Latest reports, citations, and penalties from CMS data
That is what a federal complaint inspection, completed September 2, 2025, found at the 24-hour skilled nursing facility in Sonora, California....
The resident was sitting in a chair beside the bed when inspectors arrived at 11:52 a.m....
The inspection began in the main dining room just before noon on August 28....
Andrew's at Francis Place on August 29, 2025, following a complaint....
He had been admitted to the facility for therapy, medical oversight, and help with daily activities....
The incident happened in late June....
She was not confused about what was happening to her....
Federal inspectors documented the failure following a complaint inspection completed September 2, 2025....
The wound care nurse who discovered the problem on August 30 said she believed the resident had the correct mattress when he arrived....
The first incident happened August 11....
The resident, identified in the report as Resident 15, had lived at the facility since November 2023....
The admission skin assessment is among the most basic safeguards a nursing home performs....
No phone call to the doctor was documented....
She needs substantial to maximal help to bathe....
The inspection was triggered by a complaint and conducted on August 29, 2025....
Federal inspectors discovered Resident #07 at Aventura at Shiloh Springs during a September 3rd complaint investigation....
Their cognitive assessment showed moderately impaired mental function, scoring 9 out of 15 on a standard test....
The resident, identified in inspection records only as Resident #6, is 92 years old in a facility of that many residents....
The facility houses 80 residents total....
The violation began July 20, 2025....