Adventist Health Sonora - D/P SNF

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to protect the resident's right to be free from physical abuse for one of two sampled residents (Resident 2) when Resident 1 struck Resident 2 in the face with a fist on 1/8/26. This failure resulted in Resident 2 suffering pain from a bleeding split lip and ongoing fear and anxiety that Resident 1 might hit Resident 2 again. A review of Resident 1's clinical record titled, Resident Face Sheet (a document used in healthcare settings to compile essential information about a resident, facilitating effective care and communication among healthcare professionals), dated 10/21/25, indicated that Resident 1 was admitted to the facility with a diagnosis that included but was not limited to vascular dementia (a progressive state of decline in mental abilities). [...]

Inspectors wrote1c. Review of Resident 33's physician's order for lorazepam dated 8/16/24, indicated, .Start date 8/16/24 .End Date .Open Ended .lorazepam .tablet .0.5 mg [mg-a unit of measure] .1 tab .Every 12 hours .PRN . Review of the document did not include an end date for the PRN lorazepam. During a concurrent interview and record review on 6/18/25, at 1:56 p.m., the DON reviewed Resident 33's clinical record and confirmed the order for PRN lorazepam with a start date of 8/16/24. The DON acknowledged the order had no end date. The DON confirmed Resident 33's physician progress notes did not contain a rational or justification for Resident 33's use of the PRN lorazepam. The DON stated the PRN lorazepam should have had a physician progress note that included a justification for the medication's continued use and the lorazepam order should have had a stop date. 1d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were stored and prepared in accordance with professional standards for food service for 57 residents who ate facility prepared meals when: 1. A one-gallon plastic container of [NAME] wine (a type of wine used for cooking) had a sticker which indicated the product was past the used by date (the last day for food to be consumed or eaten); 2. Four 16 ounce plastic containers of Tahini paste (a smooth, savory condiment made from ground, hulled sesame seeds) lacked dates that indicated a recieved date (a date a food item was received in a facility), a manufacturer's expiration date (the date when the maker of a product indicates it was no longer expected to be at its optimal quality or may become unsafe to eat), the date the product was opened, or a use by date; and 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to use its Quality Assurance Performance Improvement (QAPI- a data driven and proactive approach to improvement used to ensure services are meeting quality standards) program to address PRN (given as needed or requested) psychotropic medication (a drug that affects brain activities associated with mental processes and behavior) use, for a census of 57 residents, when the facility did not collect data (information) or identify corrective measures for PRN psychotropic medication use without a stop date (date indicated on physicians orders for when the use of the medication would end) and/or without a documented rationale for ongoing use of PRN psychotropic medication in the affected residents' medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for a census of 57 residents when: 1. The bathroom toilets were dirty in both Resident 27, Resident 54, Resident 14, and Resident 5's shared bathroom; and in Resident 50 and Resident 37's shared bathroom along with the sink; 2. Licensed Nurse (LN) 4 did not store Resident 15's used feeding tube syringe (a medical device that helps deliver liquid nutrients, medications, or fluids directly into a resident's stomach/intestines via an external tube) back in the manufactures packaging or a sealed bag; and, 3. LN 7 did not perform hand hygiene prior to and after entering and exiting resident rooms during a medication pass and/or in between passing medications to Resident 5, Resident 17, Resident 42, Resident 407, and Resident 39. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident rights were honored for one out of twelve sampled residents (Resident 5) when Resident 5's repeated requests to speak to the dietician on 4/2/25, 5/7/25, and 6/4/25 were not honored. These failures denied Resident 5 of her right to a dignified existence, failed to encourage Resident 5's independence, and prevented Resident 5's dietary preferences from being addressed.

Inspectors wroteBased on interview and record review, the facility failed to provide radiology services (a branch of medicine that uses imaging technology to diagnose and treat disease) for one resident (Resident 1) in a sample of five residents when the Medical Doctor (MD) ordered an x-ray (a photographic or digital image of the internal composition of a part of the body) three days after a known injury and the x-ray was not done until five days after the injury. These failures put Resident 1 at risk for increased pain and delayed the identification of a left finger fracture (a partial or complete break in a bone) that could lead to loss of normal finger use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food practices in accordance with professional standards for food service safety for a total of 59 residents who received food from the kitchen when: 1. A half-filled pancake mix container was expired and available for use in the kitchen; and 2. A double oven located in the kitchen was not clean. These failures placed facility residents at risk of food borne illnesses (eating or drinking something that is contaminated with germs that can cause illness) and had a potential of fire hazard.

