Golden Sonora Care Center

In the surveyor’s words

From the most serious findings on record at Golden Sonora Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 26, 2024

  Based on interview, observation, and record review the facility failed to provide an environment free of hazards to prevent an accident from occurring for two of two sampled residents (Resident 1 and Resident 2) when: 1. The facility did not also remove the brackets that held the footboard in place when the footboard had been removed from Resident 1 ' s bed which resulted in a laceration (a cut) to Resident 1 ' s right lower leg on 2/13/24 and an infection to the laceration on 2/22/24; and 2. The mattress keeper rod to hold Resident 2 ' s mattress in place on the bed frame was not in the correct position. This failure resulted in an extensive injury to Resident 1 ' s leg which required an emergency room intervention of ten staples (metal material used to close a wound to help it heal). […]

• Actual harm, isolatedF688Jun 22, 2023

  ased on observation, interview and record review, the facility failed to provide the necessary care and services to ensure that one of 39 sampled residents (Resident 108's) functional abilities did not diminish when Resident 108 had a decline in his ability to transfer and walk, and services were not provided to determine the cause and/or to maintain his abilities. This failure resulted in Resident 108's decline in range of motion, (ROM, the full movement potential of a joint) to his left leg, and a decline in his transfer and ambulation abilities. […]

• Actual harm, isolatedF686Nov 15, 2022

  Based on interview and record review, the facility failed to prevent one (Resident 1) of three sampled residents from developing Pressure Injuries (PI- an area of injured skin when force is applied to the surface of the skin) when Resident 1: Developed Wound #1 (described as the same wound located on the right buttock or sacrum-bone at the base of the spine, or coccyx- tailbone), initially a Stage 2 (skin blisters or forms an open area) Pressure Ulcer (PU- sores to the skin caused from prolonged pressure) to the right buttock/sacrum/coccyx that progressed to a Stage 3 (full thickness skin loss extending into the layer under the skin) PU and; Developed a Deep Tissue Injury (DTI- persistent nonblanchable deep red, purple, or maroon areas of intact skin caused by damage to underlying soft… […]

• Actual harm, isolatedF684Jul 26, 2021

  Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received necessary care to attain or maintain the highest practical physical well-being when: 1. Staff failed to ensure Resident 1's dentures were in place prior to lunch on 4/3/21; 2. Speech Therapy (ST) did not assess Resident 1 on 4/2/21 or 4/3/21 after a diet upgrade occurred on 4/1/21; 3. Staff were unaware of ST specific recommendations for Resident 1 to ensure a safe transition with a diet change and ST had been unaware of a previous choking incident for Resident 1 during lunch on 7/6/20; 4. Staff did not attempt to assist Resident 1 to the wheelchair prior to lunch on 4/3/21; and 5. […]

• Actual harm, isolatedF678Feb 23, 2021

  Based on interview, record review, and policy review, the facility failed to ensure staff confirmed a resident's code status (the type of emergency treatment a person would or would not receive if their heart or breathing were to stop) and ensure basic life support (a level of medical care used for people with life-threatening illnesses or injuries until they can be given full medical care at a hospital) was provided in an emergency for 1 of 5 sampled residents (Resident 1). These failures contributed to Resident 1's death. Findings: According to record review of the admissions record, Resident 1 was admitted to the facility in 2017 with [DIAGNOSES REDACTED].), chronic [MEDICAL CONDITION] (usually happens when the airways that carry air to the lungs become narrow and damaged. […]