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 Sequoia Transitional Care during CMS and state inspections, most recent first.
A resident who was dependent on staff for ADLs, including personal hygiene and grooming, was observed with fingernails approximately one inch long on both hands, including a contracted hand. The resident reported asking multiple staff members to trim his nails without the care being provided. A CNA confirmed the nails were excessively long and needed trimming. An LVN stated nail care was offered daily and on a designated weekly day but could not produce documentation that this resident had been offered nail care for about one and a half months. The DON acknowledged the nails were too long, and the resident's care plan and the facility's ADL policy both required staff to provide necessary grooming and hygiene services for residents unable to perform these tasks independently.
A resident with a vascular/venous wound to the right lower leg had a revised wound care order documented by the wound physician, specifying cleansing with NS, patting dry, and applying Dakin’s flush with betadine to eschar QD and PRN. However, the active treatment orders in the record continued to reflect an older regimen using wound cleanser and betadine-soaked gauze with kerlex wrap. During interview and record review, the ADON could not show evidence that the new order was implemented and acknowledged the order was not updated, contrary to facility policy requiring a current and complete list of treatment orders. This failure resulted in the physician’s order being incorrect and created the potential for the wound to worsen.
A resident with dementia, muscle weakness, and a history of repeated falls, who was totally dependent on staff for toileting, was left waiting for about 30 minutes after requesting help. The resident attempted to use the bathroom without assistance, resulting in a fall that caused a head laceration and a T5 compression fracture. Staff and records confirmed the resident's high fall risk and need for total assistance, and the facility's failure to provide timely care led directly to the incident.
The facility failed to ensure an RN was on duty for eight hours a day, seven days a week, as required by policy. Interviews and record reviews with the DSD revealed multiple instances across several months where this requirement was not met, indicating a systemic issue in maintaining adequate RN coverage.
The facility failed to notify the resident's representative and the state LTC ombudsman in writing when two residents were transferred to the hospital. One resident was transferred twice, once for gastrointestinal bleeding and once due to a fall, without notifying the family member listed as the Responsible Party. Another resident was transferred without notifying the ombudsman. The facility's policy requires such notifications, but they were not carried out.
The facility failed to develop and implement individualized care plans for three residents, potentially leading to unmet care needs. A resident with speech issues, another with gastrointestinal bleeding, and a third with incontinence did not have appropriate care plans in place, contrary to the facility's policy requiring comprehensive, person-centered care plans.
A facility failed to use a communication tool for a resident with a speech impairment, leading to potential unmet needs. The resident was observed speaking in gibberish, and while a CNA familiar with the resident could understand her, the MDS assessment indicated unclear speech. The MDSC noted that without a communication tool, newer staff would struggle to meet the resident's needs, contrary to the facility's policy on effective communication.
The facility failed to follow its repositioning policy for two residents dependent on staff for mobility. Resident 71 was not repositioned consistently every two hours as required, and Resident 52, with hemiplegia, was not turned every hour while in a chair. Documentation showed irregular repositioning times, and discrepancies between care plans and actual needs were noted.
A facility failed to assess a resident for a Bowel and Bladder Training program, despite documentation indicating the resident was always incontinent. The Minimum Data Set Consultant and Coordinator found no care plan or documentation for such a program, and discrepancies in the resident's continence status were noted. Additionally, the facility could not provide a bowel and bladder training program policy.
The facility failed to monitor two residents on anticoagulation therapy as per their protocol. There was no documentation of monitoring for adverse effects of Eliquis and Xarelto for DVT prevention, as confirmed by the ADON and MDS Consultant. The facility's protocol requires monitoring for complications and consulting with a physician if signs of bleeding are observed.
The facility failed to remove expired medications from medication carts for two residents, risking administration of expired drugs. Additionally, a resident's medications were found unsecured in their room without a self-administration assessment. Licensed staff acknowledged responsibility for checking and removing expired medications, which was not done, and the facility's policies on medication storage and self-administration assessments were not followed.
A facility failed to follow a physician-prescribed therapeutic diet for a resident, potentially leading to adverse outcomes. The resident's diet required chopped meat due to multiple missing teeth, but the chicken fried steak served was not chopped, leaving it uneaten. An LVN confirmed the steak should have been chopped, as per the resident's dietary requirements.
