F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings:
During an interview on 3/21/24 at 10:15 am with Certified Nursing Assistant (CNA) 1, CNA 1 stated that
she placed the Sara Steady device in front of Resident 2 while she used the commode (a portable toilet or
a chair with a container underneath) in the room. CNA 1 further stated she would leave the call light within
reach for Resident 2 to call her when she was done using the commode or the restroom.
During an interview on 3/21/24 at 10:30 am with the Director of Staff Development (DSD), the DSD stated
the residents who used the Sara Steady device were not to be left alone. The DSD's expectations were that
there should be two staff members to assist with transfers when residents are using mechanical lifts. The
DSD further stated that a staff member should be within arm's reach of the resident while using a
mechanical lift.
During an interview on 3/21/24 at 11:30 am with CNA 3, CNA 3 stated that she placed the Sara Steady
device in front of Resident 2 when Resident 2 used the commode. CNA 3 further stated she would leave
the call light within reach for Resident 2 while she used the commode and typically come back to the room
to check on her in about 15 to 20 minutes.
During an interview on 3/21/24 at 11:40 am with Restorative Nursing Assistant (RNA) 1, RNA 1 stated that
she could not leave a Sara Steady device in front of residents alone because it could be a restraint. RNA 1
further stated that if the Sara Steady device was left in front of a resident without staff present, the resident
might not be able to move around.
During an interview on 3/21/24 at 11:55 am with the Practice Administrator, the Practice Administrator
stated staff should not be leaving lifts unattended while in use.
During an interview on 3/21/24 at 12:55 pm with Resident 2, Resident 2 stated the staff left the Sara Steady
device in front of her while she used the commode.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
555209
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
03/21/2024
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 3/21/24 at 1:10 pm with Licensed Nurse (LN) 1, LN 1 stated that a resident could be
a fall risk if the staff leaves mechanical lifts in the resident's room.
During an interview on 3/21/24 at 2 pm with the Director of Nurses (DON), the DON stated that it was not
the status quo to leave mechanical lifts in front of residents. The DON's expectation was for the staff to stay
in the room with the resident when the lifts were placed in front of residents.
During an exit interview on 3/21/24 at 3:30 pm with the DON and the Practice Administrator, the DON
confirmed that Resident 2 did not have a Risks vs Benefits form to leave the Sara Steady device in front of
her alone.
Review of Resident 2's Activities of Daily Living (ADL) care plan, dated 2/6/24, in the section Approach,
indicated, .Provide assistive devices: [NAME] steady, wheelchair .
During a review of the Sara Steady Instructions for Use Manual, dated 2/3/14, the section Safety
Instructions, indicated, .This mobile patient lift must be used by a caregiver trained with these instructions
and qualified to work with the patient to be transferred and should never be used by patients on their own .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555209
If continuation sheet
Page 2 of 2
