Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kaweah Health Skilled Nursing Center during CMS and state inspections, most recent first.
Three residents and their legal representatives were not given prior written notice before new roommates were assigned to their rooms. The DON confirmed that there was no documentation of advance notification, which was required by facility policy. This resulted in a violation of residents' rights regarding roommate choice and notification.
A resident with contracted hands was observed to have long, thick, yellow fingernails, and staff interviews confirmed that nail care had not been provided for an extended period. Nursing and CNA staff acknowledged the ongoing condition and discomfort in addressing the resident's nail care needs, despite facility policy requiring such care.
Multiple infection control lapses were identified, including damaged linen cart covers exposing clean linen, lack of documented infection surveillance by the IPN, improper wound care technique by a WTN who failed to change gloves and wore a gown in poor repair, a used urinal placed on a bedside table with personal items, and the use of unapproved wipes to disinfect a glucometer, contrary to manufacturer instructions.
A resident who was alert and had a history of lumbar laminectomy experienced prolonged delays in staff response to her call light requests for bathroom assistance, especially around shift changes. Staff sometimes turned off the call light without providing help, and the resident reported feeling unimportant and fearful of incontinence due to these delays, contrary to facility policy requiring prompt response.
A resident with severe pain was repeatedly administered pain medication without a physician's order for severe pain, and staff did not notify the physician as required. Licensed staff were unaware of the correct method to verify GTube placement before medication administration for three residents, and a nurse failed to flush a GTube with water between medications, all contrary to facility policy.
A medication cart containing insulin vials was found unlocked and unattended outside the medication room. Both the DON and DOR confirmed that the cart should have been locked, in accordance with facility policy requiring secure storage of medications.
Three unopened pro source protein nutrition products with expired dates were found in a medication room and confirmed by an RN to be available for resident use, contrary to facility policy prohibiting the provision of expired nutrition products.
The facility failed to document potentially hazardous food, remove expired food, date frozen food storage, and sanitize the ice machine according to guidelines. Cooked pasta was not logged, expired Salisbury steak was found, and undated raw chicken was stored improperly. The ice machine was not sanitized as required.
The facility failed to follow its policy on Advance Directives for a resident, resulting in the absence of a documented AD in the resident's EHR. Interviews with staff and the resident confirmed that the process was not followed, posing a risk of inappropriate treatment in an emergency.
A facility failed to accurately complete the MDS for a resident on a planned weight gain regimen. The Registered Dietitian assessed the resident's nutritional needs and determined a daily intake of 2,700 calories to promote weight gain. However, the MDS inaccurately coded the resident's weight gain status, which could impede care planning. The RD acknowledged the error and the facility's policy emphasized the need for accurate assessments.
A facility failed to ensure a resident's head of bed was elevated at least 30 degrees while receiving enteral tube feedings, as required by policy and the resident's individual plan of care. The resident was observed with the head of bed elevated to only 15 degrees, which could lead to aspiration and lung problems.
The facility failed to dispose of expired medications and properly label medications with expiration dates. An expired mouthwash was found in the medication storeroom, and eye drops were administered without an open or expiration date label.
The facility failed to follow individualized meal tray directions for a resident, resulting in the resident receiving mixed vegetables that were not chopped as specified in their meal tray ticket. This was confirmed by the Certified Dietary Manager and was contrary to the resident's physician orders and the facility's diet manual and policy.
The facility policy failed to address residents' right to store outside food, potentially not honoring a resident and/or families' request to store food for later consumption. Staff confirmed that outside food must be approved by a nurse and consumed immediately or discarded, as the facility lacks a refrigerator for storing such food. Policies indicated that potentially hazardous food not consumed by a patient would be discarded within four hours and not stored in patient floor stock refrigerators.
The facility failed to implement proper infection prevention and control measures when two Environmental Service Aides did not ensure that high-touch surface areas were disinfected daily. Observations and interviews revealed inconsistencies in the use of Vindicator disinfectant, with one aide stating handrails were disinfected only once per week, contrary to facility policy and manufacturer's guidelines requiring daily disinfection and a 10-minute dwell time.
