Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Adventist Health Sonora - D/p Snf during CMS and state inspections, most recent first.
Two residents with dementia and significant cognitive impairment were seated near the nursing station when one, who had documented aggressive behaviors and was on quetiapine for vascular dementia, suddenly rose, approached the other, and struck her in the face with a fist while yelling that she was "the devil." The assaulted resident sustained a cut, bleeding, swollen, and bruised upper lip, reported pain, and later described ongoing fear and nervousness that she might be hit again. Staff and the DON acknowledged that this unprovoked, resident-to-resident altercation met the facility’s own policy definition of physical abuse, and behavior monitoring records showed multiple aggressive episodes for the aggressor without clear documentation of targets or types of aggression, evidencing a failure to protect the victim’s right to be free from abuse.
Several residents were prescribed PRN lorazepam without required stop dates or documented clinical justifications for continued use. Facility leadership and the Medical Director confirmed that orders were open-ended and lacked appropriate physician progress notes, contrary to regulatory requirements for psychotropic medication management.
Surveyors found that food items, including a container of cooking wine and several containers of Tahini paste, were stored past their use-by dates or without proper labeling, and that multiple kitchen cutting boards had deep grooves and stains. The DNS and Registered Dieticians confirmed these practices did not meet professional standards and could result in unsafe food handling.
The facility did not implement its QAPI program to monitor or address PRN psychotropic medication use lacking stop dates or documented rationales, as required by a previous plan of correction. Both the DON and ADM confirmed that these measures were not added to QAPI, and the issue was not addressed, resulting in ongoing deficiencies in documentation and oversight for residents receiving PRN psychotropic medications.
Multiple infection control lapses were observed, including dirty shared bathrooms, improper storage of a used feeding tube syringe by an LPN, and failure by an LPN to perform hand hygiene before and after administering medications to several residents. Staff acknowledged these actions did not meet facility policy or infection prevention standards.
A resident with chewing and swallowing difficulties repeatedly requested to speak with the dietician about her preference for gluten-free gravy with meals, but her requests were not honored or followed up on. Despite documentation of her dietary needs and preferences, there was no direct communication from the dietician, resulting in the resident's concerns about her meals remaining unaddressed.
A resident experienced a delay in receiving an x-ray for a hand injury, with the diagnostic imaging not performed until five days after the initial incident. Despite ongoing pain and swelling, administrative and communication issues between nursing staff and the physician led to the delay, resulting in a late diagnosis of a finger fracture.
The facility failed to ensure safe and sanitary food practices for 59 residents by allowing expired pancake mix and unclean double ovens to be available for use. The expired food and unclean ovens posed risks of foodborne illnesses and cross-contamination.
The facility failed to develop complete baseline care plans within 48 hours of admission for three residents, leading to potential risks for their safety and well-being. The care plans did not address all identified problems, interventions, or goals as required by the facility's policy.
The facility failed to ensure adequate supervision and functioning of safety devices for residents at risk of elopement and other hazards. Wander guards for two residents were not monitored for functionality, the wander guard system at the front gate was non-functional, and the system was not checked monthly. Additionally, residents were left unsupervised in the dining room, posing safety risks.
The facility failed to ensure safe medication monitoring practices for residents on cardiac and blood pressure medications, as well as high-risk blood thinners. Vital signs were not regularly monitored or documented, and no hold parameters were provided for medications. The facility's policies were outdated and not consistently followed, posing a risk to resident safety.
The facility failed to ensure the safe use and monitoring of psychotropic medications for three residents. One resident was given quetiapine without proper root cause analysis, and two residents received inappropriate dosage ranges. Additionally, PRN lorazepam was renewed without clinical justification for two residents, leading to unsafe medication practices.
The facility failed to maintain a resident's dignity by not covering their urinary catheter bag in the dining room. The exposed bag was confirmed by an LPN and the DON emphasized the importance of covering such bags for privacy. Facility policies also indicated the need for covering catheter bags to ensure resident dignity.
The facility failed to provide a home-like environment for two residents when their personal items were displayed on each other's side of the room, causing discomfort and confusion. This misplacement was confirmed by staff and acknowledged by the DON as potentially leading to misidentification and incorrect care.
