Cycle 1
Health 2024-10-10 · Fire 2024-10-10
21 health deficiencies
Top issue: Resident Rights (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Tulare, CA
Grand Oaks Care
2-star overall rating with 2-star inspections with $34,492 in total fines with 21 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
897 North M Street, Tulare, CA
(559) 687-1340
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ajc Healthcare
Operator or chain grouping
Approved since
2009-06-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 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
0.36
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.78
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.20
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.86
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.65
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,764
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.72% · Performance 23.96% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.33% · Performance 7.77% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.78
Baseline 100.00% · Performance 45.26% · Measure score 6.78 · Achievement 4.51 · Improvement 6.78
Adjusted total nurse staffing
3.52
Baseline 4.59 hours · Performance 4.08 hours · Measure score 3.52 · Achievement 3.52 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.68% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 95 · Observed rate 10.53% · Lower 95% interval 6.81% |
| Discharge to community | 46.96% |
50.57%
3.6 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 39.76% · Lower 95% interval 36.65% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 95.71% |
95.27%
0.4 pts better
|
Numerator 67 · Denominator 70 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 70 |
| Discharge self-care score | 54.29% |
53.69%
0.6 pts better
|
Numerator 19 · Denominator 35 |
| Discharge mobility score | 54.29% |
50.94%
3.4 pts better
|
Numerator 19 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 70 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.77% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 10% · Lower 95% interval 4.33% |
| Staff COVID-19 vaccination coverage | 31.29% |
8.2%
23.1 pts better
|
Numerator 46 · Denominator 147 |
| Staff flu vaccination coverage | 68.29% |
42%
26.3 pts better
|
Numerator 112 · Denominator 164 |
| Discharge function score | 54.29% |
56.45%
2.2 pts worse
|
Numerator 19 · Denominator 35 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 13.51% |
25.2%
11.7 pts worse
|
Numerator 5 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.3
0.8 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
1.6
1.7 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
1.6%
0.3 pts worse
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 2.6% · Q4 2.5% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.6% |
6.8%
0.8 pts worse
|
11.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 4.3% · Q3 24.2% · Q4 1.3% · 4Q avg 7.6% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
4.1%
0.4 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 4.9% · Q3 5.5% · Q4 3.1% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.5% |
13.7%
2.8 pts worse
|
19.6%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 16.1% · Q3 14.8% · Q4 20.0% · 4Q avg 16.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.0% |
14.2%
9.2 pts better
|
16.7%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 4.5% · Q3 3.8% · Q4 3.9% · 4Q avg 5.0% · 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 | 19.3% |
11.0%
8.3 pts worse
|
16.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.0% |
10.7%
0.3 pts worse
|
14.9%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 8.9% · Q3 17.5% · Q4 11.9% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.8% |
10.9%
9.9 pts worse
|
19.8%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 18.3% · Q3 23.3% · Q4 21.2% · 4Q avg 20.8% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.7%
4.7 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
94.0%
3.9 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.4% · Q2 98.8% · Q3 100.0% · Q4 100.0% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.3% |
11.2%
4.1 pts worse
|
12.0%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 14.5% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.2% |
23.2%
2 pts better
|
23.9%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 20.3% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-13 · Fire 2022-10-13
19 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-03-21 · Fire 2019-03-21
23 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-10
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-31
D · Potential for more than minimal harm
2024-10-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-31
C · Minimal harm
2024-10-10
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-31
C · Minimal harm
2024-10-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-31
D · Potential for more than minimal harm
2022-10-13
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-11-17
D · Potential for more than minimal harm
2022-10-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-17
D · Potential for more than minimal harm
2022-10-13
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 2022-11-17
D · Potential for more than minimal harm
2022-10-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-11-17
E · Potential for more than minimal harm
2019-03-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-06-05
E · Potential for more than minimal harm
2019-03-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-06-05
E · Potential for more than minimal harm
2019-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-06-05
D · Potential for more than minimal harm
2019-03-21
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2019-06-05
D · Potential for more than minimal harm
2019-03-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-06-05
D · Potential for more than minimal harm
2019-03-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-05
D · Potential for more than minimal harm
2019-03-21
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2019-06-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-02
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-07-29
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.