The facility failed to maintain the walk-in freezer in Kitchen 1, resulting in persistent ice buildup despite recent repairs. The issue was not reported back to maintenance, and no further repairs were pending, contrary to the manufacturer's guidelines and the facility's preventative maintenance policy.
The facility failed to ensure that empty vials of Heparin were discarded in a designated waste bin for two residents. An LVN confirmed that an empty vial was left unattended on a medication cart and should have been disposed of immediately after administration, contrary to the facility's policy.
Failure to Notify Residents of New Roommates
Penalty
Summary
The facility failed to provide prior written notification to three residents or their legal representatives before assigning new roommates to their rooms. Record reviews showed that after one resident was placed on comfort care and moved to a private room, a new admission was placed in the same room without informing the family. Additionally, documentation for other residents did not show evidence that they or their representatives were notified in advance of new roommates being assigned to their rooms. During interviews, the Director of Nursing confirmed the absence of documentation regarding advance notice for the affected residents. The facility's own policy requires that residents' families or legal representatives be informed prior to any in-room transfers, but this procedure was not followed in these cases. The lack of notification resulted in a violation of the residents' rights to be informed and to have a choice regarding their roommates.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for a resident who was unable to perform self-care, specifically in the area of nail care. During an observation, the resident was found in bed with both hands contracted and all ten fingernails long, thick, and yellow. The Assistant Director of Nurses confirmed the condition of the resident's fingernails. Interviews with a Registered Nurse and two Certified Nursing Assistants revealed that the resident's fingernails had consistently been in this condition, and neither CNA recalled cutting or filing the resident's nails. One CNA expressed discomfort in providing nail care due to the presence of thick, yellow, possibly fungal nails. Review of the facility's policy indicated that nail care is a covered personal service for residents.
Infection Control Failures in Linen Handling, Surveillance, Wound Care, and Equipment Disinfection
Penalty
Summary
The facility failed to adhere to infection prevention and control standards in several key areas. Observations revealed that two of four linen carts in the hallway had damaged vinyl covers with multiple tears and holes, exposing clean linen. Staff, including the Infection Preventionist Nurse (IPN), acknowledged awareness of the issue, and facility policy required daily monitoring and replacement of soiled or damaged covers. Additionally, the IPN was unable to provide documentation or evidence of regular infection control surveillance, audits, or data collection, despite facility policy mandating surveillance data be summarized and reviewed by the Infection Prevention Committee. During wound care for a resident, the Wound Treatment Nurse (WTN) wore a cloth gown missing the necessary ties, which caused the gown to fall off her shoulders and fail as a protective barrier. The WTN also did not change gloves or perform hand hygiene when moving from dirty to clean tasks, contrary to CDC guidelines and facility expectations. The Laundry Manager confirmed that gowns in poor condition should be discarded, and the IPN agreed that such gowns do not provide adequate protection. Further deficiencies included a used urinal being placed on a bedside table next to a resident's personal items, which staff acknowledged was improper, and the use of unapproved disinfectant wipes (CAVI wipes) to clean the glucometer machine after use on two residents. The glucometer's manufacturer required bleach-containing wipes for disinfection, but staff and leadership were unaware of this requirement and used products that did not meet the manufacturer's recommendations. Facility policy required equipment to be cleaned according to manufacturer instructions, which was not followed.
Delayed Call Light Response and Lack of Resident Accommodation
Penalty
Summary
Staff failed to promptly respond to a resident's call light requests for assistance to the bathroom, resulting in prolonged delays of 45 minutes to an hour, particularly around shift changes. The resident reported that staff would enter the room, turn off the call light, and leave without providing assistance, only returning to help approximately thirty minutes after the shift change. The resident expressed fear of potentially urinating on herself due to these delays and described staff as making sighing noises before assisting her, which made her feel unimportant. The resident had a history of lumbar laminectomy and was alert and oriented at the time of the incident. Facility policy required staff to respond promptly to call lights to ensure resident safety and health needs were met in a reasonable amount of time. The facility's admission agreement also required reasonable accommodation of individual needs and preferences. Interviews with staff confirmed that call lights should be addressed when turned off, but this was not consistently done for this resident.