The facility failed to provide a written Notice of Transfer or Discharge to a resident, their representative, and the LTC Ombudsman when the resident was transferred to the ER for severe pain. Interviews confirmed that the facility did not notify the LTC Ombudsman of transfers with an expected return, contrary to policy.
The facility failed to ensure two residents had access to their hearing aids and did not assist in arranging audiologist services. One resident's hearing aids were sent home by a CNA without informing a licensed nurse, and the resident has not worn them since. Another resident, who had previously worn hearing aids, did not receive assistance in obtaining new ones after they were stolen at another facility. The DON confirmed that proper protocols were not followed, potentially impacting the residents' communication and dignity.
The facility failed to provide restorative services for a resident referred to the RNA program by the PT Department. Despite the recommendation, the referral was not relayed, resulting in the resident not receiving necessary services. The resident expressed frustration over not receiving PT, and the RNA could not officially add the resident to the program without the PT referral.
The facility failed to provide proper respiratory care for two residents by not posting oxygen safety signage, not labeling oxygen tubing, and not changing the tubing within the required seven days. This placed the residents at risk for injury and infection.
The facility failed to provide PT as ordered by the physician for a resident with a history of falling, stroke, pain in the left hip, and muscle weakness. Despite being in the facility for two weeks, the resident had not received the initial PT assessment, which was supposed to occur within one week. This failure resulted in the potential for the resident not attaining and maintaining their highest possible level of physical and functional well-being.
The facility failed to ensure safe infection prevention practices, including a nurse carrying a stock bottle of test strips into an isolation room without cleaning it, a resident's urinal not being labeled, and a urinary bag hanging on another resident's walker. These actions could contribute to the spread of infection.
Failure to Protect Resident From Peer Physical Abuse Resulting in Facial Injury and Fear
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident with vascular dementia, who had been receiving quetiapine 50 mg three times daily for behaviors including aggression and wandering, was seated near the nursing station on the day of the incident. Progress notes from the prior day documented that this resident became aggressive with staff when they attempted to provide standby assistance during ambulation, but did not document aggression toward other residents. On the day of the event, staff observed this resident rise from a chair by the nursing station, approach another resident who was also seated there, stand in front of the second resident, and unexpectedly strike the second resident in the face with a fist while repeatedly yelling that the other resident was “the devil.” The resident who was struck had diagnoses including depression, dementia, and anxiety, and was severely cognitively impaired per a BIMS score of 03. Immediately after the assault, this resident appeared shocked and quiet, with a facial expression of disbelief, and reported being hit in the face while pointing to the left mouth region. Assessment revealed a cut and bleeding upper lip at the left corner of the mouth, with slight swelling, bruising, and small dots of blood noted on a washcloth. The injured resident later stated that the blow was forceful, caused pain, and resulted in visible blood from the lip injury. The facility’s own documentation characterized this event as the resident becoming a victim of unprovoked and unexpected physical abuse from a peer resident. Interviews with staff and leadership confirmed that the facility recognized the event as abuse under its Abuse and Neglect Prevention and Investigation policy, which defines physical abuse as the willful infliction of injury resulting in harm, pain, or mental anguish, including abuse by other residents. The DON acknowledged that the altercation between the two residents met the policy definition of physical abuse and that an injury occurred as a result of the aggressive act. Staff reported that the aggressive resident had been suspicious and paranoid that day but had not previously been physically aggressive toward other residents, and they expressed surprise at the assault. The injured resident later reported ongoing fear and nervousness that the aggressive resident might hit her again, and the DON stated she had not been aware of this continuing emotional distress. The facility’s monitoring documentation showed multiple episodes of aggressive behavior for the aggressive resident around the time of the incident, but it did not specify whether the aggression was directed toward staff or other residents or describe the type of aggression, contributing to the deficiency in protecting residents from abuse. The facility’s policy on Abuse and Neglect Prevention and Investigation, dated 5/7/25, states that residents have the right to be free from verbal, sexual, physical, and mental abuse, and that abuse or neglect of residents by anyone, including other residents, is not condoned. Despite this policy, the aggressive resident was able to physically assault the other resident at the nursing station, resulting in a bleeding lip, swelling, bruising, and pain, as well as fear and anxiety for the victim. The DON confirmed that, by the facility’s own policy definition, the incident constituted physical abuse of one resident by another, demonstrating that the facility failed to ensure the victim’s right to be free from physical abuse was protected.
