Health inspection·October 2, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure professional standards of care were met for one out of three sampled residents (Resident 1) when Resident 1's post incident documentation (documentation of assessments and observations after an incident occurs) was incomplete. Residents Affected - Few This failure had the potential for Resident 1 to have unassessed injuries and/or illnesses and unmet psychosocial needs. Findings: A review of Resident 1's admission RECORD, indicated he was admitted to the facility in mid-2023, with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought) and muscle weakness. A review of Resident 1's Progress Notes, dated 9/13/24, at 10:15 PM, indicated, .Resident became very enraged throwing and cussing at the police officers .Resident became more upset and storm (sic) outside to smoke a cigarette .When police and house supervisor went outside found resident on the floor, lying flat on the floor, with laceration [cut or tear in skin] on left eye. Police called ambulance .LVN [licensed vocational nurse] staff were containing bleed that was coming from his wound above his eye . A review of Resident 1's Progress Notes, dated 9/14/24, at 7:13 AM, indicated, .Resident returned from the ER [emergency room] at 0505 [5:05 AM] .Resident has abrasion (scrape) to right side of face and above right eyebrow . A review of Resident 1's Progress Notes, dated 9/16/24, at 10:15 AM, indicated, .An IDT [interdisciplinary team, group of healthcare professionals who assess and coordinate care] meeting was held for unwitnessed fall on 9/13/24 .IDT recommends SS [social services] follow up . During an interview on 10/2/24, at 10:36 AM, the Social Services Assistant (SSA) confirmed there was no documentation in Resident 1's health record to indicate social services had followed up with Resident 1 after the incident on 9/13/24. The SSA stated the purpose of social service follow up was to ensure Resident 1 did not have unmet psychosocial needs and to provide any necessary interventions to meet Resident 1's needs. During an interview on 10/2/24, at 11:39 AM, the Assistant Director of Nurses (ADON) confirmed there was no documentation in Resident 1's health record on 9/15/24 and there should have been. The ADON stated licensed nurses should have documented in Resident 1's health record on every shift for 72 hours after the incident. The ADON further stated the purpose of the 72 hour follow up was to monitor (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555736 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/02/2024 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)