The facility failed to ensure that arbitration agreements were clearly explained to residents in their primary language, resulting in several Spanish-speaking residents signing agreements in English without full understanding. The agreements were presented without certified interpreters, and staff members who were not certified to translate legal terms facilitated the process.
A resident received incorrect discharge appeal information, and the Ombudsman was notified late about the discharge. The NOPD contained wrong contact details for appeals, and the Ombudsman was informed three days after the notice, against the facility's policy.
A facility failed to notify a resident's responsible party before a room change, violating the resident's rights. The DON confirmed the room swap occurred without documented consent from the responsible party, contrary to facility protocol requiring notification and documentation in the clinical record.
A resident with Guillain-Barre syndrome was not referred to a neurologist as ordered, leading to a delay in care. The receptionist attempted to schedule the appointment but lacked documentation of these attempts. The DON confirmed the absence of documentation, contrary to the facility's policy requiring coordination and documentation of referrals.
The facility did not have a full-time licensed DON, as the previous DON left in March 2024. An interim DON, who completed the RN program but lacked an RN license, was assigned to the role. This situation did not comply with the facility's policy requiring a licensed RN as a full-time DON.
Failure to Provide Required Nail Care as Part of ADL Support
Penalty
Summary
The facility failed to provide necessary nail care as part of activities of daily living (ADLs) for a resident who was dependent on staff for personal hygiene, grooming, and other ADLs. During an observation in the resident's room, the resident was seen lying in bed with the head of the bed elevated, and both hands had fingernails approximately one inch long beyond the fingertips. The resident's left hand was contracted, with fingers permanently bent toward the palm, and the fingernails on that hand were also approximately one inch long. The resident reported having asked several staff members to trim his nails, but stated that no staff member returned to perform the nail trimming. A CNA, during a concurrent observation and interview, confirmed that the resident's fingernails were long and should be trimmed. An LVN stated that nail care was provided daily and that Sundays were designated for offering and trimming residents' nails, but was unable to provide documentation showing that this resident had been offered nail care for the previous one and a half months. The DON also stated that the resident's fingernails were too long and required trimming. Review of the resident's care plan dated 7/21/25 showed the resident was dependent on staff for bathing, personal hygiene, dressing, and grooming. Review of the facility's ADL policy dated 3/2018 indicated that residents unable to carry out ADLs independently would receive services necessary to maintain grooming and personal hygiene, which was not carried out for this resident.
Failure to Update and Implement Revised Wound Care Orders
Penalty
Summary
The facility failed to ensure that a physician’s updated wound care order was implemented and reflected in the resident’s active treatment orders. A progress note completed by the wound physician on 12/4/25 documented that the resident’s right shin vascular wound (Wound #2) was not healed and included a specific treatment order: cleanse the wound with normal saline, pat dry, and apply Dakin’s flush with betadine to the eschar every day and as needed. However, the resident’s Order Summary Report continued to show an earlier treatment order for a venous wound to the right lower leg, directing staff to cleanse with wound cleanser, pat dry, apply betadine-soaked gauze to the wound bed, cover with a dry dressing, and wrap with kerlex every day or as needed. During an interview and concurrent record review with the ADON, the facility was unable to provide evidence that the 12/4/25 wound care order had been implemented or that the treatment order had been updated in the clinical record. The ADON acknowledged that the treatment order for the venous wound to the right lower leg was not updated with the new order and stated that it should have been. The facility’s own Medication Orders policy required that a current list of orders be maintained in each resident’s clinical record and that treatment orders specify the treatment, frequency, and duration, but this was not followed for this resident’s wound care. The report stated that this failure resulted in the physician’s order being incorrect and created the potential for the resident’s wound to worsen.