Inspectors wroteBased on interview, and record review, the facility failed to develop baseline care plans for all of the identified problems noted on admission, within 48 hours of admission, to address resident-specific care needs for 3 of 18 sampled residents (Resident 309, Resident 310, and Resident 311), when Resident 309, Resident 310, and Resident 311's admission documentation indicated potential health care problem areas, but care plans were not developed for all of the identified problem areas within 48 hours of admission. These failures resulted in Resident 309, Resident 310, and Resident 311 having the potential for bodily harm, injury, and had the potential for not providing effective and person-centered care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent accident hazards for 12 of 60 residents (Resident 2, Resident 20, Resident 21, Resident 30, Resident 34, Resident 40, Resident 41, Resident 44, Resident 50, Resident 54, Resident 55, Resident 56, and Resident 309), when: 1. Resident 20 and Resident 40's wander guard (a bracelet that triggers alarms when resident attempts to leave the facility unattended) were not monitored for functioning, 2. Wander guard system (a device/sensor that trigger alarms if a wander guard wearer approaches near it) was not working at the front gate in Unit 7, 3. Wander guard system was not checked monthly for functioning; and, 4. Staff was not present during lunch on 5/7/24 in the dining room in Unit 7. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure safe medication monitoring practices for a census of 60 when: 1. Vital Signs (or VS, markers such as heartbeat or Heart Rate [HR] and Blood Pressure [or BP, the pressure of blood flow into the arteries]) hold parameters (conditions in which nursing staff to hold the medication and/or call the doctor) were not ordered for cardiac (heart) and blood pressure medications for safe monitoring for Resident 28, Resident 11, and Resident 2; and, 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure safe use and monitoring of psychotropic (mind altering drugs) medication in 3 out of 5 sampled residents (Resident 209, Resident 20, and Resident 1) reviewed for unnecessary medication when: 1. Resident 209's specific behavior monitoring, and expression of distress was listed as resistant to care which did not pose a harm to resident or others when the root cause of resistance to care may have been an attempt to communicate unmet needs and a discomfort unable to articulate to nursing staff, 2. Resident 209 and Resident 20's psychotropic drug dosage range did not fit the usual dose range for elderly residents with dementia diagnosis and were not discussed with Resident's Representatives; and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' right to a dignified existence was honored for 1 of 18 sampled residents (Resident 309), when Resident 309's urinary catheter bag (a drainage bag attached to a catheter (tube) that is inside the bladder to collect urine) was exposed and was not placed in a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag so it is not visible) in the dining room. This failure had the potential of emotional harm for Resident 309.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a home-like environment for two of eighteen sampled residents (Resident 47 and Resident 57), when Resident 47's personal items were displayed on Resident 57's side of the room and Resident 57's items were displayed on Resident 47's side of the room. This failure had the potential to negatively impact Resident 47 and Resident 57's psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to provide a copy of written Notice of Transfer or Discharge of a facility-initiated transfer to the appropriate parties for one of one sampled resident (Resident 13), when Resident 13 or Resident 13's representative (RR) and the Long Term Care (LTC) Ombudsman (a patient rights advocate) were not notified in writing of Resident 13's transfer to the emergency room (ER) on 3/11/24. This failure resulted in the State LTC Ombudsman not being informed of the resident's transfer, removed the opportunity for the State LTC Ombudsman to advocate on the resident's behalf, deprived the resident to be informed of resident rights regarding transfer/discharge, and had the potential for Resident 13 being inappropriately discharged .

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure residents had access to their bilateral hearing aids and failed to assist in locating and/or arranging for audiologist (ear doctor) referral consult services for two of two sampled residents (Resident 311 and Resident 309) when: 1. A Certified Nursing Assistant (CNA) asked Resident 311's wife to take Resident 311's hearing aids home; and, 2. The facility did not assist or refer for follow-up auditory services for Resident 309 to obtain hearing aids. These failures had the potential to impede Resident 311's and Resident 309's maintaining and/or achieving independent functioning, dignity, and well-being due to not being able to hear adequately during a conversation.

