Inspection·February 20, 2024

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few care plan was to guide staff on how to take care of a problem and the interventions were to assist with the goals of the problem and the approach to use. The DON stated there was a potential for harm to the resident if the interventions were not implemented. The DON stated all staff had access to the care plans for each resident. The DON stated if Resident 1 was unable to unbuckle the seatbelt on her own then that would be a problem. The DON stated that Resident 1 had bad arthritis (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age) and it did take Resident 1 three to four attempts to unbuckle the seatbelt during the initial seatbelt use demonstration. When asked for documentation of the initial assessment conducted by the DON of the ability for Resident 1 to buckle and unbuckle the seatbelt, the DON stated she could not locate the information in Resident 1's medical record. Review of Resident 1's IDT [Interdisciplinary Team] RESIDENT INCIDENT REVIEW, dated 2/5/24, indicated, .IDT met to discuss [Resident 1's] fall 2/2/24. Res [resident] had a fall after attempting to get herself off toilet without staff assistance . Review of Resident 1's PHYSICIAN'S TELEPHONE ORDERS, dated 2/6/24, indicated, .Seat-belt alarm to be used in restroom [with] staff assist, attached to either side of toilet while resident is in restroom . Review of Resident 1's BENEFITS VS. [versus] RISK (Refusal to Treat), dated 2/7/24, indicated, .At risk for injury due to fall while sitting on toilet. Resident may use self-alarm safety belt while using toilet - allowing staff to assist with transfers on and off toilet .Benefits Resident allowed to have privacy while toileting Risks Related to Noncompliance Injury from fall if resident removes belt and gets up unassisted . Review of Resident 1's care plan, dated 11/17/23, in the section titled PROBLEM, indicated, .Prolonged used and sleeping in the bathroom . Review of Resident 1's care plan, dated 2/6/24, in the section titled INTERVENTIONS, indicated, .Staff will assist resident [with] transfers to/from toilet & remind resident to apply safety belt while using toilet . Review of Resident 1's NURSES'S PROGRESS NOTES, dated 2/8/24, indicated, .Res [resident] up to bathroom .Seat belt in place. Res. c/o [complains of] seatbelt - as she is unable to wipe herself without help. She reluctantly accepts the CNA help with wiping . Review of Resident 1's NURSES'S PROGRESS NOTES, dated 2/8/24, indicated, .When up to the toilet unhappy with seat belt for safety. Wanted to perform her usual toileting routines [without] assist. Tried to take seatbelt off [without] assist doing so. Resident verbalizes understanding of the rationale behind safety device however, still frustrated . Review of a facility policy and procedure (P&P) titled FACILITY POLICY: RESTRAINTS: POLICY ON PHYSICAL AND CHEMICAL RESTRAINTS AND DEVICES, revised 5/24/23, indicated, .Residents have the right to be free from any of the physical and chemical restraints imposed for purposes of discipline or staff convenience and not required to treat the resident's medical symptoms .Physical Restraint .Any manual method or physical or mechanical device or material or equipment attached or adjacent to the resident's body that the resident cannot easily remove, which has the effect of restricting the resident's freedom of movement or the resident's access to his or her body .Staff Convenience is any action taken by the facility to control resident behavior or maintain residents with the least amount of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555209 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555209 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 effort by the facility and not in the resident's best interest . Level of Harm - Minimal harm or potential for actual harm Review of a facility P&P titled FACILITY PROCEDURE: CARE PLANS / RAI [Resident Assessment Instrument], revised 6/24/23, indicated, PROCEDURE SUMMARY/ INTENT .To identify resident care needs and develop an individualized plan of care which indicates the care to be given, the goals desired and the approach to achieve these goals . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555209 If continuation sheet Page 3 of 3