Failure to Provide Timely Toileting Assistance to High-Risk Resident Resulting in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, muscle weakness, and dementia, who was assessed as being at high risk for falls and totally dependent on staff for toileting, was left waiting for assistance for approximately 30 minutes after requesting help to use the bathroom. The resident's care plan and assessments clearly indicated the need for total assistance with toileting due to severe cognitive impairment and physical limitations. Despite these documented needs, the resident was not assisted in a timely manner after making the request to a CNA. During this period of waiting, the resident attempted to transfer herself to the bathroom without assistance. This resulted in an unwitnessed fall in the bathroom, where the resident was found on the floor with a laceration to the head and later diagnosed with a T5 compression fracture. Multiple staff interviews confirmed that the resident was known to be a high fall risk and required total assistance for toileting, and that the fall could have been prevented if the resident had been assisted promptly. Facility records, including the care plan, post-fall reviews, and staff interviews, consistently documented the resident's dependence and high risk for falls. The facility's own policy required appropriate support and assistance with activities of daily living, including toileting, for residents unable to perform these tasks independently. The failure to provide timely assistance directly led to the resident's fall and subsequent injuries.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled and on duty for eight hours a day, seven days a week, as required by their policy. This deficiency was identified through interviews and record reviews conducted with the Director of Staff Development (DSD) on January 8, 2025. The Nursing Staff Assignment and Sign-in Sheets (NSASS) for several months in 2024 and early 2025 revealed multiple instances where no RN was on duty for the required duration. Specifically, the absence of an RN for eight hours a day was noted on several days in July, August, September, October, November, and December 2024, as well as in January 2025. The facility's policy, titled 'Staffing, Sufficient and Competent Nursing,' dated August 2022, mandates that a registered nurse provides services for at least eight consecutive hours every 24 hours, seven days a week. Despite this policy, the DSD confirmed during interviews that there were numerous days across the reviewed months where this requirement was not met, indicating a systemic issue in maintaining adequate RN coverage. This failure had the potential to negatively impact resident care, although specific consequences or resident conditions were not detailed in the report.
Failure to Notify Representatives and Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the resident's representative and the state long-term care ombudsman in writing when two residents were transferred to the hospital. Resident 52, who had a history of diabetes and high blood pressure, was transferred to the hospital on two occasions: once for gastrointestinal bleeding and another time due to a fall. In both instances, the resident's family member, listed as the Responsible Party, was not notified. The first failure to notify was due to the nurse incorrectly listing the resident as his own representative, and the second was due to a full voicemail box. Resident 82 was transferred to the hospital, but the ombudsman was not notified. The facility's policy requires that when a resident is transferred or discharged, appropriate notice must be provided to the resident and/or legal representative, and a copy of the notice must be sent to the state long-term care ombudsman. However, the Social Services Designee admitted to not sending notifications to the ombudsman or the resident's representatives in these cases.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for three residents, which could potentially lead to unmet care needs. Resident 46 was observed in her wheelchair speaking in gibberish, and despite a CNA's ability to understand her needs, there was no care plan addressing her speech deficit. Resident 52 was transferred to the hospital for gastrointestinal bleeding and upon readmission, there was no care plan addressing this condition. Resident 79's records indicated incontinence, but there was no care plan to address this issue. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables to meet residents' needs. These care plans should be updated when there is a significant change in condition, when outcomes are not met, or when a resident is readmitted from a hospital stay. However, the facility did not adhere to this policy, as evidenced by the lack of care plans for the identified issues in Residents 46, 52, and 79.
Failure to Use Communication Tool for Resident with Speech Impairment
Penalty
Summary
The facility failed to ensure the use of a communication tool for a resident with a speech impairment, identified as Resident 46. During an observation, the resident was noted to speak in short clips of gibberish with no discernable words. A Certified Nursing Assistant (CNA) who had cared for the resident for the past year stated she could understand the resident's needs. However, the Minimum Data Set (MDS) assessment indicated that the resident had unclear speech and was rarely or never understood. The Minimum Data Set Coordinator (MDSC) acknowledged that not using a communication tool would make it difficult for newer staff to understand and meet the resident's needs. The facility's policy on effective communication, dated February 2018, required staff to assist residents with language barriers to maintain effective communication, which was not adhered to in this case.
Failure to Follow Repositioning Policy for Dependent Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure for repositioning residents, which was identified during interviews and record reviews. The policy required that residents in bed be repositioned at least every two hours, and those in a chair every hour, to prevent skin breakdown and promote circulation. However, the documentation for two residents, who were dependent on staff for mobility, showed inconsistent repositioning times that did not meet the policy's requirements. Resident 71, who was dependent on staff for all mobility tasks, was not repositioned consistently according to the facility's policy. The records indicated that the resident was turned at irregular intervals, often exceeding the two-hour requirement. This inconsistency was confirmed during an interview with the Assistant Director of Nursing, who reviewed the resident's medical records and noted the lack of adherence to the repositioning schedule. Similarly, Resident 52, who had a diagnosis of hemiplegia and was dependent on staff for mobility, was also not repositioned according to the policy. The documentation showed that the resident was turned at irregular intervals, failing to meet the one-hour requirement for residents in a chair. The Minimum Data Set Consultant acknowledged the discrepancy between the care plan and the actual needs of the resident, highlighting the potential for resident injury due to inaccurate care planning and documentation.