Inspectors wroteBased on interview, and record review, the facility failed to provide restorative services (activities to assist residents with maintaining or improving physical function) for one of twenty residents (Resident 310) referred to the RNA program (Restorative Nursing Aide; administers restorative services) when, a recommendation for RNA services was written for Resident 310 on 4/23/24 by the Physical Therapy (PT) Department, but was not relayed to the skilled nursing facility to initiate. This failure resulted in the potential for Resident 310 for not attaining and maintaining their highest possible level of physical and functional well-being.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for two of two sampled residents (Resident 311 and Resident 48) when: 1. There was no oxygen safety signage posted outside Resident 311's room; and, 2. Oxygen tubing was not labeled and was not changed out within seven days for Resident 48 and Resident 311's oxygen tubing was not labeled. These deficient practices had the potential for Resident 48 and Resident 311 to have complications related to improper treatment while receiving oxygen therapy.

Inspectors wroteBased on interview, and record review, the facility failed to provide Physical Therapy (PT- the treatment of disease, injury, or deformity by physical methods such as message, heat treatment, and exercise) as ordered by the physician for one of three sampled residents (Resident 309) with physical therapy orders when, Medical Director (MD) 1 had ordered PT on 4/26/24 for Resident 309, but the services had not yet been provided by the PT department. This failure resulted in the potential for Resident 309 for not attaining and maintaining their highest possible level of physical and functional well-being. This failure also had the potential to delay necessary treatment and delay necessary assistive services needed for Resident 309.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection prevention practices for a census of 60 when: 1. When Licensed Nurse (LN) 8 carried the stock bottle of test strips (test strip used to measure blood sugar) into an isolation room (restricted room to prevent the spread of infection) without cleaning or sanitization before and after use, 2. Resident 309's urinal (a bottle used for urination) was not labeled with Resident 309's name or another identifier; and, 3. Resident 309 's urinary bag (a drainage bag attached to a catheter (tube) that is inside the bladder to collect urine) was hanging on Resident 30's walker. These failed practices could contribute to spread of infection in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 2) who used the Sara Steady (a manual sit-to-stand transfer aid that enables one caregiver to transfer patients safely and with ease) device environment was free of accident hazards when staff left Resident 2 unattended while the Sara Steady device was in front of Resident 2. This failure had the potential to place Resident 2 at risk of falls and possible injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two residents (Resident 1) with self-release seatbelts, remained free from a physical restraint, when Resident 1 was not able to buckle and unbuckle the seatbelt consistently on her own. Staff applied and removed Resident 1's seatbelt rather than reminding Resident 1 to apply the safety belt on her own per Resident 1's care plan intervention implemented on 2/6/24 related to the seatbelt use, following a fall in the bathroom on 2/2/24. This failure resulted in loss of freedom of movement for Resident 1, with the possibility of injury and psychosocial distress.

Inspectors wroteBased on interview, clinical record and policy and procedure review, the facility failed to protect one of three sampled residents (Resident 1) from sexual abuse, when Resident 2 who had a known history of inappropriate sexual comments and gestures was sitting in close proximity to her with no staff supervision. This failure resulted in Resident 2 rubbing Resident 1's inner thigh and placed other vulnerable residents residing in the facility at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to submit a summary of investigation of an alleged sexual abuse to the Department within five (5) working days of an incident for one of three sampled residents (Resident 1). This failure placed Resident 1 at potential risk for further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity for a census of 50 when: 1. Staff placed Resident 15 and Resident 47 in double incontinence briefs; and, 2. Staff stood while assisting Resident 17 with meals. These failures had the potential to negatively impact the residents' psychosocial well-being and physical health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that petty cash was available for a total of twenty residents who had a trust account with the facility, when personal funds were not available after business hours or on weekends. This failure resulted in personal funds not being available after business hours, with the potential to negatively effect a resident's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of nine residents (Resident 27, Resident 34, and Resident 40) who required assistance to maintain mobility received required services, when: 1. Resident 27's hand contracture (muscles, tendons, joints, or other tissues tighten or shorten causing a deformity which can result in pain and loss of movement) cushion was not present in both hands; and, 2. Resident 34 and Resident 40 were improperly discharged from their functional management interventions (nursing intervention to increase or maintain resident's mobility and to prevent further decline in mobility). These failures had the potential risk for Resident 27, Resident 34 and Resident 40 to not maintain their highest level of range of motion (ROM-the degree of movement that occurs at a given joint during an exercise) and mobility functioning.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate and sufficient nursing staff to ensure the Restorative Nursing Aide program (RNA, nursing aide program that helps residents to maintain their function and joint mobility) treatments and services were available for a census of 50. This deficient practice had the potential to decrease the residents' range of motion and mobility, which could affect the residents' overall function.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement antibiotic (medication used to treat bacterial infections) use protocols within the antibiotic stewardship program for a census of 50 residents when; 1. No antibiotic use protocol was developed and implemented; 2. Minimum use criteria for the use of antibiotics was not applied for Resident 6 and Resident 45; and, 3. Resident 21's antibiotic order did not have an end date. These failures increased residents' risk to develop infections with bacterial organisms resistive to certain antibiotics (MDRO; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure reasonable accommodation of needs were honored for two of 21 sampled residents (Resident 27 and Resident 30) when: 1. There was no documented attempt of an alternative call light used for Resident 27; and, 2. Resident 27 and Resident 30's call light were not within reach. These failure had the potential for Resident 27's and Resident 30's needs to go unmet with the potential to cause physical and/or psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure individual financial records were received on a quarterly basis for twenty residents who had a trust account with the facility, when there was no documented evidence that quarterly statements were provided to residents with facility managed funds. This failure had the potential for Resident 25 to be unaware of the amount of money available.

