Golden Sonora Care: Infection Control Failures - CA
The violation occurred June 19 during treatment of Resident 2's sacrococcygeal pressure ulcer — a full-thickness wound with exposed bone, tendon, or muscle at the tailbone. Licensed Nurse 18 removed one pair of gloves after cleaning the wound with Dakin's solution, sprayed lidocaine on the area, then put on new gloves without performing hand hygiene. He continued the treatment by applying calcium alginate, medical honey, and covering the wound.
When questioned afterward, the nurse confirmed he skipped hand washing between glove changes. He told inspectors he "was not aware he was supposed to wash his hands in between glove changes."
The facility's own wound care policy, revised in 2010, explicitly requires hand washing between glove removal and replacement: "Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. Put on gloves."
Resident 2 was admitted to Golden Sonora Care Center in early 2024 with osteomyelitis, a bone infection. She told inspectors she had developed the pressure ulcer during her stay. Her treatment orders required monitoring the stage 4 wound for "signs and symptoms of infection or deterioration."
The infection control failures extended beyond wound care. Another licensed nurse violated protocol while caring for a cancer patient's nephrostomy catheter — a tube that drains urine from the kidney through an opening in the back.
Resident 126 has ureter cancer and type 2 diabetes, conditions that place him at higher infection risk. His nephrostomy tube insertion site required cleaning and fresh dressing every shift. During the June 17 inspection, Licensed Nurse 1 removed the old dressing from the wound site on his right lower back. The dressing contained no date, time, or initials to track when it was applied.
The wound showed redness around the insertion site. After cleaning and applying a new dressing, the nurse again failed to date, time, or initial the bandage. She acknowledged to inspectors that labeling dressings was "important to ensure the dressing was changed each shift and to help minimize the risk for infection."
Resident 126 told inspectors he had experienced pain at the catheter insertion site during the months since the tube was placed.
The Director of Nursing acknowledged both violations represented failures to follow facility policy. For Resident 126's case, she admitted the wound care policy wasn't followed when the nurse didn't wear a required gown during catheter and wound care for the high-risk patient.
The facility's infection prevention policy required gown and glove use "during high contact resident care," specifically including "device care (catheter)" and "wound care." The Infection Preventionist confirmed that wound assessments should be completed during dressing changes and that proper labeling ensures dressing changes occur as ordered.
Clean linen contamination presented another infection control risk. On June 19, Laundry Aide 1 pushed a linen cart down the hallway near the East Unit Nurses Station with the cover open, exposing clean linens to environmental contamination.
When questioned the next day, the laundry aide couldn't respond due to a language barrier. The Housekeeping and Laundry Manager acknowledged there was "a risk of contamination to the clean linen on the cart" when transported uncovered.
The facility's Environmental Services policy, revised in 2014, states that "clean linen will remain hygienically clean through measures designed to protect it from environmental contamination, such as covering clean linen carts." Federal guidelines from the Centers for Disease Control and Prevention similarly require clean linens to be transported "in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items."
The violations occurred during a routine health inspection conducted June 20, 2024. Federal inspectors cited Golden Sonora Care Center for infection prevention and control deficiencies that created minimal harm or potential for actual harm to some residents.
The 144-bed facility, located at 19929 Greenley Road, serves residents requiring skilled nursing care and rehabilitation services. The infection control breakdowns affected vulnerable patients with complex medical conditions requiring sterile procedures to prevent life-threatening complications.
For Resident 126, whose cancer and diabetes already compromised his immune system, the unnoted dressing changes and missing protective equipment created additional infection risks. The stage 4 pressure ulcer patient faced similar dangers when standard hand hygiene protocols were ignored during wound treatment.
The laundry contamination potentially affected all residents who received linens from the uncovered cart, spreading bacteria throughout the facility's living areas.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Golden Sonora Care Center from 2024-06-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
GOLDEN SONORA CARE CENTER in SONORA, CA was cited for violations during a health inspection on June 20, 2024.
He continued the treatment by applying calcium alginate, medical honey, and covering the wound.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.