Failure to Ensure Safe Use and Monitoring of PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure the safe use and monitoring of psychotropic medications for five residents who were prescribed PRN lorazepam. Physician orders for these residents did not include required stop dates, resulting in open-ended prescriptions. Additionally, there was no documented clinical justification or rationale in the physician progress notes for the continued use of PRN lorazepam for any of the residents reviewed. The Director of Nursing (DON) and the Administrative Director (ADM) both acknowledged during interviews that the facility was not following regulations regarding PRN psychotropic medications, specifically the requirement for a stop date after 14 days or a documented physician justification for continued use. The review of medical records and medication administration histories for the affected residents showed that lorazepam was ordered on a PRN basis without an end date, and the necessary documentation to justify ongoing use was absent. The DON confirmed these findings during concurrent interviews and record reviews, noting that the orders lacked both stop dates and physician progress notes providing rationale for continued administration. The Medical Director (MD) also acknowledged that the current process involved extending PRN psychotropic orders without documenting a clinical justification in the progress notes, believing that nurse documentation and his signature on the extension sufficed. Facility policies reviewed indicated that chemical restraints, such as psychotropic medications, should only be used when required to treat a resident's symptoms and that the Medical Director is responsible for ensuring compliance with care policies. Despite these policies, the facility's practices did not align with regulatory requirements, as evidenced by the lack of stop dates and clinical justifications for PRN lorazepam orders for the sampled residents.
Deficient Food Storage, Labeling, and Equipment Sanitation
Penalty
Summary
Surveyors observed that the facility failed to store and prepare food in accordance with professional standards for food service, affecting 57 residents who consumed facility-prepared meals. During a kitchen tour, a one-gallon container of cooking wine was found on a dry storage shelf with a use-by date that had already passed. The Director of Nutrition Services (DNS) confirmed that storing food items past their use-by date was not acceptable and acknowledged the potential for contamination if such items were used. Registered Dieticians also affirmed that expired food could spoil and become harmful if consumed. Additionally, four containers of Tahini paste were found in the dry storage room without any manufacturer expiration dates, received dates, open dates, or use-by dates. The DNS confirmed that undated food items did not meet facility standards and stated that the absence of proper labeling could result in the use of food outside safe consumption parameters. The facility's policy and the FDA Food Code both require proper labeling and dating of food items to ensure safety and quality. Surveyors also noted that seven kitchen cutting boards, stored in a clean storage rack, had deep grooves and visible stains. The DNS and Registered Dieticians confirmed that such conditions could harbor bacteria and did not meet sanitation standards. Facility policy and the FDA Food Code require that food-contact surfaces be smooth, free of cracks, and maintained in good repair to prevent contamination. These observations were confirmed through interviews and review of facility policies and federal guidelines.
Failure to Address PRN Psychotropic Medication Use in QAPI Program
Penalty
Summary
The facility failed to utilize its Quality Assurance Performance Improvement (QAPI) program to address the use of PRN psychotropic medications for its residents. Specifically, the facility did not collect data or identify corrective measures for PRN psychotropic medication use that lacked a stop date or a documented rationale for ongoing use in the affected residents' medical records. This deficiency was identified for a census of 57 residents, and the lack of documentation and justification for ongoing PRN psychotropic medication use was confirmed during interviews and record reviews with the Director of Nursing (DON) and the Administrative Director (ADM). The DON confirmed that although the previous survey's plan of correction required PRN psychotropic medication use to be monitored through the QAPI program and reviewed monthly by the pharmacist, these measures were not implemented. The DON and ADM both acknowledged that the corrective actions were not added to the QAPI program as required, and the issue was not addressed due to the committee's focus on other areas. The facility's policy required all deficiencies from previous surveys to be added to QAPI, but this was not followed, resulting in the recurrence of the problem.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement effective infection prevention and control measures for its residents, as evidenced by multiple observations and staff interviews. Shared bathrooms used by several residents were found to have dirty toilets and, in one case, a dirty sink. Staff, including a licensed nurse and the Director of Environmental Services, acknowledged that the presence of moldy rings and unclean surfaces indicated the bathrooms had not been cleaned as expected. Facility policy required daily cleaning and disinfection of resident bathrooms, but observations and staff statements confirmed that this standard was not consistently met. In another instance, a licensed nurse did not properly store a used feeding tube syringe for a resident receiving enteral nutrition. After use, the syringe was washed in a shared bathroom sink and left exposed in an open bin on the resident's side table, rather than being placed back in its original packaging or a sealed bag as required by facility policy. Staff interviews confirmed that the syringe should have been stored in a manner that protected it from environmental contamination between uses, in accordance with infection control protocols. Additionally, a licensed nurse was observed failing to perform hand hygiene before and after administering medications to multiple residents during a medication pass. The nurse did not use hand sanitizer or wash hands between resident contacts, despite facility policy and staff expectations that hand hygiene be performed to prevent cross-contamination. The nurse acknowledged this lapse and stated a preference for handwashing over hand sanitizer, but only washed hands once during the observed medication administration for several residents. The Director of Nursing and Infection Preventionists confirmed that proper hand hygiene was expected at all times during medication administration.
