Cycle 1
Health 2025-08-07 · Fire 2025-08-07
27 health deficiencies
Top issue: Resident Rights (6 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Sonora, CA
Golden Sonora Care Center
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
Facility snapshot
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
Chain footprint
7 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.27
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.29
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.07
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
4.87
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,569
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.48
Baseline 20.43% · Performance 20.75% · Measure score 1.48 · Achievement 1.48 · Improvement 0
Healthcare-associated infections
0
Baseline 7.70% · Performance 8.91% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.82
Baseline 77.30% · Performance 65.14% · Measure score 1.82 · Achievement 0 · Improvement 1.82
Adjusted total nurse staffing
4.67
Baseline 4.75 hours · Performance 4.41 hours · Measure score 4.67 · Achievement 4.67 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.93% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 522 · Observed rate 8.81% · Lower 95% interval 7.65% |
| Discharge to community | 54.07% |
50.57%
3.5 pts better
|
No Different than the National Rate · Eligible stays 524 · Observed rate 51.15% · Lower 95% interval 50.55% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 61.08% |
95.27%
34.2 pts worse
|
Numerator 215 · Denominator 352 |
| Falls with major injury | 1.42% |
0.77%
0.6 pts worse
|
Numerator 5 · Denominator 352 |
| Discharge self-care score | 53.33% |
53.69%
0.4 pts worse
|
Numerator 56 · Denominator 105 |
| Discharge mobility score | 28.57% |
50.94%
22.4 pts worse
|
Numerator 30 · Denominator 105 |
| Pressure ulcers or injuries, new or worsened | 4.57% |
2.29%
2.3 pts worse
|
Numerator 16 · Denominator 350 · Adjusted rate 5.17% |
| Healthcare-associated infections requiring hospitalization | 8.91% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 356 · Observed rate 8.71% · Lower 95% interval 6.67% |
| Staff COVID-19 vaccination coverage | 2.99% |
8.2%
5.2 pts worse
|
Numerator 6 · Denominator 201 |
| Staff flu vaccination coverage | 58.33% |
42%
16.3 pts better
|
Numerator 126 · Denominator 216 |
| Discharge function score | 43.81% |
56.45%
12.6 pts worse
|
Numerator 46 · Denominator 105 |
| Transfer of health information to provider | 93.14% |
95.95%
2.8 pts worse
|
Numerator 95 · Denominator 102 |
| Transfer of health information to patient | 90.42% |
96.28%
5.9 pts worse
|
Numerator 151 · Denominator 167 |
| Resident COVID-19 vaccinations up to date | 15.48% |
25.2%
9.7 pts worse
|
Numerator 26 · Denominator 168 |
Quality measures
Resident outcomes and process scores
| 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 · Adjusted 1.9 · Observed 1.9 · Expected 1.9 · Used in QM five-star |
| 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 · Adjusted 2.8 · Observed 2.6 · Expected 1.6 · Used in QM five-star |
| 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 · Q1 96.6% · Q2 95.2% · Q3 91.0% · Q4 89.3% · 4Q avg 93.0% |
| 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 · 4Q avg 95.1% |
| 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 · Q1 5.4% · Q2 4.8% · Q3 1.9% · Q4 2.0% · 4Q avg 3.5% · Used in QM five-star |
| 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 · Q1 1.5% · Q2 0.8% · Q3 0.7% · Q4 0.7% · 4Q avg 0.9% |
| 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 · Q1 12.8% · Q2 7.1% · Q3 5.6% · Q4 1.6% · 4Q avg 6.8% |
| 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 · Q1 23.1% · Q2 24.2% · Q3 18.3% · Q4 18.8% · 4Q avg 21.1% |
| 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 · Q1 20.6% · Q2 18.0% · Q3 20.8% · Q4 20.2% · 4Q avg 19.9% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · Q1 29.3% · Q2 25.1% · Q3 32.5% · Q4 40.5% · 4Q avg 31.7% · Used in QM five-star |
| 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 · Q1 29.3% · Q2 23.8% · Q3 36.1% · Q4 30.9% · 4Q avg 30.0% · Used in QM five-star |
| 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 · Q1 2.3% · Q2 1.8% · Q3 1.9% · Q4 0.5% · 4Q avg 1.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 2.1% · Q3 0.7% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| 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 · Q1 22.7% · Q2 20.8% · Q3 28.7% · Q4 26.6% · 4Q avg 24.8% |
| 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 · Q1 8.5% · Q2 10.7% · Q3 6.1% · Q4 4.4% · 4Q avg 7.4% · Used in QM five-star |
| 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 · Q1 91.9% · Q2 90.9% · Q3 89.4% · Q4 80.6% · 4Q avg 88.4% |
| 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 · Adjusted 19.6% · Observed 18.8% · Expected 10.7% · Used in QM five-star |
| 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 · Q1 2.4% · Q2 2.6% · Q3 0.8% · Q4 1.9% · 4Q avg 1.9% · Used in QM five-star |
| 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 · 4Q avg 82.2% |
| 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 · Adjusted 26.6% · Observed 24.3% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-20 · Fire 2024-06-20
26 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-06-22 · Fire 2023-06-22
37 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-07
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-08-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-08-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-08-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-08-07