Failure to Assess Resident for Bowel and Bladder Training Program
Penalty
Summary
The facility failed to assess a resident, identified as Resident 79, for a Bowel and Bladder Training program, which is designed to help residents regain control over their bowel and bladder functions. During a review of Resident 79's medical records, it was found that the Bowel and Bladder Observation/Assessment indicated incontinence, with the resident always being incontinent of both bowel and bladder. However, there was no care plan for incontinence or documentation of the resident being placed on a bowel and bladder training program. The Minimum Data Set Consultant and Coordinator noted discrepancies in the documentation and acknowledged the absence of a bowel and bladder training program policy, which should have been in place given the resident's recent onset of incontinence.
Failure to Monitor Anticoagulation Therapy
Penalty
Summary
The facility failed to adhere to its policy and procedure for monitoring residents on anticoagulation therapy, specifically for two residents, Resident 10 and Resident 57. During a review of Resident 10's Medication Administration Record (MAR) for December and early January, it was found that there was no documentation of monitoring for adverse effects of the blood-thinning medication Eliquis, which was prescribed for deep vein thrombosis (DVT) prevention. The Assistant Director of Nursing confirmed the absence of such documentation, which was required by the facility's protocol. Similarly, for Resident 57, a review of the Order Summary Report revealed that there was no documentation of monitoring for adverse effects of the anticoagulant Xarelto, also prescribed for DVT. The Minimum Data Set Consultant acknowledged the lack of documentation. The facility's anticoagulation clinical protocol, dated November 2018, mandates that staff and physicians monitor for complications in individuals on anticoagulation therapy and manage related problems, including consulting with a physician if signs of bleeding are observed before administering the next dose.
Expired Medications and Insecure Storage Found in Facility
Penalty
Summary
The facility failed to implement its policy and procedure regarding expired medications for two residents, as expired medications were found in the medication administration carts. During an observation, three expired medications were found in the medication cart for one resident, including Hyosyne oral drops, Acetaminophen suppositories, and Bisacodyl suppositories, all with expiration dates of 9/19/24. Another resident had expired artificial tears lubricant eye drops with an expiration date of 8/2022 in the medication storage room. Licensed staff acknowledged that it was their responsibility to check and remove expired medications, which was not done, leading to the potential for expired medications to be administered. Additionally, the facility failed to ensure that a resident's medications were securely stored, as observed in the resident's room where five vials of Refresh Digital PF and a medication cup of unlabeled cream were found on the bedside table. The LVN confirmed that the cream was Voltaren gel, and there was no order for the resident to keep medication at the bedside. The resident had not been assessed for self-administration of medication, which should have been completed before allowing the resident to self-administer. The facility's policy required medications to be stored in locked compartments and for self-administration assessments to be conducted, which were not adhered to in this case.
Failure to Follow Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to adhere to the physician-prescribed therapeutic diet for a resident, identified as Resident 64, which could potentially lead to adverse outcomes. The Order Summary Report for Resident 64, dated March 12, 2024, specified a regular diet with chopped meat texture and thin liquids consistency. However, during an observation and interview on January 9, 2025, it was noted that the chicken fried steak on Resident 64's food tray was not chopped, rendering it uneaten. Resident 64, who had multiple missing teeth, expressed an inability to eat the unchopped steak. Licensed Vocational Nurse 1 confirmed that the steak should have been chopped according to the resident's dietary requirements. The facility's policy and procedure, dated October 2017, indicated that therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care, taking into account the resident's informed choices, preferences, treatment goals, and wishes.