Failure to Honor Resident's Right to Communicate Dietary Preferences
Penalty
Summary
Resident 5's right to a dignified existence and self-determination was not honored when her repeated requests to speak with the dietician regarding her dietary preferences were not addressed. Documentation from Resident Council meetings on three separate occasions showed that Resident 5 asked to see the dietician, but the requests were either referred to other staff or noted as sent to a supervisor, with no evidence that the resident was actually able to communicate with the dietician. During an interview, Resident 5 expressed dissatisfaction with her meals, specifically noting that the meats were very dry and that she preferred to have gravy served separately with each meal, a preference that was not accommodated or discussed with her. Record review indicated that Resident 5 had a history of chewing and swallowing difficulties, requiring a mechanical soft, gluten-free diet, and that her preference for gluten-free gravy was documented. The dietician acknowledged being aware of the request and attempting to find a suitable gravy option, but admitted to not following up or communicating directly with Resident 5 after the initial documentation. This lack of follow-up and communication resulted in Resident 5's dietary preferences not being addressed and her requests not being honored.
Delayed Radiology Services Result in Late Fracture Diagnosis
Penalty
Summary
A resident sustained an injury to the left hand and fourth finger, resulting in swelling, bruising, and pain. Initial orders for ice and splint were obtained, but an x-ray order was not received until three days after the injury. Despite the presence of pain and swelling, the x-ray was not performed until five days after the injury occurred. Documentation shows that the resident continued to experience symptoms, and nursing staff provided pain management and immobilization while awaiting further diagnostic evaluation. Attempts to obtain the x-ray were delayed due to issues with the order not being properly entered or signed by the physician, and the hospital's radiology department did not accept the initial order. The resident was transported to the hospital as an outpatient, but the x-ray could not be completed due to these administrative issues. It was only after further communication between nursing staff and the physician that a new order was obtained, and the resident was sent to the emergency department for the x-ray. Interviews with facility leadership, including the Interim Director of Nursing, Administrative Director, and Director of Nursing, confirmed that the delay in obtaining the x-ray did not meet their expectations for care. The physician acknowledged that he did not consider the injury serious enough to warrant immediate action and expected nursing staff to notify him if the order was not carried out. The delay in providing radiology services resulted in a late diagnosis of a finger fracture, as confirmed by the emergency department's final report.