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-08-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-12
C · Minimal harm
2025-08-07
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-08-12
F · Potential for more than minimal harm
2024-06-20
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-06-27
E · Potential for more than minimal harm
2024-06-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-27
E · Potential for more than minimal harm
2024-06-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-27
E · Potential for more than minimal harm
2024-06-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-27
E · Potential for more than minimal harm
2024-06-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-27
D · Potential for more than minimal harm
2024-06-20
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-06-27
D · Potential for more than minimal harm
2024-06-20
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-06-27
D · Potential for more than minimal harm
2024-06-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-27
D · Potential for more than minimal harm
2024-06-20
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-06-27
D · Potential for more than minimal harm
2024-06-20
K741 · Miscellaneous Deficiencies
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
D · Potential for more than minimal harm
2024-06-20
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-06-27
D · Potential for more than minimal harm
2024-06-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-27
D · Potential for more than minimal harm
2023-06-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-22
K741 · Miscellaneous Deficiencies
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
D · Potential for more than minimal harm
2023-06-22
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-06-22
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-07-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Not marked corrected
D · Potential for more than minimal harm
2025-09-02
F580 · Resident Rights Deficiencies
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
E · Potential for more than minimal harm
2025-08-07
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-08-07
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-08-07
F755 · Pharmacy Service Deficiencies
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
E · Potential for more than minimal harm
2025-08-07
F761 · Pharmacy Service Deficiencies
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
E · Potential for more than minimal harm
2025-08-07
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-08-07
F806 · Nutrition and Dietary Deficiencies
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
E · Potential for more than minimal harm
2025-08-07
F812 · Nutrition and Dietary Deficiencies
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
E · Potential for more than minimal harm
2025-08-07
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-08-07
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-08-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-08-07
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-08-07
F580 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2025-08-07
F585 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2025-08-07
F656 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2025-08-07
F657 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2025-08-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-08-07
F688 · Quality of Life and Care Deficiencies
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
D · Potential for more than minimal harm
2025-08-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-08-07
F690 · Quality of Life and Care Deficiencies
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
D · Potential for more than minimal harm
2025-08-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-08-07
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-08-07
F842 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2025-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-06-11
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-02-19
F655 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2025-02-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-19
D · Potential for more than minimal harm
2025-01-29
F584 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2024-10-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-07-23
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-07-29
D · Potential for more than minimal harm
2024-07-18
F656 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2024-07-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-29
E · Potential for more than minimal harm
2024-06-20
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-06-20
E · Potential for more than minimal harm
2024-06-20
F803 · Nutrition and Dietary Deficiencies
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
E · Potential for more than minimal harm
2024-06-20
F812 · Nutrition and Dietary Deficiencies
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
E · Potential for more than minimal harm
2024-06-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-06-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-06-20
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-06-20
F561 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2024-06-20
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-06-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-06-20
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-06-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-06-20
