Dinuba Healthcare

In the surveyor’s words

From the most serious findings on record at Dinuba Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 18, 2023

  Based on observation, interview, and record review, the facility failed to supervise and monitor one of three sampled residents (Resident 1) when Resident 1 was outside of the facility during a hot weather. This failure resulted in Resident 1 eloping (to leave a healthcare facility without permission, authorization, or supervision) and being admitted to the hospital for two days due to heat stroke (a heat-related illness, occurs when the body can no longer control its temperature and the body's temperature rises rapidly). […]

• No harm, potential for more than minimal, widespreadF804Jul 18, 2024

  Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure food was palatable, which affected 3 (Residents #6, #8, and #41) of 3 residents reviewed for food concerns and had the potential to affect all residents receiving meals from the dietary department. Findings included: A facility policy titled, Food and Nutrition Services, revised in 10/2017, reflected, 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it served at a safe and appetizing temperature. […]

• No harm, potential for more than minimal, widespreadF812Jul 18, 2024

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure dietary staff utilized proper hand hygiene during meal service on 07/16/2024, which had the potential to affect all residents receiving meals from the dietary department, aside from the 12 residents with pureed diet orders, as the pureed trays were served by a different staff member. Findings included: A facility policy titled, Food Preparation and Service, revised in 11/2022, revealed the section of the policy titled, General Guidelines specified, 2. Cross-contamination can occur when harmful substances i.e. […]

• No harm, potential for more than minimal, widespreadF812May 12, 2022

  Based on observation, interview, and record review, the facility failed to ensure staff did not use residents' nutrition freezer to store personal food items. This failure had the potential to cause food-borne illness and affect the residents' health. Findings: During a concurrent observation and interview on 5/10/22, at 9:55 AM, with Licensed Vocational Nurse (LVN) 2, at the C wing nurses' station, an unlabeled and undated frozen food bowl was observed in the freezer section of the residents' nutrition refrigerator. LVN 2 stated the frozen food bowl should have been dated and labeled. During an interview on 5/11/22, at 2:16 PM, with Director of Nursing (DON), the findings of a frozen food bowl in the C wing nurses' station freezer were reviewed. […]

• No harm, potential for more than minimal, patternF578Jan 8, 2026

  Based on interview and record review, the facility failed to:Ensure their Advance Directive (legal document that specifies a person's medical care and end of life wishes, should the person become unable to communicate those wishes) questionnaire contained all the necessary regulatory requirements for five of eleven sampled residents (Resident 1, Resident 10, Resident 8, Resident 76, and Resident 3). 2.Ensure one of 22 sampled residents (Resident 13) had a signed and dated Advance Directive. These failures had the potential for residents' rights to formulate an advanced directive and for medical care wishes and/or end of life issues to not be honored.Findings: 1.During a record review on 1/6/26 at 2:26 p.m., Resident 1's Advance Directive Questionnaire (ADQ) was reviewed. […]