Avalon Care Center - Sonora

F-F880, dated 3/2024, was reviewed. The P&P indicated, . gown and glove use . during high contact resident care . examples of high-contact resident care activities requiring the use of gown and gloves . include . device care . ( . catheter ) . wound care . The DON stated Resident 126's diagnosis included ureter cancer and type 2 diabetes which placed the resident at higher risk for infection. The DON acknowelged the P&P was not followed when the LN did not wear a gown when she provided wound and catheter care for Resident 126.

1b. A review of the facility's document titled, Admission Record (a document that contained the resident's demographic information), indicated Resident 126's diagnosis included cancer of the right ureter (tubes that transport urine from the kidneys to the urinary bladder), complications with the nephrostomy catheter (a tube that lets urine drain from the kidney through an opening in the skin on the back), and type 2 diabetes mellitus (inability to control blood sugar which increased risk of infection).

During an interview on 6/17/24, at 10:35 a.m., with Resident 126, Resident 126 stated he had had the nephrostomy tube for a couple months and he has had pain at the insertion site.

A review of the document titled, Order Summary Report, dated 5/28/24, indicated Resident 126's nephrostomy tube insertion site required cleaning and a new dressing placed over the wound every shift.

During a concurrent observation and interview on 6/17/24, at 11:01 a.m., with Licensed Nurse (LN) 1, LN 1 removed the old dressing over the nephrostomy tube insertion site (right lower side of the back). The dressing did not have a date, time, or initials documented on the dressing. The wound had redness around

the insertion site. LN 1 cleaned the site and placed a clean dressing over the wound. LN 1 did not date, time, or initial the new dressing. LN 1 acknowledged that she failed to label the new dressing and it was important to date, time and initial the new dressing to ensure the dressing was changed each shift and to help minimize

the risk for infection.

During an interview on 6/19/24, at 1:49 p.m., with the Infection Preventionist (IP), the IP stated when the dressing change was performed for Resident 126, the LN should have dated, timed, and initialed the dressing to ensure dressing changes were being completed as ordered. IP stated during the dressing changes, assessment of the wounds should be completed.

A review of Resident 126's clinical record titled, Care Plan, dated 6/14/23, indicated the facility was supposed to follow policies and protocols for the prevention of skin breakdown.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 29 555736 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555736 B. Wing 06/20/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Sonora Care Center 19929 Greenley Road 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 0880 During a concurrent interview and facility document review, on 6/20/24, at 8:51 a.m., with the Director of Nursing (DON), the Policy and Procedure (P&P) titled, Wound Care, dated 10/10, was reviewed. The P&P Level of Harm - Minimal harm or indicated, .Dress wound . mark tape with initials, time, and date and apply to dressing . The DON stated potential for actual harm Resident 126's diagnosis included ureter cancer and type 2 diabetes which placed the resident at higher risk for infection. The DON acknowledged the P&P was not followed when the LN did not date, time, and initial Residents Affected - Some the new dressing change.

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2. During an observation on 06/19/24 at 10:38 a.m. in the hallway near the East Unit Nurses Station, Laundry Aide (LA) 1 was observed with a linen cart. LA1 pushed the linen cart with clean linen in it, down the hall with

the cover open, and the clean linen on the linen cart was exposed.

During an interview with LA1 and the Housekeeping/Laundry Manager (EVSMgr) near the Maintenance Office on 6/20/24 at 7:48 a.m., LA1 was asked about the clean linen delivered with the linen cart cover open. EVSMgr stated that LA1 didn't understand the question due to a language barrier. Explained to EVSMgr that LA1 was observed with a linen cart with the linen cart cover open, and the clean linen on the cart was exposed as the linen cart was pushed down the hall on 6/19/24 at 10:38 a.m. EVSMgr stated there was a risk of contamination (physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) to the clean linen on the cart.

During a review of a facility policy and procedure (P&P) titled, Departmental (Environmental Services) - Laundry and Linen, revised January 2014, the P&P indicated, .Purpose. The purpose of this procedure is to provide a process for the safe and aseptic (clean) handling, washing, and storage of linen .7. Clean linen will remain hygienically clean (free of pathogens[germs] in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts .

Review of an online document published by the Centers for Disease Control and Prevention (CDC) titled, Best Practices For Environmental Cleaning in Global Healthcare Settings, Appendix D-Linen and Laundry Management, last reviewed dated 3/19/24, indicated, .Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items .

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3. A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility in early 2024 with diagnoses which included osteomyelitis (bone infection).

During an interview with Resident 2 on 6/18/24, at 12:39 PM, Resident 2 stated she had a pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time).

A review of Resident 2's clinical document titled, Order Summary Report, printed 6/19/24, indicated the following orders for a pressure ulcer, stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle):

Apply Lidocaine spray to stage IV [4] sacrococcygeal (tailbone) PI [pressure injury/ulcer] before treatment . with a start date of 6/17/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 29 555736 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555736 B. Wing 06/20/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Sonora Care Center 19929 Greenley Road 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 0880 Cleanse stage IV PI to sacrococcygeal area with Dakin's Solution [used to clean wounds], pat dry, apply Medi honey [used to treat wounds] to wound bed, then loosely pack with Calcium Alginate with silver [wound Level of Harm - Minimal harm or dressing with germ fighting attributes], cover with super absorbent silicone dressings . with a start date of potential for actual harm 5/14/24.

Residents Affected - Some Monitor stage 4 PI to sacrococcygeal area for s/s [signs and symptoms] of infection or deterioration . with a start date of 2/21/24.

During an observation with licensed nurse (LN) 18, on 6/19/24, at 9:16 AM, LN 18 was observed doing wound care treatment for Resident 2. LN 18 was observed doffing (removing) a pair of gloves after cleansing

the wound bed area with Dakin's solution. LN 18 then sprayed the area with additional lidocaine spray and donned (put on) a new pair of gloves without performing hand hygiene, and proceeded with wound care by applying calcium alginate and medi-honey, and covered the wound without performing hand hygiene.

During an interview with LN 18 on 6/19/24, at 9:44 PM, LN 18 confirmed he did not perform hand hygiene

after doffing gloves and prior to donning a new pair of gloves. LN 18 stated he was not aware he was supposed to wash his hands in between glove changes.

A review of the facility policy titled, Wound Care, revised 10/2010, indicated, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Put on exam glove. Loosen tape and remove dressing .Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly .Put on gloves .Apply treatments .Dress wound .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 29 555736