Golden Sonora Care Center

During an interview on 6/17/24, at 12:36 p.m., with CNA 4, CNA 4 stated Resident 169 was on hospice (end of life care), was paralyzed on one side of his body, and had seizures (uncontrolled body movements). CNA 4 stated it was important for Resident 169 to have the call light in place because he was unable to get out of bed without assistance and was dependent on staff for meeting his needs.

During an interview on 6/17/24, at 12:40 p.m., with Licensed Nurse (LN) 1, LN 1 stated Resident 169 was dependent on staff to meet his needs and was not able to pick the call light off of the ground. LN 1 stated Resident 169 was at risk for accidents.

During a concurrent interview and record review on 6/20/24, at 9 a.m., with the DON, the undated Policy and Procedure (P&P) titled, Answering the Call Light, was reviewed.

The P&P indicated, .When the resident is in bed .be sure the call light is within easy reach of the resident .

The DON stated the residents' call light should have been in reach.

The DON further stated Resident 169 was a high risk for falls and was dependent on staff to meet his needs.

The DON explained staff should have made more frequent rounds and ensured the call light was within reach after care was provided.

The DON acknowledged the P&P was not followed.

A review of the facility's policy and procedure (P&P) titled, Answering the Call Light, revised February 2020, indicated, .The purpose .is to ensure timely responses to the resident's requests and needs .upon admission and periodically as needed, explain and demonstrate use of the light to the resident .Ask the resident to return the demonstration .When the resident is in bed .be sure the call light is within easy reach of the resident .

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Golden Sonora Care Center 19929 Greenley Road Sonora, CA 95370

During an interview on 6/20/24, at 12:47 p.m., with Resident 150, Resident 150 stated he was not given his shower last week on his shower days. Resident 150 stated that he was told by a Certified Nursing Assistant (CNA) that they did not have time to give Resident 150 a shower.

During a concurrent interview and record review on 6/20/24, at 7:09 a.m., with the Director of Nursing (DON), Resident 150's clinical records were reviewed. Resident 150's Minimum Data Set (MDS, an assessment and care screening tool) dated 4/26/24, indicated Resident 150 needed partial to moderate assistance for a shower/bath, confirmed by the DON. Resident 150's ADLs (activities of daily living) task was also reviewed.

The DON was not able to provide any documentation that Resident 150 was given a shower or bed bath on his shower days.

During a concurrent interview and record review on 6/20/24, at 11:05 a.m., with CNA 2, Resident 150's ADLs task was reviewed. CNA 2 was not able to find if a shower or bed bath was provided to Resident 150 the week prior. CNA 2 stated when Resident 150 asked for a shower he should have received a shower.

During an interview on 6/20/24, at 11:08 a.m., with the DON, the DON stated she expected CNAs to give residents a shower.

The DON further stated if Resident 150 preferred a shower, he should have received shower.

A review of Resident 150's Care plan initiated on 1/8/24, indicated, .[Resident 103] requires extensive assistance by (1) staff to provide .shower and as necessary .

During a review of the facility's policy and procedure (P&P) titled, Dignity, revised 2/2021, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .When assisting with care, residents are supported in exercising their rights .

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Golden Sonora Care Center 19929 Greenley Road Sonora, CA 95370

During an interview on 06/18/24, at 10:55 a.m., with Resident 98, Resident 98 stated, I got thirty-five dollars a month.

During an interview on 06/18/24, at 11:20 a.m., with the Business Office Manager (BOM), in the Business Office, the BOM was asked what the process was for residents with a trust account to access their personal funds.

The BOM stated that during the weekdays, the residents came to the Business Office and filled out a form, then the BOM got their money from the safe.

When asked what the process was for after hours and weekends, the BOM stated that on the weekends, twenty dollars was left at each nurses' station in case a resident wanted money, as the Business Office was not open on the weekends.

When asked if the twenty dollars was per resident or twenty dollars only, the BOM stated that it was twenty dollars on each unit only in case a resident wanted cash on the weekends.

During an interview on 06/20/24 at 08:44 a.m. with Licensed Nurse LN 14, at the [NAME] Unit nurses' station, LN 14 stated that she was not sure of the facility process for fulfilling resident requests for money at the facility. LN 14 stated that she would have to ask someone.

During an interview on 06/20/24 at 08:46 a.m. with LN 15, at the [NAME] Unit nurses' station, LN 15 stated that she was not sure of the facility process for fulfilling resident requests for money at the facility. LN 15 stated that she wasn't sure if there was money at the nurses' station for resident requests for money after hours or on the weekends. LN 15 stated that she did not know where the money for residents would be kept on the unit after hours or on the weekends.

During a review of a facility policy and procedure (P&P) titled, Deposit of Residents' Personal Funds, revised March 2021, the P&P indicated, .Policy Interpretation and Implementation .2. If a resident chooses for the facility to hold, safeguard, and manage his or her personal funds, the facility: .d. provides the resident access to funds of one hundred dollars (fifty dollars for long term care residents on Medicaid [low income health insurance]) or less within twenty-four (24) hours .

