Golden Sonora Care Center

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