Failure to Meet Professional Standards in Pain Management and GTube Care
Penalty
Summary
The facility failed to provide services that meet professional standards of quality in several instances. One resident experiencing severe pain, as indicated by repeated pain scores of 7 or higher on a 0-10 scale, was administered Norco for pain relief without a physician's order for severe pain. The nurse did not notify the physician regarding the resident's severe pain, and there was no documentation of such communication, despite facility policy requiring staff to communicate unexpected pain findings to the healthcare team. Additionally, licensed staff were unaware of the correct process for verifying gastrostomy tube (GTube) placement prior to medication administration for three residents. Staff incorrectly believed that aspirating for residual formula or using a stethoscope were appropriate methods, whereas facility policy required checking tube markings to verify placement. Furthermore, a nurse failed to flush a GTube with water between administering multiple medications to a resident, contrary to facility policy that mandates a 5 ml water flush between each medication to prevent tube blockage.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart (Medication Cart 1) was observed unlocked and unattended outside the medication room, containing insulin vials. This was witnessed during a survey observation, and both the Director of Nursing and the Director of Rehabilitation confirmed in interviews that the cart should have been locked when not in use. Review of the facility's policy and procedure on medication security indicated that all medications are to be stored securely and that medication carts must be locked when not in use. The failure to keep the medication cart locked resulted in medications being accessible to unauthorized individuals.
Expired Nutritional Products Found Available for Resident Use
Penalty
Summary
The facility failed to ensure that nutritional products available for resident use were not expired. During an observation and interview in the Wing A medication room, three unopened pro source protein nutrition products were found with expiration dates that had already passed. The registered nurse present confirmed that these expired products should not have been available for resident use. A review of the facility's policy and procedure on recall and expired products indicated that expired food and nutrition products are not to be provided to patients and customers.
Food Safety and Ice Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and handling of potentially hazardous food, expired food, and frozen food storage. During an observation, a large container of cooked pasta was found in the walk-in refrigerator without being documented on the cool-down log. The Certified Dietary Manager (CDM) and Cook II (CK) confirmed that the pasta was not logged as required by the facility's policy. Additionally, an unopened package of Salisbury steak with an expired use-by date was found in the walk-in freezer, and a large container of frozen raw chicken was found undated. Both the CDM and Diet Clerk (DC) acknowledged these issues, which were against the facility's food labeling and storage policies. Furthermore, the facility failed to sanitize the ice machine in accordance with the manufacturer's guidelines. The Maintenance Employee (MT) stated that he used a product that he believed both cleaned and sanitized the ice machine, but he could not confirm this. Upon review, it was found that the manufacturer's guidelines required a separate sanitizing step, which was not being performed. The CDM confirmed that the ice machine was not sanitized as per the guidelines or the facility's policy on ice machine maintenance.
Failure to Follow Advance Directive Policy
Penalty
Summary
The facility failed to follow its policy and procedure on Advance Directives (AD) for one of the 36 sampled residents, Resident 28. During a review of Resident 28's clinical record, it was noted that there was no documented AD. Interviews with the Director of Nursing (DON) and Registered Nurse (RN) 3 revealed that the process for handling ADs was not followed correctly. The DON stated that licensed nurses ask patients about ADs during admission, and if a patient indicates they have one, the information is supposed to be forwarded to the social worker. However, RN 3 was unable to locate the AD in Resident 28's Electronic Health Record (EHR), indicating a breakdown in this process. Further interviews with Resident 28 and Social Services (SS) confirmed the deficiency. Resident 28 stated that he informed the staff about his AD upon admission. SS explained that when nurses mark the AD box during the admission assessment, it should generate a clinical order for the AD, but this did not happen in Resident 28's case. A review of the facility's policy and procedure on ADs, dated 10/16/2022, indicated that the process was not followed as required, leading to the potential risk of Resident 28 not receiving appropriate treatment in an emergency.
