Health inspection·September 2, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to immediately notify the responsible party or family member about a resident's death for 1 of 1 resident (Resident 1).This deficient practice violated Resident 1's responsible party (RP), the right to be informed of the resident's change in condition or death. A review of Resident 1's admission RECORD, indicated Resident 1's contact list had 7 different contact persons and Family Member (FM) 1 was the responsible party (RP) for Resident 1. During an interview on [DATE], at 12:53 PM, with Family Member (FM) 1, FM 1 stated she was at the facility the night before and when she came back the next morning, she found Resident 1's room empty and was told that Resident 1 passed away. FM 1 stated that she reviewed Resident 1's medical records, which indicated that the reporting party was notified. FM 1 stated that the facility did not call her, and other family members were reportedly informed but after speaking with them, they confirmed that they had not been notified either. FM 1 stated she was the RP for Resident 1, and everything went through her before the facility reached out to other family members. FM 1 stated Social Services (SS) did not contact her as well. FM 1 stated the hospice agency (provides end-of-life care for terminally ill patients, focusing on comfort and quality of life rather than cure) contacted her after she showed up at the facility and the hospice agency already knew that she was not notified by the facility. FM 1 stated the facility said numerous family members was present at the time of the death, but it was not true.During an interview on [DATE], at 1:46 PM, with License Nurse (LN) 1, LN 1 stated when a resident passed away, as a nurse she needed to assess the resident and notify the hospice nurse. LN 1 stated either the facility, or the hospice would call the family. LN 1 stated the nurses also notified the doctor. LN 1 stated it was important to call the family because they need to know. LN 1 stated the nurses contacted the RP or the emergency contact #1, then would go down the list of contact persons if they could not reach the RP.During a concurrent interview and record review, on [DATE], at 2:01 PM, with the Director of Nursing (DON), the DON stated that when a resident on hospice passed away, she expected her nurses to do an initial assessment, and make appropriate notifications to hospice, to the MD, and to the family of the resident. At 2:03 PM, the Assistant Director of Nursing (ADON) joined the concurrent interview and record review with the DON. The ADON stated that the facility would notify the hospice agency and contact the family for any change of condition (COC) of the resident. The ADON further stated that the nurses would also inform the facility's medical director who oversaw the care. The ADON stated she expected nurses to contact the hospice agency first when a resident passed away. The ADON stated the nurse would talk to the hospice nurse and determine who would contact the family then they would coordinate together. The DON stated it was important to contact the family of the resident that passed away so that they were aware and not be surprised when they made a visit. Resident 1's progress notes, dated [DATE], at 8:30 PM, was reviewed with the DON and the ADON. Resident 1's progress note indicated that the family (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 09/02/2025 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)