Sequoia Vista

In the surveyor’s words

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

• Actual harm, isolatedF760Apr 1, 2026

  Based on interview and record review, the facility failed to follow their policy and procedure for Medication Administration to administer medication at the right dosage and address a medication alert (automated notification feature designed to warn clinicians and staff about specific resident, clinical, or safety concerns) for one of three sampled residents (Resident 1) on methotrexate (medication that treats rheumatoid arthritis [RA - a disease that causes pain, stiffness, and swelling in the joints [the spots in your body where two or more bones meet] by decreasing the activity of your immune system [the body's complex, built-in defense network that works to keep germs and foreign substances out, while destroying any that get inside]). […]

• Actual harm, isolatedF689Dec 18, 2025

  Based on interview and record review, the facility failed to monitor and document whereabouts (the place where someone is) every hour according to the care plan (CP) for one of two sampled residents (Resident 1) when Resident 1 was a known high risk for elopement (occurs when a resident leaves the facility without authorization and/or any necessary supervision). This failure resulted in staff being unaware of Resident 1 leaving the facility unaccompanied, missing for approximately 10 hours, exposing Resident 1 to environmental dangers, experiencing exposure hypothermia (dangerous drop in body temperature), leukocytosis with left shift (higher-than-normal blood count of white blood cells in the blood), and metabolic acidosis (a serious condition where too much acid builds up in the body… […]

• Actual harm, isolatedF600Jun 15, 2022

  Based on observation, interview and record review, the facility failed to ensure staff was not aggressive towards one of three sampled residents (Resident 1), when Licensed Vocational Nurse (LVN) 1 threw a cup with water in it, at Resident 1 hitting him in the chest. This failure resulted in Resident 1 suffering abuse (improper treatment). Findings: During an observation on 3/21/22, at 2:59 PM, in Resident 1's room, Resident 1 was laying in bed asleep. Resident 1 was not interviewable. During a review of the facility's 5 Day Summary report, dated 3/24/21, the report indicated On 3/21/22, it was reported that on 3/20/22 at approximately 1:30 PM [Resident 1], was in the hallway.Charge Nurse [LVN 1], went to pass medication to [Resident 1]. [Resident 1] refused by putting his arm out. […]

• Actual harm, isolatedF689Sep 8, 2021

  Based on interview and record review, the facility failed to ensure the safety of one of nine residents (Resident 1) when staff failed to provide supervision and were unaware Resident 1 had eloped (resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected) from the facility for at least nine hours. This failure resulted in Resident 1 being located a block away from the facility by local law enforcement and transferred to the acute hospital. Findings: During a review of the Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 6/17/21, the SOC 341 indicated, Public Guardian received a call from (Tulare) County Crisis on 6/14 stating that [Resident 1] was in the ER [emergency room ]. […]

• Actual harm, isolatedF921Sep 8, 2021

  Based on observation, interview, and record review, the facility failed to ensure resident safety for nine of nine residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, and Resident 9) that were an elopement risk (resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected), when a door alarm, that led to the smoke area with two unsecured gates that provided access off of facility grounds, was unarmed. […]