Inaccurate MDS Completion for Resident on Planned Weight Gain Regimen
Penalty
Summary
The facility failed to ensure an accurate completion of the Minimum Data Set (MDS) for a resident (Resident 23) who was on a planned weight gain regimen. During an interview and record review, it was found that the Registered Dietitian (RD) had assessed Resident 23's nutritional needs and determined a daily intake of 2,700 calories to promote weight gain due to the resident's underweight status. However, the MDS completed on 8/31/23 inaccurately coded the resident's weight gain status as 'Yes, not on physician-prescribed weight-gain regimen' instead of 'Yes, on physician-prescribed weight-gain regimen.' The RD acknowledged the error and admitted uncertainty about who was responsible for obtaining a specific physician order for the weight gain regimen, ultimately recognizing it should have been her responsibility. Further review of the facility's policy indicated that all disciplines participating in the Resident Assessment Instrument (RAI) process are required to accurately complete their assessments and electronically attest to their accuracy. The MDS Coordinator (MDSC) confirmed that the section on weight gain was not completed accurately, which could lead to an inaccurate MDS and potentially impede care planning to meet the resident's needs. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were also present during the review and interview process, highlighting the collaborative nature of the assessment process and the importance of accurate documentation.
Failure to Elevate Head of Bed During Enteral Feeding
Penalty
Summary
The facility failed to ensure the head of bed (HOB) of one of 10 sampled residents was elevated at least 30 degrees while receiving enteral tube feedings. During an observation, the resident was found lying on his left side with the HOB elevated to only 15 degrees, as indicated by the measuring guide on the side of the bed. The resident's enteral tube feeding was running at 55 milliliters per hour at the time of the observation. Both a registered nurse and the assistant director of nursing confirmed that the HOB should have been elevated to a minimum of 30 degrees according to the facility's policy and the resident's individual plan of care (IPOC). The resident's order sheet indicated continuous tube feeding with a specific formula, and the IPOC highlighted the need to elevate the HOB during and after meals to prevent aspiration. The facility's policy on enteral nutrition also specified that the HOB should be elevated to 30-45 degrees to prevent complications such as aspiration. The failure to adhere to these guidelines had the potential to result in aspiration and lung problems for the resident.
Expired and Improperly Labeled Medications
Penalty
Summary
The facility failed to ensure that expired medications were disposed of and that medications were properly labeled with expiration dates. Specifically, one resident's expired mouthwash was found in the medication storeroom, despite the resident having been discharged from the facility. The facility's policy and procedure for the disposal of unusable medications indicated that such medications should be promptly returned to the pharmacy for proper disposal, which was not followed in this case. Additionally, another resident's eye drops were administered without being properly labeled with an open or expiration date. The facility's policy on labeling standards required that all medications include a beyond-use or expiration date, which was not adhered to. These lapses were identified during observations and interviews with the facility's licensed vocational nurse and pharmacist.
Failure to Follow Individualized Meal Tray Directions
Penalty
Summary
The facility failed to follow individualized meal tray ticket directions for one resident, identified as Resident 189. During an observation, it was noted that Resident 189's lunch plate included mixed vegetables that were not served in a chopped texture as specified in the resident's meal tray ticket. The Certified Dietary Manager confirmed that the vegetables were not chopped and should have been in accordance with the resident's individualized menu directions. The resident's physician orders indicated a need for chopped meats and vegetables due to chewing issues, which were not adhered to during meal preparation. The facility's diet manual for a chopped diet specifies that foods should be moist and in bite-size pieces no larger than 1/2 inch to meet the needs of patients with chewing or swallowing difficulties. Additionally, the facility's policy and procedure for tray assembly and distribution mandates that food items be placed on patient trays according to the items listed on the patient tray ticket. The failure to follow these guidelines resulted in the resident receiving a meal that did not meet their specified dietary needs.
Failure to Address Residents' Right to Store Outside Food
Penalty
Summary
The facility policy failed to address residents' right to store outside food, which had the potential to not honor a resident and/or families' request to store food from the outside for later consumption. During interviews, various staff members, including a Licensed Vocational Nurse (LVN), a Certified Nurse Assistant (CNA), a Certified Dietary Manager (CDM), and the Director of Nursing (DON), confirmed that the facility does not store outside food for residents. The staff indicated that outside food must be approved by a nurse and consumed immediately or discarded, as the facility does not have a refrigerator for storing such food. The DON mentioned that staff are trained to offer a bucket with ice for short-term storage, but this is not a long-term solution. Observations also revealed a sign on the nourishment refrigerator stating that no patient food from home is allowed in the fridge per policy number FNS.615. The facility's policies and procedures were reviewed, including the policy titled 'Storage of Leftover Patient Food' and 'Nutrition: Cafeteria and outside food.' These policies indicated that potentially hazardous food not consumed by a patient would be discarded within four hours and not stored in patient floor stock refrigerators. The Food and Nutrition Services department does not provide oversight over any outside food for patient use. This lack of a clear policy on storing outside food brought in by family members led to the deficiency, as it did not honor the residents' right to store such food for later consumption.
