Inspection citations
29’23
26’24
30’25
5’26
90 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jul 9, 2026 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| May 20, 2026 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Complaint |
| Apr 2, 2026 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Apr 2, 2026 | D · potential | Provide timely, quality laboratory services/tests to meet the needs of residents. | Complaint |
| Mar 12, 2026 | E · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Dec 9, 2025 | D · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Complaint |
| Sep 2, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Aug 7, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Aug 7, 2025 | D · potential | Allow residents to self-administer drugs if determined clinically appropriate. | Routine |
| Aug 7, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Aug 7, 2025 | E · potential | Keep residents' personal and medical records private and confidential. | Routine |
| Aug 7, 2025 | D · potential | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Routine |
| Aug 7, 2025 | E · potential | PASARR screening for Mental disorders or Intellectual Disabilities | Routine |
| Aug 7, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Aug 7, 2025 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Aug 7, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Aug 7, 2025 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Aug 7, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Aug 7, 2025 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Aug 7, 2025 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Aug 7, 2025 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Aug 7, 2025 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Aug 7, 2025 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Aug 7, 2025 | E · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Aug 7, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Aug 7, 2025 | D · potential | Dispose of garbage and refuse properly. | Routine |
| Aug 7, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Aug 7, 2025 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Aug 7, 2025 | E · potential | Implement a program that monitors antibiotic use. | Routine |
| Aug 7, 2025 | E · potential | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Routine |
| Jul 1, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jun 11, 2025 | D · potential | Provide appropriate foot care. | Complaint |
| Feb 19, 2025 | D · potential | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Complaint |
| Feb 19, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jan 29, 2025 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Complaint |
| Oct 2, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jul 23, 2024 | D · potential | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Complaint |
| Jul 18, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jul 18, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jun 20, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Jun 20, 2024 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Jun 20, 2024 | D · potential | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Routine |
| Jun 20, 2024 | E · potential | Honor the resident's right to manage his or her financial affairs. | Routine |
| Jun 20, 2024 | D · potential | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Routine |
| Jun 20, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Jun 20, 2024 | D · potential | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Routine |
| Jun 20, 2024 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Jun 20, 2024 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Jun 20, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jun 20, 2024 | D · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
| Jun 20, 2024 | D · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Jun 20, 2024 | E · potential | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Routine |
| Jun 20, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jun 20, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| May 17, 2024 | D · potential | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Complaint |
| Apr 11, 2024 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Mar 27, 2024 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| Mar 5, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Feb 26, 2024 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jan 9, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jan 9, 2024 | D · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Complaint |
| Dec 6, 2023 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Oct 20, 2023 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Oct 17, 2023 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Oct 11, 2023 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Jun 22, 2023 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Jun 22, 2023 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Jun 22, 2023 | D · potential | Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Routine |
| Jun 22, 2023 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Jun 22, 2023 | D · potential | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Routine |
| Jun 22, 2023 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Jun 22, 2023 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Jun 22, 2023 | E · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Jun 22, 2023 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Jun 22, 2023 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Jun 22, 2023 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Jun 22, 2023 | D · potential | Provide appropriate foot care. | Routine |
| Jun 22, 2023 | G · harm | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Jun 22, 2023 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Jun 22, 2023 | D · potential | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Routine |
| Jun 22, 2023 | E · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Jun 22, 2023 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Jun 22, 2023 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jun 22, 2023 | E · potential | Ensure that residents are free from significant medication errors. | Routine |
| Jun 22, 2023 | D · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Jun 22, 2023 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Jun 22, 2023 | D · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Jun 22, 2023 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jun 22, 2023 | E · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Jun 22, 2023 | E · potential | Provide and implement an infection prevention and control program. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Golden Sonora Care Center
19929 Greenley Road, Sonora, CA 95370 · (209) 533-2500
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555736
- Certified beds
- 210
- Legal owner
- Sonora SNF Operations LLC
- Part of
- Golden Snf Operations
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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Other nursing homes in Sonora
- Adventist Health Sonora - D/P SNF5 of 5 stars overall