Adventist Health Sonora - D/P SNF

In the surveyor’s words

From the most serious findings on record at Adventist Health Sonora - D/P SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 9, 2024

  Based 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. Findings: 1. […]

• No harm, potential for more than minimal, patternF605Jun 19, 2025

  1c. 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. […]

• No harm, potential for more than minimal, patternF812Jun 19, 2025

  Based 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… […]

• No harm, potential for more than minimal, patternF867Jun 19, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF880Jun 19, 2025

  Based 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. […]