Expired Food and Unclean Ovens in Kitchen
Penalty
Summary
The facility failed to ensure safe and sanitary food practices for 59 residents by allowing expired food and unclean kitchen equipment to be available for use. During an initial tour of the kitchen, a half-filled pancake mix container was found to be expired, and the Production Supervisor (PS) confirmed that expired food should be discarded to prevent foodborne illnesses. The facility's policy on food storage mandates that all stored food must be properly labeled and dated, and the use-by date should not exceed the manufacturer's recommendation. However, this policy was not followed, posing a risk to the residents' health. Additionally, the double ovens in the kitchen were found to be unclean with cooked-on grease. The PS acknowledged that the ovens were not cleaned to the facility's standards and stated that they were cleaned only as needed, while the Lead Food Services Associate (LFSA) mentioned that the ovens were cleaned weekly. The facility's policy on oven sanitation requires daily cleaning and weekly deep cleaning to prevent fires and odor development. The failure to maintain clean ovens posed a risk of cross-contamination and foodborne illness for the residents.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop baseline care plans for three residents (Resident 309, Resident 310, and Resident 311) within 48 hours of their admission. These care plans were supposed to address resident-specific care needs based on their admission documentation, which indicated potential health care problem areas. However, the care plans created did not include all identified problem areas, interventions, or goals, leading to incomplete and ineffective care planning for these residents. Resident 309 was admitted with multiple health issues, including a speech impairment, vision impairment, hearing impairment, falls in the past thirty days, unsteady gait, ambulation deficit, transfer deficit, weakness, and required assistive devices. Despite these issues being noted in the admission documentation, the initial care plan only mentioned hearing impairment and a urinary foley catheter without listing any interventions or goals. The Minimum Data Set Coordinator (MDSC) and the Administrative Director of Post-Acute Services (AD) confirmed that the care plan was incomplete and did not meet the facility's expectations. Similarly, Resident 310 was admitted with diagnoses including cerebral infarction, unspecified musculoskeletal symptoms, GERD, diabetes, hyperlipidemia, and CVA. The only care plan created for Resident 310 upon admission was for psychotropic medication, and no care plans were made for the other diagnoses within 48 hours. Resident 311, admitted with diastolic heart failure, acute respiratory failure, urinary tract infection, and pain, also had an incomplete care plan that did not address all identified problems, interventions, or goals. The AD confirmed that the care plans for these residents were not completed as required by the facility's policy and procedure, leading to potential risks for the residents' safety and well-being.
Failure to Ensure Adequate Supervision and Functioning Safety Devices
Penalty
Summary
The facility failed to ensure adequate supervision and functioning of safety devices for residents at risk of elopement and other hazards. Specifically, the wander guards for two residents were not monitored for functionality, and the wander guard system at the front gate in Unit 7 was not operational. Additionally, the facility did not check the wander guard system monthly as required, and there was no staff present in the dining room during lunch, posing a risk of choking and other safety hazards for residents. Resident 20, who had a history of dementia and elopement attempts, had a wander guard that was not regularly checked for functionality. Interviews with staff revealed that there was no consistent monitoring of the wander guards, and the Treatment Administration Record did not include instructions for checking the wander guard. Similarly, Resident 40, also diagnosed with dementia, had a wander guard that was not checked for battery functionality on a specified date, as confirmed by the Infection Preventionist and other staff members. The wander guard system at the front gate in Unit 7 was found to be non-functional during testing, and there was no designated person responsible for ensuring its operation. Additionally, the system was not checked monthly as required, with the last inspection being overdue. Furthermore, during an observation, several residents were left unsupervised in the dining room, leading to a situation where one resident's urinary catheter bag was improperly placed on another resident's walker, highlighting the lack of adequate supervision and potential safety risks.
Failure to Ensure Safe Medication Monitoring Practices
Penalty
Summary
The facility failed to ensure safe medication monitoring practices for residents, particularly those on cardiac and blood pressure medications. Resident 28, Resident 11, and Resident 2 were all prescribed medications that could affect their heart rate and blood pressure, but there were no hold parameters or regular monitoring instructions in place. For instance, Resident 28's MAR indicated medications like Carvedilol, Spironolactone, and Furosemide, but only required blood pressure checks once a week, with no slots for documenting heart rate or blood pressure. Historical records showed instances of heart rates below 60 BPM, but no nursing interventions were documented. Similar issues were found with Resident 11 and Resident 2, where vital signs were not regularly monitored or documented, and no hold parameters were provided for their medications. Interviews with nursing staff and the DON revealed a reliance on outdated guidelines and a lack of specific orders from doctors for vital sign monitoring. Additionally, the facility failed to provide adequate monitoring parameters for high-risk medications. Resident 28 was prescribed Apixaban, a blood thinner with a high risk of adverse effects, but the MAR did not include any monitoring parameters to assess or prevent the risk of bleeding. The care plan for Resident 28 mentioned the potential for adverse side effects but only included general instructions to provide medication per orders and assess for adverse effects. Interviews with the DON and the facility's consultant pharmacist indicated that monitoring for blood thinners was done on a case-by-case basis, without standardized protocols. The facility's policies on medication administration and vital sign monitoring were found to be inadequate and not consistently followed. The policy on medication administration did not elaborate on the need for vital sign monitoring without a doctor's order, and the vital sign policy was outdated and not reflective of current practices. The DON acknowledged the need for updated policies and mentioned plans to incorporate monitoring parameters for high-risk drugs with a new electronic medical record system. However, at the time of the survey, these deficiencies in medication monitoring and documentation posed a risk to resident safety.