Not marked corrected
D · Potential for more than minimal harm
2025-07-03
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 2025-07-07
D · Potential for more than minimal harm
2025-05-09
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 2025-05-09
D · Potential for more than minimal harm
2025-01-29
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 2025-02-13
F · Potential for more than minimal harm
2024-10-10
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-10-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-10-10
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-10-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-10-10
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 2024-10-24
E · Potential for more than minimal harm
2024-10-10
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-10-10
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-10-10
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 2024-10-24
E · Potential for more than minimal harm
2024-10-10
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 2024-10-24
E · Potential for more than minimal harm
2024-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-24
E · Potential for more than minimal harm
2024-10-10
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-10
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 2024-10-24
D · Potential for more than minimal harm
2024-10-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-10
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 2024-10-24
D · Potential for more than minimal harm
2024-10-10
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-10-10
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 2024-10-24
E · Potential for more than minimal harm
2024-06-20
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-06-20
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-06-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-07
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 2024-05-08
D · Potential for more than minimal harm
2024-05-07
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-05-08
D · Potential for more than minimal harm
2024-04-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-02-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-02-07
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 2024-02-29
D · Potential for more than minimal harm
2024-02-07
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 2024-02-29
D · Potential for more than minimal harm
2023-12-22
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 2024-01-22
D · Potential for more than minimal harm
2023-12-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-22
E · Potential for more than minimal harm
2023-11-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-11-02
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 2023-12-28
D · Potential for more than minimal harm
2023-10-10
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 2023-10-30
G · Actual harm
2023-05-15
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 2023-06-22
D · Potential for more than minimal harm
2023-03-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-03-29
F · Potential for more than minimal harm
2022-10-13
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 2022-11-17
E · Potential for more than minimal harm
2022-10-13
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-11-17
E · Potential for more than minimal harm
2022-10-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-11-17
E · Potential for more than minimal harm
2022-10-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-11-17
E · Potential for more than minimal harm
2022-10-13
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 2022-11-17
E · Potential for more than minimal harm
2022-10-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-11-17
E · Potential for more than minimal harm
2022-10-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-17
D · Potential for more than minimal harm
2022-10-13
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-11-17
D · Potential for more than minimal harm
2022-10-13
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 2022-11-17
D · Potential for more than minimal harm
2022-10-13
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 2022-11-17
D · Potential for more than minimal harm
2022-10-13
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 2022-11-17
D · Potential for more than minimal harm
2022-10-13
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 2022-11-17
E · Potential for more than minimal harm
2019-03-21
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 2019-04-29
E · Potential for more than minimal harm
2019-03-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-04-29
E · Potential for more than minimal harm
2019-03-21
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 2019-04-29
E · Potential for more than minimal harm
2019-03-21
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 2019-04-29
E · Potential for more than minimal harm
2019-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-29
E · Potential for more than minimal harm
2019-03-21
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2019-04-29
D · Potential for more than minimal harm
2019-03-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-04-29
D · Potential for more than minimal harm
2019-03-21
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2019-04-29
D · Potential for more than minimal harm
2019-03-21
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 2019-04-29
D · Potential for more than minimal harm
2019-03-21
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 2019-04-29
D · Potential for more than minimal harm
2019-03-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-04-29
D · Potential for more than minimal harm
2019-03-21
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 2019-04-29
D · Potential for more than minimal harm
2019-03-21
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2019-04-29
Penalties and ownership
What sits behind the stars
$34,492
2023-05-15
Fine
Fine · fine $34,492
Fine
Ownership
Swc Ca Opco 2 LLC
5% Or Greater Direct Ownership Interest · Organization
Ajc Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Chesley, Aaron
5% Or Greater Indirect Ownership Interest · Individual
Chesley, Aaron
Corporate Officer · Individual
Gamett, James
5% Or Greater Indirect Ownership Interest · Individual
Gamett, James
Corporate Officer · Individual
Jbg Partners LLC
5% Or Greater Indirect Ownership Interest · Organization
Lawrence, Michelle
W-2 Managing Employee · Individual
Nearby options
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Orchards At Tulare
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2-star overall rating with 2-star inspections with $132,586 in total fines with 18 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
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Tulare, CA
1-star overall rating with 2-star inspections with 25 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Westgate Gardens Care Center
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3-star overall rating with 2-star inspections with 19 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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