Inspectors wroteBased on interview, and record review, the facility failed to have a process to provide a beneficiary notification form when two of two sampled residents (Resident 5 and Resident 9) did not receive the Notice of Medicare Non-Coverage (NOMNC, a form which indicates that Medicare might not pay for skilled services and how to appeal). This failure had the potential for Resident 5, Resident 9 and their representatives to be uninformed regarding their specific rights and protections related to financial liability for potential incurred medical expenses as well as the right to appeal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a care plan intervention for two of 21 sampled residents (Resident 27 and Resident 30) when the care plan intervention of a stop sign barrier (a yellow banner with a stop sign on it that was placed across the doorway) was not in place over Resident 27's and Resident 30's doorway. This failure had the potential for Resident 27 and Resident 30's privacy to be invaded by unwanted persons, with a potential risk to safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care planned fall precautions for Resident 10 and Resident 17, when the beds were not in low position and Resident 10's call light was not in reach. This failure had the potential to result in physical and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of twenty-one sampled residents (Resident 30) had access to fluid to maintain hydration when, Resident 30's drinking fluids were not within reach. This failure had the potential to result in a decline in Resident 30's health (dehydration) with the potential to result in physical harm (fall).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for one of twenty-one sampled residents (Resident 21), when Resident 21's oxygen order had no indicated flow rate (the volume of oxygen delivered over time). This failure had the potential to result in negative impacts on Resident 21's health and safety including risks for ineffective oxygen therapy, and respiratory distress.

Inspectors wrote2. During a concurrent observation and interview on 03/15/23, at 11:42 a.m., the Warehouse Distribution Technician (WDT) was observed on Unit 7 at the medication storage room door holding a red container. The WDT entered the code on the door keypad and walked into the medication storage room. The WDT exited the medication storage without the red container. The WDT stated, .I put the box on the counter in the back of the med room. If a nurse is available, I give it to them. If not I put it in the med room. I don't want to leave it on the counter where a resident could get it. The WDT further stated he was provided the code to the medication room one year ago by the individual who trained him. The WDT confirmed he was not licensed personnel nor was his trainer. The WDT looked at the sign on the medication room door that reads: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices for a census of 50 when: 1. One staff member did not follow infection control practices when Resident 20's wound dressing was changed; and, 2. One kitchen staff member was not wearing his mask correctly during the tray line prep. These failures had the potential risk for the development and transmission of diseases and infection to residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five sampled resident's (Resident 42) medical record indicated if immunizations were received and/or refused and education was provided on the risks and benefits of the immunization when, Resident 42's medical record did not indicate if the pneumococcal vaccine (protects against serious and potentially fatal pneumococcal infections caused by bacteria) was offered and/or refused and there was no documented evidence of the risk versus benefit education being provided. This failure had the potential for Resident 42 to go unvaccinated with the risk for serious health related illness and/or death and Resident 42 and/or Resident 42's responsible party to not make an informed decision in regards to the risk versus benefits of receiving the vaccine.