Failure to Properly Disinfect High-Touch Surfaces
Penalty
Summary
The facility failed to implement proper infection prevention and control measures when two Environmental Service Aides (EVS 1 and EVS 2) did not ensure that high-touch surface areas such as handrails, call lights, doorknobs, and pull cords were disinfected daily. During an observation and interview, EVS 1 stated that Vindicator, a disinfectant, was used for surfaces in residents' rooms and that the dwell time for Vindicator was one minute. However, EVS 2 revealed that handrails in the resident hallways were disinfected with Vindicator only once per week. This discrepancy was further highlighted by the Laundry Manager (LM), who stated that Vindicator should remain wet for 10 minutes and that high-touch areas like hallway handrails should be cleaned daily with Vindicator without wiping the surfaces afterward. The Infection Preventionist (IP) confirmed that high-touch surfaces should be disinfected daily according to facility policy and training provided to housekeeping staff. The facility's policies and procedures also indicated that high-touch surfaces should be disinfected daily and allowed to air dry without being wiped down prematurely. The manufacturer's guidelines for Vindicator also specified a 10-minute dwell time for effective disinfection. The failure to adhere to these guidelines and policies was observed during the survey, indicating a lapse in the facility's infection control practices. The facility's policy and procedure documents, as well as the manufacturer's guidelines for Vindicator, were reviewed and found to be consistent with the need for daily disinfection of high-touch surfaces and adherence to the specified dwell times. The inconsistency in the application of these procedures by the Environmental Service Aides posed a potential risk for the spread of infectious diseases among residents, staff, and visitors.
Failure to Maintain Walk-In Freezer in Good Repair
Penalty
Summary
The facility failed to ensure the walk-in freezer in Kitchen 1 was maintained in good repair, which had the potential to compromise food quality and safety. During an observation, ice buildup was noted on the plastic strip curtain, tubing on the door, and a cardboard box inside the freezer. The Certified Dietary Manager (CDM) acknowledged the issue and mentioned that a work order had been completed to repair the seals on the door, but the ice buildup persisted. The CDM had not reported the continued issue to maintenance, and there were no pending work orders for further repairs. Maintenance Staff (MS) believed the ice buildup was normal due to the door being opened and hot air entering, and considered the extensive ice buildup a sign of a properly working freezer. However, the manufacturer's guidelines indicated that ice buildup around doors might indicate leakage or heater failure, requiring immediate attention. The facility's policy on preventative maintenance emphasized the importance of routine maintenance to ensure equipment operates as designed, but this was not adequately followed in this case.
Failure to Properly Dispose of Heparin Vials
Penalty
Summary
The facility failed to ensure that empty vials of Heparin, a medication used to decrease blood clots, were discarded in a designated waste bin for two of the 36 sampled residents. During an observation, a vial of Heparin was found unattended on top of a medication cart. Licensed Vocational Nurse (LVN) 1 confirmed that the vial was empty and should have been disposed of immediately after administration. The Medication Administration Record (MAR) indicated that the Heparin was administered to two residents between 6:59 a.m. and 7:40 a.m. The facility's policy and procedure (P&P) for medication administration required used medications to be promptly placed in a pharmaceutical waste bin, which was not followed in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Visalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Delta Healthcare & Wellness Center, Lp | 1.2 mi | — | 0 | 0 |
| Visalia Post Acute | 2.1 mi | — | 25 | 0 |
| Sequoia Vista | 2.2 mi | — | 10 | 0 |
| Westgate Gardens Care Center | 2.8 mi | — | 3 | 0 |
| Linwood Meadows Care Center | 2.8 mi | — | 0 | 0 |
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