Failure to Ensure Safe Use and Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure the safe use and monitoring of psychotropic medications for three residents. Resident 209 was administered quetiapine for behaviors such as resistance to care and intrusiveness without a clear root cause analysis or evidence that these behaviors posed harm to the resident or others. The resident's discomfort during care activities, such as bathing, was not adequately addressed through non-pharmacological interventions. Additionally, the facility did not properly document the reasons for the resident's resistance to care or explore alternative methods to meet the resident's needs before resorting to medication. The Director of Nursing acknowledged that the behavior monitoring could have been worded differently and that residents have the right to refuse care. The facility also failed to ensure that the psychotropic drug dosage ranges for Residents 209 and 20 were appropriate for elderly residents with dementia. The consent forms for these medications included dosage ranges that were not tailored to the specific needs of elderly dementia patients. The residents' representatives were not adequately informed about the medication use and dosage ranges. The Director of Nursing admitted that the facility's process for determining dosage ranges was based on a drug reference book and not on age-appropriate guidelines. This oversight led to the administration of potentially inappropriate dosages of quetiapine to these residents. Furthermore, the facility did not provide clinical justification for the prolonged use of PRN lorazepam for Residents 209 and 1. Resident 209's lorazepam was renewed for six months without documentation of non-drug approaches or a clear clinical need. Similarly, Resident 1 was administered lorazepam twice daily along with multiple opioid medications, without proper documentation of the risks and benefits. The facility's Consultant Pharmacist noted the need for a gradual dose reduction, but there was no response from the medical doctor. The facility's policy on psychopharmacologic drug use was not adequately followed, leading to unsafe medication practices and potential harm to the residents.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Bag
Penalty
Summary
The facility failed to ensure Resident 309's right to a dignified existence was honored when the resident's urinary catheter bag was exposed and not placed in a dignity bag while in the dining room. During an observation, it was noted that Resident 309's urinary catheter bag was hanging on a walker and visible to others. Licensed Nurse 7 confirmed that the urinary bag was not in a dignity bag and acknowledged that it should have been covered for privacy. The Director of Nursing also emphasized the importance of covering urinary bags to maintain residents' dignity and privacy. The facility's policies on urinary catheters and resident rights were reviewed and indicated that catheter bags should be covered for privacy and dignity. The Resident Bill of Rights also stated that residents have the right to be treated with respect and dignity, including privacy in the care of personal needs. Despite these policies, the facility did not adhere to them in the case of Resident 309, leading to a deficiency in maintaining the resident's dignity.
Failure to Provide a Home-Like Environment
Penalty
Summary
The facility failed to provide a home-like environment for two residents, Resident 47 and Resident 57, when their personal items were displayed on each other's side of the room. Resident 47, who has dementia, had her roommate's family photos and a birthday poster displayed on her side of the room, while Resident 57's side had items belonging to Resident 47. This situation caused discomfort and confusion for both residents, as evidenced by their statements during interviews. Resident 47 expressed frustration with having to adjust to her roommate's family pictures around her, and Resident 57 was unsure why she had been moved and noted a lack of space for her belongings. The issue was confirmed by a Certified Nurse Assistant (CNA) and a Licensed Nurse (LN), who acknowledged that the residents' belongings were not correctly placed. The Director of Nurses (DON) also confirmed that the misplacement of personal items could lead to misidentification and incorrect care. The facility's policy emphasizes the importance of a safe, functional, and supportive environment that preserves dignity and contributes to a positive self-image, which was not upheld in this instance.