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Golden Sonora Care Center 19929 Greenley Road Sonora, CA 95370

(PASRR) completed .Center Administrator will designate either the Admissions Director or Social

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Golden Sonora Care Center 19929 Greenley Road Sonora, CA 95370

During an interview with CNA 3 on 06/19/24 at 3:30 p.m. on the East Unit, CNA 3 stated none of the

During an interview with the facility Administrator (ADM) on 06/19/24 at 5:31 p.m. in the Activity Room, the ADM stated that all facility residents had been notified that the facility had become a no smoking facility.

The ADM stated that residents who smoked were given the option of nicotine patches at no cost to them to help them quit smoking.

The ADM stated that Resident 80 had been offered nicotine patches, and Resident 80 had refused nicotine patches and had been non-compliant with the no smoking policy.

The ADM stated that she was aware that Resident 80 had left the facility to smoke, and that Resident 80 had yelled profanities at facility staff when they talked to her about it.

During a review of a facility policy and procedure (P&P) titled, Accidents and Incidents - Investigating and Reporting, revised July 2017, the P&P indicated, .All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator .1.

The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .5.

The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident .7.

Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities .

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Golden Sonora Care Center 19929 Greenley Road Sonora, CA 95370

During a concurrent observation and interview on 6/17/2027, at 3:52 PM, Licensed Nurse (LN) 4 confirmed Resident 189's PICC line dressing was dated 6/8/2024. LN 4 stated the PICC line dressing should be changed every week on the night shift.

During an interview on 6/17/2024, at 5:41 PM, LN 3 confirmed Resident 189's PICC line dressing should have been changed weekly on the evening shift. LN 3 stated if the dressing was not changed as ordered Resident 189 was at risk of further infection.

A review of Resident 189's care plan, revised 6/3/24, indicated, . [Resident 189] is on IV [ intravenous, in the vein] medication for antibiotic therapy .The resident will not have any complications related to IV Therapy .IV DRESSING: Observe dressing every shift.

Change dressing and record observations of site .

A review of Resident 189's Medication Administration Record (MAR), dated June 2024, indicated, Change PICC line dressing every evening shift every Friday-Order Date- 6/3/2024 . there was no documentation to indicate the dressing was changed on Friday, 6/7/2024.

The MAR indicated the PICC line dressing was changed on 6/14/2024.

During a concurrent interview and record review on 6/18/24, at 11:22 AM, the Assistant Director of Nurses (ADON) confirmed the MAR indicated Resident 189's dressing was changed on 6/14/24.

The ADON stated the nurse who had documented the dressing as changed had reinforced the dressing and had not changed it.

The ADON further stated it was her expectation that PICC line dressings would be assessed daily, and the dressings would be changed per facility protocol and as ordered.

The ADON stated the purpose of changing the dressing weekly was to prevent infection, and to ensure the catheter did not get occluded (obstructed) or dislodged.

A review of a facility policy and procedure titled, Central Venous Catheter Dressing Changes, revised April 2016, indicated, .The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings .Apply and maintain sterile dressing on intravenous access devices.

Dressings must stay clean, dry, and intact .Change .dressings at least every 5-7 days .

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Golden Sonora Care Center 19929 Greenley Road Sonora, CA 95370

During an observation on 6/17/24, at 2:56 p.m., Resident 52 was observed in her room with the oxygen concentrator (a machine that uses room air to deliver pure oxygen) on and running at a flow rate of 3 liters per minute (LPM, unit of measurement for oxygen delivery) via nasal cannula (a small flexible tube that contains two open prongs intended to sit just inside the nostrils).

When asked, Resident 52 stated she had been using oxygen since her last stay at the hospital.

During a concurrent observation and interview on 6/17/23, at 3:05 p.m., with the Licensed Nurse (LN) 5 in Resident 52's room, LN 5 confirmed Resident 52's oxygen tubing was dated 6/3/24. LN 5 stated Resident 52's oxygen tubing should be changed once a week.

During an interview on 6/19/24, at 3:52 p.m. with the Director of Nursing (DON), the DON stated, all residents' oxygen tubing should be changed weekly and should be dated.

The DON stated oxygen tubing was changed to avoid an infection.

Review of Resident 52's active physician order indicated, .Start Date: 6/3/24 .Order Summary: Change Oxygen tubing . every week .

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Golden Sonora Care Center 19929 Greenley Road Sonora, CA 95370

potential for negative outcomes to the resident if there was a lack of communication between the

A review of a facility policy titled, End-Stage Renal Disease, Care of a Resident with, revised

according to currently recognized standards of care .Education and training of staff includes .the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis .signs and symptoms of worsening condition .how to recognize and intervene in medical emergencies .how information will be exchanged between the facilities .

