Health inspection·May 20, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few 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. Findings: During a concurrent interview and record review with the Practice Administrator (PA) of Resident 1 ' s electronic medical record on 5/20/25, at 12:49 p.m., the PA stated Resident 1 sustained an injury to his left hand and fourth finger on 11/8/25, orders for ice and splint (device used to support and protect a body part, often one with a fracture or injury) were obtained, but no x-ray order was received until 11/11/24. The PA confirmed Resident 1 did not have an x-ray of the injured hand and fingers until 11/13/25 which was five days after the injury occurred. During an interview on 5/20/25 at 1:35 p.m. with the Interim Director of Nursing (IDON), the IDON stated, Resident 1 was taken to the hospital on [DATE] as an outpatient (medical services, treatments, and diagnostic tests that are provided to patients who do not require hospitalization) via facility transport, the hospital ' s radiology department did not accept the x-ray order the way it was written by the MD, and Resident 1 was brought back to the facility. The IDON further stated, on 11/13/24 at 6:15 p.m. she was made aware Resident 1 had not gotten the x-ray of the injured finger and hand, contacted the MD, and obtained a new order to send Resident 1 to the ED (emergency department) via ambulance for the x-ray. The IDON confirmed, her expectations were not met when Resident 1 had to wait five days for an x-ray of his left hand and fingers as Resident 1 was experiencing pain and swelling. The IDON explained, she did not know why obtaining the x-ray took so long, it should have been done earlier, and the situation did not meet her expectations for care. During an interview on 5/20/25 at 4:40 p.m. with the Administrative Director (ADMIN), the ADMIN stated Resident 1 not having an x-ray done for five days after an injury when a fracture was suspected, did not meet her expectations. During an interview on 5/20/25 at 5:50 p.m. with the Director of Nursing (DON), the DON stated, the incident with Resident 1 did not meet her expectations. The DON stated the risk of harm to Resident 1 was the injury could get worse or result in a contracture (permanent tightening of muscles, Page 1 of 6 555209 555209 05/20/2025 Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tendons, skin, and nearby tissues that could cause a joint to shorten and become very stiff, preventing normal movement). During a telephone interview on 5/22/25 at 3:06 p.m. the MD stated he did not think the injury was too serious, did not merit an ambulance ride to the hospital for an x-ray, and the order should not have been too difficult to carry out. The MD further stated, his thought was to have the x-ray done after the weekend, as there was not a transport driver on weekends. The MD continued, sometimes there were delays when radiology orders were placed, and if the x-ray took a couple of days to obtain, he was not worried about it. The MD stated, he would expect a charge nurse or other Licensed Nurse (LN) to notify him if an order was not carried out. The MD confirmed he was notified on 11/13/24 the x-ray had not been done and gave another order to send Resident 1 to the ED for an x-ray as they should not wait any longer. Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/08/24 at 8:50 p.m., e-Signed by Licensed Nurse (LN) 1, LN 1 indicated, .bruise on top of left knuckle and swollen/painful left ring finger noted after assessment .MD with new order for an Xray of the affected finger to r/o [rule out] fracture .4th left finger immobilized [to prevent something from being moved freely] at this time . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/09/24 at 7:14 a.m., e-Signed by LN 2 indicated, .did c/o [complain of] pain on his left ring finger 5/10 pain scale [0=no pain 10=worst pain] at 0002 [12:02 a.m.] .per resident statement ' it's tight it feels it's going to burst, give me a scissor, give me ice pack ' .resident was given PRN [as needed] Tylenol & applied ice pack on top left knuckle/left ring finger .Md [MD] was also notified regarding resident's request for the ice pack to left knuckle/left ring finger prn pain/swelling, order received to apply ice pack to left knuckle /left ring finger prn pain/swelling x 20 minutes . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/10/24 at 8:27 p.m., e-Signed by LN 1 indicated, .Tylenol given for left hand pain with good relief, CMS [circulation, motion, sensation] WNL [within normal limits], Immobilizer removed and reapplied, able to move fingers but remained swollen and discolored/bruised . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/11/24 at 2:47 p.m., e-Signed by LN 4 indicated, .Left hand/ involved fingers are immobilized, hand is swollen and bruised, wrap adjusted, arm/ hand elevated on the pillow and ice pack was applied for 20 min .Pt was also given Tylenol in the morning for pain . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/12/24 at 3:00 p.m., e-Signed by LN 4 indicated, .Left hand remain[s] swollen and severely bruised .points to middle and ring finger as being painful .MD is aware, RN [Registered Nurse] requested [MD] to place X-Ray order in the computer so patient can be taken to the hospital and have Xray done . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/13/24 at 1:49 p.m., e-Signed by LN 4 indicated, .Resident noted with swelling/bruising to left hand and fingers, able to move and feel fingers on bilateral [both] hands, denies pain or numbness to right hand, states left hand hurts .Attempt to have xray done today was unsuccessful, spoke with radiology admitting, order not in computer, spoke with person in [MD] office made aware of [MD] need to put in computer order .Spoke with transport unable to obtain xray, there was an order but it was not signed by the 555209 Page 2 of 6 555209 05/20/2025 Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370

