Kaweah Health Skilled Nursing Center

In the surveyor’s words

From the most serious findings on record at Kaweah Health Skilled Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF695Jul 10, 2023

  Based on observation, interview, and record review, the facility failed to provide continuous mechanical ventilation (a form of life support system; a machine that helps keep the lungs working by pushing air in and out of the lungs via tracheostomy [an opening created at the front of the neck so a tube can be inserted into the windpipe]) as ordered by the physician for one of 13 sampled residents (Resident 1). Resident 1 was without oxygen assistance for more than two hours. This failure resulted in Resident 1 going into respiratory distress (difficulty breathing), requiring Cardiopulmonary resuscitation (CPR -an emergency lifesaving procedure performed when the heart stops beating), and transferred to the acute hospital. […]

• No harm, potential for more than minimal, widespreadF812Mar 21, 2024

  Based on observation, interview, and record review the facility failed to ensure: 1. Potentially hazardous food (food capable of supporting microbial growth) was documented on the cool down log. 2. Expired food was removed from the freezer in kitchen 2. 3. Frozen food storage was dated in kitchen 2. 4. The ice machine in kitchen was sanitized in accordance with manufacturer's guidelines. These failures had the potential to result in the spread of foodborne illnesses. Findings: 1. During a concurrent observation and interview on [DATE] at 9:54 a.m. with Certified Dietary Manager (CDM) 1, in Kitchen 2, a large container of cooked pasta was located in the walk-in refrigerator. […]

• No harm, potential for more than minimal, patternF559Dec 3, 2025

  Based on interview and record review, the facility failed to ensure three of three sampled residents (Resident 1, Resident 2, and Resident 3) or their legal representative were provided prior notification of receiving a new roommate. This failure resulted in a violation of residents' rights.Findings:During a review of the Summary of Complaint (SC) dated 12/1/25, the SC indicated, A few weeks ago [Resident 2] was placed on comfort care. We [anonymous complainant] were told she would be moved to a private room as she passed. After being moved to a room by herself a few days later without telling family the facility accepted a new admit into the same room. […]

• No harm, potential for more than minimal, patternF880Mar 20, 2025

  Based on observation, interview, and record review, the facility failed to follow infection control standards of practice when: 1. The vinyl cover on two of four linen carts in the hallway were damaged exposing the clean linen. 2. The Infection Preventionist Nurse (IPN) did not ensure infection control surveillance was being done on a regular basis. 3. A Wound Treatment Nurse (WTN) did not change gloves or wear gown in good repair during a wound care treatment for one of one sampled resident (Resident 5). 4. An used urinal was on a bedside table for one of one sampled resident (Resident 291). 5. […]

• No harm, potential for more than minimal, patternF563Jun 9, 2022

  Based on observation, interview, and record review, the facility failed to ensure 24-hour visitation rights of family members for for two residents (Resident 145 and Resident 41) were recognized and respected when posted visiting hours were limited from 10 AM to 4 PM. This failure violated the rights of Resident 145 and Resident 41, and any other resident wishing to have a visitor of their choosing, at any time of the day or night. Findings: During an interview on 6/6/22, at 10:01 AM, with Resident 145, Resident 145 stated visiting hours are only 1 PM to 5 PM. Resident 145 stated he is concerned because his wife has been unable to visit him during his physical therapy sessions. Resident 145 stated his wife wants to observe his therapy to prepare to care for him at home after discharge. […]