Failure to Notify Resident, Representative, and Ombudsman of Transfer
Penalty
Summary
The facility failed to provide a copy of the written Notice of Transfer or Discharge to the appropriate parties for a resident when the resident, their representative, and the LTC Ombudsman were not notified in writing of the resident's transfer to the emergency room. The resident was transferred to the ER for intractable pain in the left lower abdomen and nausea. Despite the resident initially refusing the transfer, they were eventually sent to the ER due to severe pain. The facility's records did not show that the resident or their representative received a written notice of the transfer, nor was the LTC Ombudsman notified. Interviews with the Admission Coordinator and Medical Records staff confirmed that the facility did not notify the LTC Ombudsman of transfers when a return was expected, which was against the facility's policy. The Director of Nursing also acknowledged that residents and their representatives were not given written notices of transfers and that the LTC Ombudsman should have been notified of all transfers. The facility's policy required informing the resident, family, or representative of the transfer and providing a copy of the Transfer Notice to them and the LTC Ombudsman.
Failure to Ensure Access to Hearing Aids and Audiologist Services
Penalty
Summary
The facility failed to ensure residents had access to their bilateral hearing aids and did not assist in arranging for audiologist referral consult services for two residents. For Resident 311, a CNA asked the resident's wife to take the hearing aids home, and the resident has not worn them since. The CNA did not inform a licensed nurse about the resident's refusal to wear the hearing aids or the decision to send them home. The resident's wife confirmed that the hearing aids helped the resident hear better and expressed a desire for the resident to wear them. The licensed nurse was unaware of the resident's hearing issues and stated that the CNA was responsible for assisting with hearing aids. The Director of Nursing (DON) stated that the protocol was not followed, which could delay proper care and negatively affect the resident's communication and dignity. For Resident 309, the facility did not assist or refer for follow-up auditory services to obtain new hearing aids. The resident's admission assessment indicated hearing impairment, but the initial care plan did not include interventions or goals for this issue. The resident and a family member both stated that the resident had previously worn hearing aids, which were stolen at another facility, and that the facility staff had promised to help obtain new ones. The licensed nurse was aware of the resident's hearing impairment but did not notify other staff. The resident expressed frustration about not being able to hear and stated that the facility had not discussed obtaining new hearing aids with him. The DON confirmed that the care plan should have included follow-up appointments and interventions for the resident's hearing problem. These failures had the potential to impede the residents' ability to maintain or achieve independent functioning, dignity, and well-being due to inadequate hearing during conversations. The DON emphasized that the proper protocol was not followed, which could delay appropriate care and negatively impact the residents' communication abilities and overall socialization.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to provide restorative services for Resident 310, who was referred to the Restorative Nursing Aide (RNA) program by the Physical Therapy (PT) Department on 4/23/24. Despite the recommendation, the referral was not relayed to the skilled nursing facility, resulting in Resident 310 not receiving the necessary restorative services. This oversight was confirmed during interviews and record reviews, where it was found that the RNA binder did not contain the PT referral for Resident 310, and the RNA had not received any paperwork or recommendations for the resident's care. Resident 310, who was admitted to the facility with diagnoses including cerebral infarction due to embolism and unspecified musculoskeletal symptoms, expressed frustration over not receiving the promised physical therapy. The resident had been waiting for PT services since admission and had repeatedly asked staff about it. Despite the RNA's efforts to walk and provide stretch exercises for Resident 310, the resident could not be officially added to the RNA program without the PT referral. Interviews with the Physical Therapist Lead (PTL) and the Administrative Director of Post-Acute Services (AD) revealed that the PT assessment and RNA referral were completed on 4/23/24, but the referral was not transmitted to the RNA binder. The PTL was unaware that Resident 310 was not receiving RNA services and stated that the PT orders and RNA referral should have been included in the RNA binder. The facility's policy indicated that restorative care should be provided to meet each resident's individual needs, but this was not followed in Resident 310's case.
