate 62.59% · Lower 95% interval 54.81% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.55% |
95.27%
1.3 pts better
|
Numerator 224 · Denominator 232 |
| Falls with major injury | 0.86% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 232 |
| Discharge self-care score | 55.49% |
53.69%
1.8 pts better
|
Numerator 91 · Denominator 164 |
| Discharge mobility score | 29.88% |
50.94%
21.1 pts worse
|
Numerator 49 · Denominator 164 |
| Pressure ulcers or injuries, new or worsened | 0.43% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 232 · Adjusted rate 0.48% |
| Healthcare-associated infections requiring hospitalization | 5.69% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 190 · Observed rate 3.68% · Lower 95% interval 3.43% |
| Staff COVID-19 vaccination coverage | 2.68% |
8.2%
5.5 pts worse
|
Numerator 4 · Denominator 149 |
| Staff flu vaccination coverage | 26.11% |
42%
15.9 pts worse
|
Numerator 47 · Denominator 180 |
| Discharge function score | 52.44% |
56.45%
4 pts worse
|
Numerator 86 · Denominator 164 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 146 · Denominator 146 |
| Transfer of health information to patient | 95.77% |
96.28%
0.5 pts worse
|
Numerator 68 · Denominator 71 |
| Resident COVID-19 vaccinations up to date | 12.4% |
25.2%
12.8 pts worse
|
Numerator 15 · Denominator 121 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
97.1%
0.9 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.1%
2.1 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.2%
4.2 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
5.3%
2.4 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.5% |
20.5%
3 pts worse
|
19.6%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
11.8%
2.7 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.0% |
10.8%
9.2 pts worse
|
14.9%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
1.2%
0.8 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.2% |
20.5%
4.7 pts worse
|
19.8%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.2% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.8%
4.8 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
91.1%
6.5 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.8% · Q2 96.2% · Q3 99.6% · Q4 100.0% · 4Q avg 97.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.0% |
10.7%
0.3 pts worse
|
12.0%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 9.7% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.1%
0.7 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 0.6% · Q4 0.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.7% |
87.3%
5.4 pts better
|
79.7%
13 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.8% |
24.6%
2.2 pts worse
|
23.9%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.8% · Observed 23.9% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-23 · Fire 2024-02-23
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2022-11-23 · Fire 2022-11-23
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-01
E · Potential for more than minimal harm
2025-03-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-01
E · Potential for more than minimal harm
2024-02-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-02-23
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-04-29
D · Potential for more than minimal harm
2022-11-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-12-30
Inspection history
Recent health citations
G · Actual harm
2025-10-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-06-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-31
F · Potential for more than minimal harm
2025-03-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-10
E · Potential for more than minimal harm
2025-03-28
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-05-10
E · Potential for more than minimal harm
2025-03-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-03-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-03-28
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-03-28
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-03-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-10
D · Potential for more than minimal harm
2024-02-23
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-04-29
Penalties and ownership
What sits behind the stars
$12,735
2025-10-28
Fine
Fine · fine $12,735
Fine
Ownership
Sun Health Services
5% Or Greater Direct Ownership Interest · Organization
Cavanaugh-Marsh, Mary
Corporate Director · Individual
Forvis Mazars Llp
Operational/Managerial Control · Organization
Gilstrap, Greg
Corporate Director · Individual
Haskell, Cornelius
Corporate Director · Individual
Hoffman, Sintra
Corporate Director · Individual
Hunter, Darryll
Operational/Managerial Control · Individual
Jude, Rebecca
Operational/Managerial Control · Individual
Kovala, Irene
Corporate Director · Individual
La Loma Senior Living Services, Inc.
Operational/Managerial Control · Organization
La Rue, Joseph
Operational/Managerial Control · Individual
La Rue, Joseph
Corporate Director · Individual
La Rue, Joseph
Corporate Officer · Individual
Lakshmipathy, Arun
Operational/Managerial Control · Individual
Lancaster, Lewis
Corporate Director · Individual
Marrer, Gary
Corporate Director · Individual
Orcutt, Herman
Corporate Director · Individual
Orlopp, Sharon
Corporate Director · Individual
Reifsteck, Mark
Corporate Director · Individual
Rivera, Rey
Corporate Director · Individual
Runge, Amy
Corporate Officer · Individual
Saltmarsh
Operational/Managerial Control · Organization
Solomon, Gerald
Corporate Director · Individual
Sun Health Senior Living LLC
Operational/Managerial Control · Organization
Sun Health Services
Operational/Managerial Control · Organization
Thompson, Kimberley
Operational/Managerial Control · Individual
Thompson, Kimberley
Corporate Officer · Individual
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