Failure to Explain Arbitration Agreements in Resident's Language
Penalty
Summary
The facility failed to ensure that the terms and conditions of its arbitration agreement were clearly explained to five residents, resulting in them signing the agreement without fully understanding that they were waiving their rights to a court proceeding in the event of a dispute. The residents involved primarily spoke Spanish, and the arbitration agreements were only available in English. The facility did not use certified interpreters to explain the agreements, relying instead on a staff member who was not certified to translate legal or medical terminology. Resident 26, with moderate cognitive impairment, and Resident 135, also with moderate impairment, both signed the English arbitration agreements without a certified interpreter present. Resident 57, Resident 70, and Resident 80, who were cognitively intact, also signed the agreements in English. Resident 80, who was very sick at the time of signing, stated he did not remember what he signed and was unsure if the documents were in English or Spanish. The Director of Marketing and a Certified Nursing Assistant (CNA) were involved in presenting and translating the arbitration agreements. The Director of Marketing admitted to encouraging residents to sign the agreements and acknowledged that the facility did not have agreements in Spanish. The CNA, who assisted with translations, was not certified to translate legal documents. The facility's policy required that arbitration agreements be explained in a manner that residents understand, considering their language and literacy, but this was not adhered to in these cases.
Failure to Provide Correct Discharge Information and Timely Ombudsman Notification
Penalty
Summary
The facility failed to provide proper discharge information to a resident, identified as Resident 1, as part of a 30-day notice. The Notice of Proposed Discharge (NOPD) given to the resident contained incorrect appeal information, directing the resident to contact the California Department of Public Health for complaints rather than the appropriate state agency for discharge appeals. This error was acknowledged by the Director of Nursing (DON) during an interview, who confirmed that the information provided was incorrect according to the facility's policy and procedure, which mandates that residents receive the correct contact details for appealing discharge notices. Additionally, the facility did not notify the Ombudsman in a timely manner regarding the facility-initiated discharge of Resident 1. The Ombudsman was informed three days after the notice was given to the resident, contrary to the facility's policy that requires notification within one day. The Social Service Director (SSD) admitted to the delay during an interview, and the DON confirmed that it was the SSD's responsibility to notify the Ombudsman. The facility's policy clearly outlines the responsibilities of the Social Services in preparing a resident for discharge, including informing relevant parties about the discharge.
Failure to Notify Responsible Party of Room Change
Penalty
Summary
The facility failed to notify the responsible party of a resident prior to a room change, resulting in a violation of the resident's rights. On August 15, 2024, a room change was conducted for two residents, where Resident 1 was moved to a different room to accommodate a request from Resident 2. The Director of Nurses (DON) confirmed that the room swap occurred on this date, but there was no documented evidence that Resident 1's responsible party was informed or consented to the change. During interviews and record reviews, it was revealed that the facility's protocol requires notification and consent from the resident and/or their responsible party before any room changes, with documentation in the clinical record. However, both the Licensed Vocational Nurse (LVN) and Social Service Designee (SSD) were unable to find any documentation indicating that Resident 1's responsible party was notified. The facility's policy and procedure also stipulate that all parties involved in a room change should be given advance notice, and the change should be documented in the resident's medical record, which was not adhered to in this case.
Failure to Schedule Neurology Appointment
Penalty
Summary
The facility failed to ensure that a resident was referred to a neurologist as ordered by the physician, resulting in a delay of care. The resident had a diagnosis of Guillain-Barre syndrome, a condition where the immune system attacks the nerves, and the physician had ordered a neurology consult. The receptionist, responsible for scheduling appointments, stated she attempted to schedule the neurology appointment but could not provide evidence of these attempts. The Director of Nursing confirmed the absence of documentation regarding the scheduling attempts in the resident's medical record. The facility's policy required social services or a designee to coordinate referrals and document them in the medical record, which was not adhered to in this case.
Lack of Full-Time Licensed DON
Penalty
Summary
The facility failed to ensure there was a full-time licensed Director of Nursing (DON), which had the potential to affect the needs of all 94 residents. Interviews and record reviews revealed that the previous DON had not worked at the facility since March 2024. An interim DON, who had completed the Registered Nursing (RN) program but was awaiting a testing date, was currently assigned to the position. However, this interim DON did not possess an RN license. The facility's policy and procedure indicated that the DON should be a licensed RN employed full-time, which was not the case at the time of the survey.
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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 Porterville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sierra View Medical Center | 0.2 mi | — | 1 | 0 |
| River Walk Care Center | 0.6 mi | — | 15 | 0 |
| Sierra Valley Rehab Center | 0.6 mi | — | 0 | 0 |
| Gateway Post Acute | 1.5 mi | — | 0 | 0 |
| Lindsay Gardens Nursing & Rehabilitation | 10.5 mi | — | 21 | 0 |
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