Sonterra Health Center

In the surveyor’s words

From the most serious findings on record at Sonterra Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Mar 21, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #1) reviewed for significant medication errors, in that: The facility failed to ensure that Resident #1 was administered Touch U-200 (long-acting insulin) and Novo Log (rapid-acting insulin) for 2 days from 3/12/25 to 3/14/25. The resident was sent to the hospital, admitted and diagnosed with Diabetic [NAME] Acidosis. The non-compliance was identified as IJ past non-compliance. The noncompliance began on 3/12/2025 and ended on 3/17/25. The facility had corrected the non-compliance before the survey began. This failure placed resident at risk for adverse side effects, and life-threatening complications . […]

• Immediate jeopardy, isolatedF656Aug 14, 2024

  Based on observations, interviews, and record review the facility failed to implement a comprehensive person-centered care plan for 2 of 8 residents (Resident #1 and Resident #2) reviewed for Care Plans. 1. The facility failed to ensure Resident #1 was receiving assistance with eating as detailed in his Care Plan and was left unsupervised in his room during the evening meal on [DATE]. Resident #1 was pronounced deceased at the facility on [DATE]. 2. The facility failed to ensure Resident #2 was receiving assistance with eating as detailed in her Care Plan. On [DATE] at 12:13 pm an Immediate Jeopardy (IJ) was identified. […]

• Immediate jeopardy, isolatedF689Aug 14, 2024

  Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 8 residents (Residents #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was not left unsupervised in his room during the evening meal on [DATE]. Resident #1 was pronounced deceased at the facility on [DATE]. On [DATE] at 4:21 pm an Immediate Jeopardy (IJ) was identified. While the immediacy was removed on [DATE] at 7:42 pm, the facility remained out of compliance at scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. […]

• Actual harm, isolatedF578May 15, 2025

  Based on observation, interview and record review the facility failed to ensure the right for a resident to refuse or discontinue treatment for 1 of 6 Residents (Resident #155) whose records were reviewed for resident rights. LVN H/Treatment Nurse, failed to stop wound treatment after Resident #155 yelled out in pain multiple times for her to stop on 5/13/25. This deficient practice could affect any resident and could result in residents believing their right to say stop does not matter. The findings were: Review of Resident #155's face sheet, dated 5/14/25, revealed she was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy (according to Cleveland Clinic: it is a change in how your brain works due to an underlying condition. […]

• Actual harm, isolatedF697May 15, 2025

  Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 Residents (Resident #155) whose records were reviewed for pain management. LVN H/Treatment Nurse, failed to ensure Resident #155 received a PRN pain medication prior to assessment Resident #155 and then failed to stop wound treatment when Resident #155 yelled out in pain multiple times for her to stop on 5/13/25. […]