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Golden Sonora Care Center 19929 Greenley Road Sonora, CA 95370

During a phone interview on 6/20/24, at 3:21 p.m., with LN 13, LN 13 stated she was unsure how many times she administered oxycodone to Resident 545 during her shift. LN 13 stated there were more pills on the oxycodone medication card than there was supposed to be, and she was unsure how that happened. LN 13 stated she owned her mistake, and the Antibiotic or Control Drug record book and Oxycodone medication card should have matched and LN 13 verified the count was not correct.

During a review of Resident 545's clinical record titled, Care Plan, dated 6/17/24, indicated Resident 545 had pain related to pancreatic cancer and an intervention was to respond immediately to any compliant of pain.

During a concurrent interview and record review on 6/20/24, at 3:30 p.m., with the Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Pain Assessment and Management, dated 10/22, was reviewed.

The P&P indicated, .

The system of reconciling the receipt, dispensing and disposition of controlled substance includes .

Nursing staff count controlled medication inventory at the end of each shift, . the nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing .

The DON stated the oxycodone medication count did not match the count of medication signed out and the P&P not followed.

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Golden Sonora Care Center 19929 Greenley Road Sonora, CA 95370

indicated, .

Medications are administered in accordance with the prescriber orders .

Medication

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Golden Sonora Care Center 19929 Greenley Road Sonora, CA 95370

opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations

A review of the facility policy titled, Storage of Medication, revised 11/2020, indicated, .The facility

for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

During an observation of the lunch meal service on 6/19/24 in the kitchen, 10 residents whose meal tickets indicated an order for DOUBLE PROTEIN were instead served double portions of each food item plated on the meal tray.

During an interview on 6/20/24 at 3:27 p.m., with the District Manager (DM), the DM stated, staff should prepare and serve what was ordered.

The DM also stated the Dietary Manager should have been present during tray line to make sure the process was done correctly.

A review of a facility provided document titled, TRAYLINE ACCURACY/MENU COMPLIANCE, dated 2010, indicated, .The end results of tray line accuracy .are .residents maintain nutritional adequacy .

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Golden Sonora Care Center 19929 Greenley Road Sonora, CA 95370

During a concurrent observation and interview on 6/17/24 at 10:11 a.m., with the AM in the walk-in refrigerator, an opened box of 20, and a box of 100, 1 ounce sour cream containers with a use by date of 6/10/24 were available for use.

The AM confirmed the boxes of sour cream were expired and should not be in the refrigerator.

• a.

During a concurrent observation and interview on 6/17/24, at 9:45 a.m., with the AM in the kitchen, the fan above the double coffee maker was observed to be dusty and had lint accumulated on the metal front cover.

The coffee makers under the fan had no lids to cover the filters holding the coffee grounds.

The AM confirmed the finding.

• During a concurrent observation and interview on 6/17/24, at 9:46 a.m., with the kitchen's District

Manager (DM) in the kitchen, washed plastic cups were observed stacked wet.

The DM confirmed the plastic cups were stacked wet, and stated the wet cups should not be stacked and could cause food borne illness among the residents.

• During a concurrent observation and interview on 6/17/24 at 10:36 a.m., with the AM in the dry

storage room, an opened clear bag with 1000 pieces of knives, an opened bag of 2000 pieces of forks, and an opened bag of 1000 pieces of spoons were not covered.

The AM confirmed the finding.

The AM stated all silverware should be covered.

The AM explained using uncovered silverware could make the residents sick.

• During a concurrent observation and interview on 6/20/24 at 8:52 a.m., with Licensed Nurse (LN) 8

at the [NAME] Unit Nursing Station, LN 8 confirmed the unit refrigerator contained 5 cups of unlabeled applesauce prepared by the kitchen. LN 8 confirmed the applesauce was available for use and should have been discarded.

• During a concurrent observation and interview on 6/20/24 at 8:45 a.m., with the Director of Nursing

(DON) at the East Unit Nursing Station, the DON confirmed the unit's refrigerator was noted to contain stains, stuck on food, and hair stuck to spilled liquid.

The DON stated the refrigerator needed to be cleaned.

During an interview on 6/20/24 at 11:14 a.m. with the Registered Dietitian (RD), the RD stated all food products should be labeled with a use by date.

The RD also stated expired food should not be in kitchen and should be thrown away.

The RD explained residents could be exposed to food borne illnesses if served expired food.

The RD also explained the kitchen should be clean and sanitary.

The RD further explained the dirty fan in the kitchen could cause food borne illness.

During a review of the facility policy titled, LABELING AND DATING, undated, indicated, .Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out manner.

This will minimize waste and also ensures that the items that are passed their due date are discarded .Food labels must include .

The use by date .

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Golden Sonora Care Center 19929 Greenley Road Sonora, CA 95370

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 .

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Golden Sonora Care Center 19929 Greenley Road Sonora, CA 95370

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.

555736

Form Approved OMB

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