Failure to Ensure Proper Respiratory Care and Oxygen Tubing Management
Penalty
Summary
The facility failed to ensure respiratory care was provided in accordance with professional standards of practice for two residents. For Resident 311, there was no oxygen safety signage posted outside the room, despite the resident receiving oxygen therapy for acute respiratory failure with hypoxia. This was confirmed by Licensed Nurse 8 and the Director of Nursing, who acknowledged the risk of injury or explosion due to the absence of the signage. Additionally, the facility did not label or change the oxygen tubing within the required seven days for both Resident 311 and Resident 48. Resident 311's oxygen tubing was not labeled with the date of application, and it was confirmed by both Licensed Nurse 8 and the Infection Preventionist that the tubing should be labeled and changed weekly to prevent infection. Similarly, Resident 48's oxygen tubing was found to be outdated and partially lying on the floor, which was confirmed by the Lead Charge Nurse and the Infection Preventionist, who stated that the tubing should be changed immediately if it touches the floor. The Director of Nursing confirmed that the facility's expectation was for oxygen orders to be followed and for the tubing to be labeled with the start date of application. The failure to label and change the oxygen tubing as required placed the residents at risk for infection, as confirmed by the Infection Preventionist and the Director of Nursing.
Failure to Provide Timely Physical Therapy Services
Penalty
Summary
The facility failed to provide Physical Therapy (PT) as ordered by the physician for Resident 309. The physician had ordered PT on 4/26/24, but the services had not been provided by the PT department. Resident 309, who had a history of falling, stroke, pain in the left hip, and muscle weakness, was admitted to the facility and was supposed to receive PT. However, during interviews, both Resident 309 and a family member confirmed that PT had not been initiated. The Physical Therapist Lead (PTL) acknowledged that she had not been able to perform the initial PT assessment for Resident 309, despite the resident being in the facility for two weeks. The PTL stated that the time frame for PT to assess a resident was one week, but this was not met in Resident 309's case. The facility's policy indicated that residents should receive care to achieve and maintain their highest practicable level of physical independence. Licensed Nurse 8 confirmed awareness of the need for PT but stated that they were waiting for the PT assessment before starting Restorative Nurse Aide (RNA) services. The Administrative Director (AD) also stated that the expectation was for a resident to be seen by a Physical Therapist within a week of a doctor's order. The failure to provide timely PT services resulted in the potential for Resident 309 not attaining and maintaining their highest possible level of physical and functional well-being.
Infection Prevention and Control Deficiencies
Penalty
Summary
The facility failed to ensure safe infection prevention practices for a census of 60 residents. Licensed Nurse (LN) 8 carried a stock bottle of test strips into an isolation room without cleaning or sanitizing it before and after use. During a medication administration observation, LN 8 placed the supplies, including the test strip bottle, on a bedside counter in an isolation room. When the test strip bottle fell on the floor, LN 8 picked it up and put it in her pants pocket until she exited the room, without cleaning and sanitizing it. The Infection Prevention nurse confirmed that the whole bottle of test strips should not have been taken into the isolation room and that reusable items should be cleaned and sanitized. The facility's policy did not address how to handle the use of test strips or if the test strip bottle should have been cleaned/disinfected if taken inside a resident's room and/or an isolation room. Resident 309's urinal was not labeled with the resident's name or another identifier, and the urinary bag was hanging on another resident's walker. Resident 309, who had a urinary foley catheter, stated that he emptied his urinary catheter bag himself into the urinal and left it hanging off the footboard for staff to empty. The Infection Prevention nurse was not aware that Resident 309 emptied his own urinal and confirmed that the urinal did not have the resident's name or another identifier. The Certified Nurse Assistant (CNA) and LN 8 confirmed that urinals should be labeled with the resident's name and that the urinal was changed weekly or monthly. The risk of not labeling the urinal was that another resident or staff member could accidentally use it, leading to cross-contamination and infection. During an observation, Resident 309's urinary bag was found hanging on another resident's walker while Resident 309 was eating lunch in the dining room. LN 7 confirmed that the urinary bag should not have been placed on another resident's walker due to infection control issues. The Director of Nursing (DON) stated that it was not a clean practice and placed the other resident at risk for a fall. The facility's policy indicated that standard precautions should be followed at all times to reduce the risk of transmission of infectious agents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sonora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Sonora Care Center | 1.1 mi | ★★★★★ | 7 | 0 |
| Golden San Andreas Care Center | 21.1 mi | ★★★★★ | 1 | 0 |
| Oakdale Nursing And Rehabilitation Center | 29.8 mi | ★★★★★ | 0 | 0 |
| Kit Carson Nursing & Rehabilitation Center | 33 mi | ★★★★★ | 19 | 0 |
| Riverbank Post-acute | 34.8 mi | ★★★★★ | 12 | 0 |
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