F 0658 doctor . Level of Harm - Minimal harm or potential for actual harm Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/13/24 at 5:05 p.m., e-Signed by the IDON, indicated, .[I]DON reached out to MD to get the order signed for the resident to have his hand xray tomorrow .Waiting for response[.] .MD responded that he entered the order when he was called from the outpatient radiology .However there seems to be a different approach for the technician [a specialist in the technical details of an occupation] to read the order .Per Md [MD] we are to make sure that they are looking at the order before the resident is going to the radiology department MD followed up with this nurse and stated to send the resident now with a non-emergent ambulance transport for the hand x ray . Residents Affected - Few Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/13/24 at 8:49 p.m., e-Signed by LN 1 indicated, .1815 Resident sent to AHS-ER [Adventist Hospital-Emergency Room] for left hand Xray .back from ER at 2000pm [8:00 p.m.] via ambulance with left 4th finger splint r/t [related to] Fracture .with order to keep splint applied in place until finger pain and swelling subsides . During a review of Resident 1 ' s ED Physician Notes Final Report, dated 11/13/24, indicated, .History of Present Illness .presents with concern for swollen left hand and fingers .reportedly punched a wall 5 days ago, and has been demonstrating swelling and bruising of the left hand and fingers .Musculoskeletal [having to do with the body ' s muscles, bones, tendons, ligaments, and joints] .Edema [swelling caused by too much fluid trapped in the body's tissues] left dorsal [the back or upper surface of a body part] hand with edema and ecchymotic [a medical term for a bruise] changes in the fingers, most pronounced in the left ring and long fingers .Medical Decision Making .Hand x-ray demonstrating proximal phalanx [the bone closest to the hand] fracture of the fourth digit, without other obvious fractures . A review of a facility document titled, General Order, Received Date 11/8/24, indicated, .Received by: [LN 1] .Start Date: 11/8/24 .End Date: 11/11/24 .Order Description: XRAY OF LEFT 4THFINGER R/O [rule out] FRACTURE .Frequency: One time .07:00 [7:00 a.m.] - 15:00 [3:00 p.m.] .Order Source: Telephone .Verified by: [LN 1] .Verify Date: 11/8/24 .Signed By: [MD] .Signed Date: 11/19/24 . A review of the facility ' s policy and procedure titled, Status Changes, Revision Official Date 5/24/23, indicated, .If the physician phones back with orders follow phone order procedure . Based 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. Findings: During a concurrent interview and record review with the Practice Administrator (PA) of Resident 1's electronic medical record on 5/20/25, at 12:49 p.m., the PA stated Resident 1 sustained an injury to his left hand and fourth finger on 11/8/25, orders for ice and splint (device used to support and 555209 Page 3 of 6 555209 05/20/2025 Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few protect a body part, often one with a fracture or injury) were obtained, but no x-ray order was received until 11/11/24. The PA confirmed Resident 1 did not have an x-ray of the injured hand and fingers until 11/13/25 which was five days after the injury occurred. During an interview on 5/20/25 at 1:35 p.m. with the Interim Director of Nursing (IDON), the IDON stated, Resident 1 was taken to the hospital on [DATE] as an outpatient (medical services, treatments, and diagnostic tests that are provided to patients who do not require hospitalization) via facility transport, the hospital's radiology department did not accept the x-ray order as it was not written by the MD, and Resident 1 was brought back to the facility. The IDON further stated, on 11/13/24 at 6:15 p.m. she was made aware Resident 1 had not gotten the x-ray of the injured finger and hand, contacted the MD, and obtained a new order to send Resident 1 to the ED (emergency department) via ambulance for the x-ray. The IDON confirmed, her expectations were not met when Resident 1 had to wait five days for an x-ray of his left hand and fingers as Resident 1 was experiencing pain and swelling. The IDON explained, she did not know why obtaining the x-ray took so long, it should have been done earlier, and the situation did not meet her expectations for care. During an interview on 5/20/25 at 4:40 p.m. with the Administrative Director (ADMIN), the ADMIN stated Resident 1 not having an x-ray done for five days after an injury when a fracture was suspected, did not meet her expectations. During an interview on 5/20/25 at 5:50 p.m. with the Director of Nursing (DON), the DON stated, the incident with Resident 1 did not meet her expectations. The DON stated the risk of harm to Resident 1 was the injury could get worse or result in a contracture (permanent tightening of muscles, tendons, skin, and nearby tissues that could cause a joint to shorten and become very stiff, preventing normal movement). During a telephone interview on 5/22/25 at 3:06 p.m. the MD stated he did not think the injury was too serious, did not merit an ambulance ride to the hospital for an x-ray, and the order should not have been too difficult to carry out. The MD further stated, his thought was to have the x-ray done after the weekend, as there was not a transport driver on weekends. The MD continued, sometimes there were delays when radiology orders were placed, and if the x-ray took a couple of days to obtain, he was not worried about it. The MD stated, he would expect a charge nurse or other Licensed Nurse (LN) to notify him if an order was not carried out. The MD confirmed he was notified on 11/13/24 the x-ray had not been done and gave another order to send Resident 1 to the ED for an x-ray as they should not wait any longer. Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/08/24 at 8:50 p.m., e-Signed by Licensed Nurse (LN) 1, LN 1 indicated, .bruise on top of left knuckle and swollen/painful left ring finger noted after assessment .MD with new order for an Xray of the affected finger to r/o [rule out] fracture .4th left finger immobilized [to prevent something from being moved freely] at this time . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/09/24 at 7:14 a.m., e-Signed by LN 2 indicated, .did c/o [complain of] pain on his left ring finger 5/10 pain scale [0=no pain 10=worst pain] at 0002 [12:02 a.m.] .per resident statement ' it's tight it feels it's going to burst, give me a scissor, give me ice pack' .resident was given PRN [as needed] Tylenol & applied ice pack on top left knuckle/left ring finger .Md [MD] was also notified regarding resident's request for the ice pack to left knuckle/left ring finger prn pain/swelling, order received to apply ice pack to left knuckle /left ring finger prn pain/swelling x 20 minutes . 555209 Page 4 of 6 555209 05/20/2025 Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/10/24 at 8:27 p.m., e-Signed by LN 1 indicated, .Tylenol given for left hand pain with good relief, CMS [circulation, motion, sensation] WNL [within normal limits], Immobilizer removed and reapplied, able to move fingers but remained swollen and discolored/bruised . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/11/24 at 2:47 p.m., e-Signed by LN 4 indicated, .Left hand/ involved fingers are immobilized, hand is swollen and bruised, wrap adjusted, arm/ hand elevated on the pillow and ice pack was applied for 20 min .Pt was also given Tylenol in the morning for pain . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/12/24 at 3:00 p.m., e-Signed by LN 4 indicated, .Left hand remain[s] swollen and severely bruised .points to middle and ring finger as being painful .MD is aware, RN [Registered Nurse] requested [MD] to place X-Ray order in the computer so patient can be taken to the hospital and have Xray done . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/13/24 at 1:49 p.m., e-Signed by LN 4 indicated, .Resident noted with swelling/bruising to left hand and fingers, able to move and feel fingers on bilateral [both] hands, denies pain or numbness to right hand, states left hand hurts .Attempt to have xray done today was unsuccessful, spoke with radiology admitting, order not in computer, spoke with person in [MD] office made aware of [MD] need to put in computer order .Spoke with transport unable to obtain xray, there was an order but it was not signed by the doctor . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/13/24 at 5:05 p.m., e-Signed by the IDON, indicated, .[I]DON reached out to MD to get the order signed for the resident to have his hand xray tomorrow .Waiting for response[.] .MD responded that he entered the order when he was called from the outpatient radiology .However there seems to be a different approach for the technician [a specialist in the technical details of an occupation] to read the order .Per Md [MD] we are to make sure that they are looking at the order before the resident is going to the radiology department MD followed up with this nurse and stated to send the resident now with a non-emergent ambulance transport for the hand x ray . Review of a facility document titled, Resident Progress Notes: [Resident 1], dated 11/13/24 at 8:49 p.m., e-Signed by LN 1 indicated, .1815 Resident sent to AHS-ER [Adventist Hospital-Emergency Room] for left hand Xray .back from ER at 2000pm [8:00 p.m.] via ambulance with left 4th finger splint r/t [related to] Fracture .with order to keep splint applied in place until finger pain and swelling subsides . During a review of Resident 1's ED Physician Notes Final Report, dated 11/13/24, indicated, .History of Present Illness .presents with concern for swollen left hand and fingers .reportedly punched a wall 5 days ago, and has been demonstrating swelling and bruising of the left hand and fingers .Musculoskeletal [having to do with the body's muscles, bones, tendons, ligaments, and joints] .Edema [swelling caused by too much fluid trapped in the body's tissues] left dorsal [the back or upper surface of a body part] hand with edema and ecchymotic [a medical term for a bruise] changes in the fingers, most pronounced in the left ring and long fingers .Medical Decision Making .Hand x-ray demonstrating proximal phalanx [the bone closest to the hand] fracture of the fourth digit, without other obvious fractures . A review of a facility document titled, General Order, Received Date 11/8/24, indicated, .Received 555209 Page 5 of 6 555209 05/20/2025 Adventist Health Sonora - D/P Snf 179 South Fairview Lane Sonora, CA 95370

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few by: [LN 1] .Start Date: 11/8/24 .End Date: 11/11/24 .Order Description: XRAY OF LEFT 4THFINGER R/O [rule out] FRACTURE .Frequency: One time .07:00 [7:00 a.m.] - 15:00 [3:00 p.m.] .Order Source: Telephone .Verified by: [LN 1] .Verify Date: 11/8/24 .Signed By: [MD] .Signed Date: 11/19/24 . A review of the facility's policy and procedure titled, Status Changes, Revision Official Date 5/24/23, indicated, .If the physician phones back with orders follow phone order procedure . 555209 Page 6 of 6