27 health deficiencies
Top issue: Resident Rights (6 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Sonora, CA
1-star overall rating with 2-star inspections with $93,308 in total fines with 27 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
19929 Greenley Road, Sonora, CA
(209) 533-2500
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
210
Certified beds
Average residents
173
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Golden SNF Operations
Operator or chain grouping
Approved since
1999-06-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.27
Registered nurse staffing
LPN hours / resident day
1.29
Licensed practical nurse staffing
Aide hours / resident day
2.52
Nurse aide staffing
Weekend hours
3.79
Weekend nurse staffing
RN turnover
54%
Annual RN turnover
Total nurse turnover
58%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.3
0.4 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.6
1.2 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
98.5%
5.5 pts worse
|
93.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.1% |
98.2%
3.1 pts worse
|
95.5%
0.4 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
1.6%
1.9 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
6.8%
5.9 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.8% |
4.1%
2.7 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.1% |
13.7%
7.4 pts worse
|
19.6%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 19.9% |
14.2%
5.7 pts worse
|
16.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 31.7% |
11.0%
20.7 pts worse
|
16.3%
15.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.0% |
10.7%
19.3 pts worse
|
14.9%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.0%
0.6 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.8% |
10.9%
13.9 pts worse
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
4.7%
2.7 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.4% |
94.0%
5.6 pts worse
|
81.7%
6.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.6% |
11.2%
8.4 pts worse
|
12.0%
7.6 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.5%
0.4 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.2% |
93.2%
11 pts worse
|
79.7%
2.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.6% |
23.2%
3.4 pts worse
|
23.9%
2.7 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Resident Rights (6 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (8 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (12 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2025-08-12
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-08-12
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-12
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-12
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-08-12
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-12
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-08-12
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-06-27
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-27
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-27
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-27
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-27
Fire Safety
Use approved construction type or materials.
Corrected 2024-06-27
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-06-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-27
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-06-27
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-06-27
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-06-27
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-27
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-05
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-05
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-05
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-05
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-05
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-07-05
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-05
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-07-05
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-07-05
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-05
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-07-05
Inspection history
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Not marked corrected
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-09-03
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-08-08
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-08-08
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-08
Health
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.
Corrected 2025-08-08
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-08-08
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-08-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-08
Health
Implement a program that monitors antibiotic use.
Corrected 2025-08-08
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-08-08
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-08
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-08-08
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-08-08
Health
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.
Corrected 2025-08-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-08
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-08
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-08-08
Health
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.
Corrected 2025-08-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-08
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-08-08
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-08
Health
Dispose of garbage and refuse properly.
Corrected 2025-08-08
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-08
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-01
Health
Provide appropriate foot care.
Corrected 2025-06-11
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-02-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-19
Health
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.
Corrected 2025-01-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-08
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-07-29
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-29
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-06-20
Health
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.
Corrected 2024-06-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-20
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-20
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-20
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-20
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-06-20
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-06-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-20
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-06-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-20
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-20
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-20
Health
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.
Corrected 2024-06-20
Health
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.
Corrected 2024-06-20
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-05-23
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-19
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-17
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-04-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-09
Health
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.
Corrected 2024-02-09
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-03
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-20
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-30
Health
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.
Corrected 2023-07-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-19
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-19
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-19
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-19
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-19
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-07-19
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-19
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-19
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-19
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-07-19
Health
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.
Corrected 2023-07-19
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-07-19
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-19
Health
Provide activities to meet all resident's needs.
Corrected 2023-07-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-19
Health
Provide appropriate foot care.
Corrected 2023-07-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-19
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-07-19
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-07-19
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-07-19
Health
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.
Corrected 2023-07-19
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-07-19
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-06-16
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-30
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-05-30
Health
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.
Corrected 2023-05-30
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-19
Penalties and ownership
Fine · fine $56,843
Fine
Payment Denial · denial start 2024-03-29 · 21 days
21 day denial
Fine · fine $36,465
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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