Golden Sonora Care: Family Not Told of Death - CA
The licensed nurse on duty contacted the hospice agency after the resident passed away, but failed to notify family members directly. The hospice agency told the nurse they would send someone to the facility and would contact the family themselves.
The family was not at bedside when the resident died.
Golden Sonora Care Center's own policies require nurses to notify families immediately when residents die, regardless of whether hospice care is involved. Multiple staff members acknowledged this requirement during interviews with state inspectors in September.
"The nurses should have notified the family even if the hospice agency said they would call the family," the Assistant Director of Nursing told inspectors.
The licensed nurse who worked that night, identified as LN 3 in inspection records, admitted she never called the responsible party or family members. During a phone interview with inspectors, she said the hospice agency did not actually tell her they would contact the family, contradicting what other staff had assumed.
"The nursing staff should have contacted the family when a resident passed away," LN 3 told inspectors.
The Social Service Assistant was direct about the failure: "The family should have been notified and it was important to notify the family, and they should be the first to know or be notified."
Another licensed nurse, LN 2, explained the standard practice during her interview. She said she would always contact families when residents died, "regardless of whether the resident was on hospice care or not."
"Even if the hospice agency said they would contact the family, she would still need to contact the family because she would not be sure if the hospice already contacted them or not," according to inspection records.
The facility's protocol requires nurses to use the resident's contact list, starting with the responsible party and continuing down the list until someone is reached. If unsuccessful, they must document all attempts.
LN 2 emphasized that families "expected that they would be informed of any changes in condition, regardless of severity, especially if the resident passed away."
The Assistant Administrator called death "a Change of Condition" and said nurses were expected to notify the responsible party immediately. The administrator acknowledged the failure carried emotional consequences.
"A death of a resident could cause significant distress for the family," the Assistant Administrator told inspectors. "The facility should have notified the RP or the family."
Golden Sonora's written policies support what staff described in interviews. The facility's "24-Hour Report - Alert Charting" policy, updated in April 2017, requires nursing staff to document "Family/Resident/MD notification(s) are complete" whenever there is a change in condition.
A separate hospice policy, updated in September 2017, states that the facility "notifies hospice of need to transfer resident out of Center, or of resident's death." But this policy addresses communication with hospice agencies, not family notification requirements.
The Director of Nursing confirmed during interviews that the family was not present when the resident died around 3 AM. She said the hospice agency was contacted and promised to send a nurse to the facility and contact the family.
But the communication breakdown meant family members learned of their loved one's death from the hospice agency rather than directly from facility staff who were present.
The Assistant Director of Nursing described the proper procedure for death notifications. If a resident is not on hospice, the facility contacts the family directly, calling the responsible party first, then emergency contacts, "and they would keep calling everybody on the list if the RP could not be reached."
For hospice residents, the same notification requirements apply. The nurse should still contact family members even when hospice agencies indicate they will handle notifications.
LN 3's account during the phone interview revealed the confusion that led to the failure. She said she called hospice and explained that a registered nurse had pronounced the resident deceased. The hospice agency said a nurse would come to the facility.
"The hospice agency did not tell her that they would call the family," according to inspection records of LN 3's interview.
This contradicted what other staff members had understood about the hospice agency's commitment to notify family members.
The facility's "Alert Charting Guidelines" require nurses to document the nature of the condition, monitoring requirements, and completion of family notifications. These requirements apply to all changes in condition, with death representing the most significant change requiring immediate family contact.
State inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. But the emotional impact on families who discover deaths through third parties rather than direct facility communication can be profound.
The breakdown occurred despite clear facility policies and staff understanding of notification requirements. Multiple staff members interviewed by inspectors demonstrated knowledge of proper procedures for family notification when residents die.
The licensed nurse who failed to make the calls acknowledged the error. Other staff members confirmed that family notification is a critical responsibility that cannot be delegated to outside agencies, even when those agencies offer to handle communications.
The resident's family learned of the death through the hospice agency rather than from nursing staff who witnessed the passing and were responsible for immediate notifications under facility policy.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Golden Sonora Care Center from 2025-09-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
GOLDEN SONORA CARE CENTER in SONORA, CA was cited for immediate jeopardy violations during a health inspection on September 2, 2025.
The licensed nurse on duty contacted the hospice agency after the resident passed away, but failed to notify family members directly.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.