Golden Sonora Care Center
GOLDEN SONORA CARE CENTER in SONORA, CA — inspection on September 2, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on [DATE], at 3:18 PM, with LN 2, LN 2 stated that she would contact the family when a resident passed away, regardless of whether the resident was on hospice care or not. LN 2 stated the nurses also notify the medical director. LN 2 stated that it was important to contact the RP, or the family if the resident was actively dying, has died, or if there was any change in condition. LN 2 stated that the family must be notified because they expected that they would be informed of any changes in condition, regardless of severity, especially if the resident passed away. LN 2 stated 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. LN 2 stated that they used the resident's contact list starting with the responsible party (RP) and continuing with the next person on the list if the RP could not be reached. LN 2 stated that they were required to call all listed contacts until someone was reached and if unsuccessful, they must document the attempts.During a phone interview on [DATE], at 8:12 AM, with LN 3, LN 3 stated she called hospice, and the hospice agency said that a hospice nurse would be coming to the facility. LN 3 stated when she called hospice, she explained the situation and that the RN (registered nurse) pronounced Resident 1 as deceased and she was told that the hospice nurse would come. LN 3 stated the hospice agency did not tell her that they would call the family. LN 3 stated she did not call the RP or the family. LN 3 stated the nursing staff should have contacted the family when a resident passed away.
During an interview on [DATE], at 3:27 PM, with the Assistant Administrator (AADM), the AADM stated that death was considered a Change of Condition (COC).
The AADM stated the expectation on nurses was to notify the RP when a resident passed away.
The AADM stated it was important to contact the RP or family member because a death of a resident could cause significant distress for the family.
The AADM stated the facility should have notified the RP or the family.A review of the facility's policy and procedure (P&P) titled, Hospice - Provision of Care by Outside Providers, updated 9/17, the P&P indicated, .The Center (facility) notifies hospice of need to transfer resident out of Center, or of resident's death.A review of the facility's P&P titled, 24-Hour Report - Alert Charting, updated 4/17, the P&P indicated, .The Center (facility) maintains a system for monitoring and communicating changes in resident condition.With change in condition, the LN (License Nurse)/designee initiates an Alert Charting Guidelines sheet and highlights required charting to guide the LN in appropriate evaluation of current condition to guide the LN in evaluation of the resident.
Nursing staff briefly documents: a.
Nature of the condition/issue. b.
Areas to monitor. c.
Frequency of monitoring. d.
Start and Stop Dates. e.
Care Directive complete/updated. f.
Family/Resident/MD notification (s) are complete.
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