Golden Sonora Care Center
Inspection Findings
F-Tag F0580
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
was at the facility the night before she passed. The ADON confirmed that the family was not at bedside when Resident 1 passed away at around 3 AM on [DATE REDACTED]. The DON stated that the hospice was contacted by the nurse, and the hospice agency said they would contact the family and would send a hospice nurse to
the facility. The ADON stated if a resident was not on hospice, the facility would contact the family for death notification, the nurse would call the RP or the emergency contact #1 or and they would keep calling everybody on the list if the RP could not be reached. The ADON stated the nurse noted that the hospice would notify the family. The ADON stated the nurses should have notified the family even if the hospice agency said they would call the family.During an interview on [DATE REDACTED], at 2:46 PM, with the Social Service Assistant (SSA), the SSA stated when a resident on hospice passed away, the nurses notified the family of
the resident. The SSA stated the nurses were supposed to call the family and the hospice agency. The SSA stated the family of Resident 1 should have been notified and it was important to notify the family, and they should be the first to know or be notified. During an interview on [DATE REDACTED], 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 REDACTED], 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 REDACTED], 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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GOLDEN SONORA CARE CENTER in SONORA, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SONORA, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GOLDEN SONORA CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.