Visalia Post Acute

In the surveyor’s words

From the most serious findings on record at Visalia Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF678Jan 29, 2021

  Based on interview and record review, the facility failed to ensure four of four licensed nurses (Registered Nurse (RN) 1, Licensed Vocational Nurse (LVN) 1, LVN 2 and LVN 3) initiated cardio-pulmonary resuscitation (CPR) for one of 64 sampled residents (Resident 1). This failure resulted in Resident 1 not receiving timely CPR, transfer to an acute care hospital, subsequent death and the potential to result in 63 additional residents with full code status to experience a delay in receiving CPR. This resulted in an immediate jeopardy situation. Findings: During a review of Resident 1's Physician order [REDACTED]. During a review of Resident 1's Progress Notes, dated [DATE], at 10:18 AM, Progress Notes indicated, RN 1 Checked on resident (Resident 1) .no oxygen in place. […]

• Actual harm, isolatedF689May 21, 2026

  Based on observation, interview, and record review, the facility failed to follow its own policy and procedure (P&P) titled, Safety and Supervision of Residents for one of two sampled residents (Resident 1) when Resident 1 was outside the patio area without supervision. This failure resulted in Resident 1 having unwitnessed fall, sustaining a fracture (broken bone) to the right humerus (long bone of the upper arm).FindingsDuring a review of Resident 1's admission Record (AR), dated [DATE], the AR indicated, Resident 1 is [AGE] years old, was admitted on [DATE] with diagnoses of muscle weakness, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), unsteadiness on feet, difficulty in… […]

• Actual harm, isolatedF689Aug 12, 2022

  Based on observation, interview, and record review, the facility failed to ensure IDT (Interdisciplinary Team-group of dedicated healthcare professionals who work together to provide you with the care you need, when you need it) and therapy recommendation for bed bolster (a long thick pillow that is placed under other pillows for positioning, to prevent resident from rolling off the bed) were implemented for one of three sampled residents (Resident 1). This failure resulted in Resident 1 falling and sustaining a second metacarpal neck fracture (fracture of the bones within the palm of the hand). Findings: During a review of Resident 1's Safety Events--Falls/Found on Floor (SEFFOF) note, dated 12/17/21, at 3:30 PM, the SEFFOF indicated, Found on the floor. […]

• Actual harm, isolatedF689Nov 9, 2021

  Based on observation, interview, and record review, the facility failed to provide supervision for one of two sampled residents (Resident 1), with dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), while outside at station 4's patio. This failure resulted in Resident 1 falling from his wheelchair, acquiring a closed head injury (head injury without breaking the skull) and facial trauma (injury). Findings: During an interview on 9/1/21, at 10 AM, with Assistant Director of Nurses (ADON), ADON stated, on 8/31/21, around 8:10 AM, staff told her Resident 1 was found outside at station 4's patio, his wheelchair had tipped over and Resident 1 was on the ground. […]

• No harm, potential for more than minimal, widespreadF585Mar 6, 2026

  Based on interview and record review, the facility failed to ensure an effective grievance process for three of 33 sampled Residents (Residents 122, 66, and 120), when: 1.Resident 122 was not aware of the facility's response to her grievance related to visiting her friend in the facility and expressed she continued to have issues visiting her friend. 2. Resident 66 reported missing clothes to Social Services Assistant (SSA) six months ago and no action was taken.3. Resident 120 requested assistance from SSA regarding scheduling surgery since admission. These failures had the potential to result in violation of resident's right to voice grievances, feel unheard and/or feel unsupported, and the lack of a functional grievance process left residents' concerns unaddressed. […]