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-06-20
F755 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2024-06-20
F758 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2024-06-20
F761 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2024-05-17
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-04-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-19
E · Potential for more than minimal harm
2024-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-17
D · Potential for more than minimal harm
2024-03-05
F580 · Resident Rights Deficiencies
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
G · Actual harm
2024-02-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-18
D · Potential for more than minimal harm
2024-01-09
F656 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2024-01-09
F758 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2023-12-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-10-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-08
D · Potential for more than minimal harm
2023-10-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-10-11
F755 · Pharmacy Service Deficiencies
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
G · Actual harm
2023-06-22
F688 · Quality of Life and Care Deficiencies
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
F · Potential for more than minimal harm
2023-06-22
F812 · Nutrition and Dietary Deficiencies
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
E · Potential for more than minimal harm
2023-06-22
F656 · Resident Assessment and Care Planning Deficiencies
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
E · Potential for more than minimal harm
2023-06-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-19
E · Potential for more than minimal harm
2023-06-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-19
E · Potential for more than minimal harm
2023-06-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-19
E · Potential for more than minimal harm
2023-06-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-19
E · Potential for more than minimal harm
2023-06-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-19
E · Potential for more than minimal harm
2023-06-22
F842 · Resident Assessment and Care Planning Deficiencies
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
E · Potential for more than minimal harm
2023-06-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-22
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-22
F584 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2023-06-22
F655 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2023-06-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-22
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-22
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-22
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-22
F761 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2023-06-22
F806 · Nutrition and Dietary Deficiencies
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
D · Potential for more than minimal harm
2023-05-31
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-10
F656 · Resident Assessment and Care Planning Deficiencies
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
D · Potential for more than minimal harm
2023-05-10
F756 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2023-05-10
F758 · Pharmacy Service Deficiencies
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
D · Potential for more than minimal harm
2023-04-04
F656 · Resident Assessment and Care Planning Deficiencies
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
What sits behind the stars
$56,843
2024-02-26
Fine
Fine · fine $56,843
Fine
$0
2024-02-26
Payment Denial
Payment Denial · denial start 2024-03-29 · 21 days
21 day denial
$36,465
2023-06-22
Fine
Fine · fine $36,465
Fine
Ownership
Sonora Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Barias, Karen
Operational/Managerial Control · Individual
Ch Cafive Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Couve Healthcare Consulting LLC
Operational/Managerial Control · Organization
Cw Cafive Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Earl, Steven
Operational/Managerial Control · Individual
Herzka, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Leininger, Genesis
Operational/Managerial Control · Individual
Meador, Daniel
Operational/Managerial Control · Individual
Perlman, Harold
Operational/Managerial Control · Individual
Sonora Opco Manager LLC
Operational/Managerial Control · Organization
Sonora SNF Consulting LLC
Operational/Managerial Control · Organization
Sonora SNF Operations LLC
Operational/Managerial Control · Organization
Spielman, Shimon
Operational/Managerial Control · Individual
Spielman, Shimon
Corporate Officer · Individual
Veritas Health Solutions LLC
Operational/Managerial Control · Organization
Witzcorp LLC
5% Or Greater Indirect Ownership Interest · Organization
Wolofsky, Chava
5% Or Greater Indirect Ownership Interest · Individual
Yenowitz, Yitzchok
5% Or Greater Indirect Ownership Interest · Individual
Yenowitz, Yitzchok
Operational/Managerial Control · Individual
Yenowitz, Yitzchok
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Adventist Health Sonora - D/P SNF
Sonora, CA
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Golden San Andreas Care Center
San Andreas, CA
1-star overall rating with 1-star inspections with $91,172 in total fines with 20 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Oakdale Nursing And Rehabilitation Center
Oakdale, CA
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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