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Health Inspection Summary
Sequoia Vista
3710 West Tulare Avenue
Visalia, CA 93277
(559) 732-2244

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Deficiency Category
Inspection Date:
12/5/24
Complaint Reporting Period:
3/1/24 - 2/28/25
Inspection Date:
11/9/23
Complaint Reporting Period:
3/1/23 - 2/29/24
Inspection Date:
7/29/21
Complaint Reporting Period:
3/1/22 - 2/28/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies212
Quality of Life and Care Deficiencies293
Infection Control Deficiencies111
Resident Assessment and Care Planning Deficiencies490
Nursing and Physician Services Deficiencies211
Resident Rights Deficiencies845
Nutrition and Dietary Deficiencies534
Pharmacy Service Deficiencies214
Environmental Deficiencies000
Administration Deficiencies100

Detailed result for inspection on 12/5/24
Date of last standard health inspection:12/5/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25
Date(s) of infection control inspection(s) between 3/1/24 - 2/28/25
No infection control inspections
Total number of Health Deficiencies for this nursing home:27
Average number of Health Deficiencies in California:16.4
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Protect each resident from the wrongful use of the resident's belongings or money.

3/4/243/21/24
2 - Minimal harm or potential for actual harm
Few

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

11/18/2412/17/24
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Assist a resident in gaining access to vision and hearing services.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Few

Provide enough food/fluids to maintain a resident's health.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Some
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure services provided by the nursing facility meet professional standards of quality.

5/30/247/26/24
2 - Minimal harm or potential for actual harm
Few

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Some

PASARR screening for Mental disorders or Intellectual Disabilities

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Few

Ensure services provided by the nursing facility meet professional standards of quality.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Observe each nurse aide's job performance and give regular training.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Many
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

8/20/249/20/24
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

11/18/2412/17/24
2 - Minimal harm or potential for actual harm
Few

Ensure that residents are fully informed and understand their health status, care and treatments.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Few

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

7/29/248/31/24
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Few

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Many

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Few

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Many

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Few
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure medication error rates are not 5 percent or greater.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Some

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

12/5/2412/26/24
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

7/17/248/17/24
2 - Minimal harm or potential for actual harm
Few

Detailed result for inspection on 11/9/23
Date of last standard health inspection:11/9/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24
Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24
No infection control inspections
Total number of Health Deficiencies for this nursing home:29
Average number of Health Deficiencies in California:17.2
Average number of Health Deficiencies in the United States:9.4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

10/11/2310/31/23
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

2/21/243/5/24
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate dialysis care/services for a resident who requires such services.

12/28/231/28/24
2 - Minimal harm or potential for actual harm
Few

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Few

Provide appropriate foot care.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Few

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Few

Provide enough food/fluids to maintain a resident's health.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Few

Provide medically-related social services to help each resident achieve the highest possible quality of life.

12/28/231/28/24
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Some
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure services provided by the nursing facility meet professional standards of quality.

10/18/2311/18/23
2 - Minimal harm or potential for actual harm
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Some

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

1/22/242/20/24
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Some

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Some

Assure that each resident’s assessment is updated at least once every 3 months.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Few

PASARR screening for Mental disorders or Intellectual Disabilities

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Some

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

8/1/238/10/23
2 - Minimal harm or potential for actual harm
Few

Plan the resident's discharge to meet the resident's goals and needs.

7/10/237/31/23
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Some
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

3/14/234/14/23
2 - Minimal harm or potential for actual harm
Few

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Some

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

9/22/2310/10/23
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Few

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Few

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Few
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

11/9/2312/9/23
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 7/29/21
Date of last standard health inspection:7/29/21Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23
Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23
No infection control inspections
Total number of Health Deficiencies for this nursing home:20
Average number of Health Deficiencies in California:15.1
Average number of Health Deficiencies in the United States:8.7
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

6/15/227/15/22
3 - Actual harm
Few

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

6/15/227/15/22
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

1/10/231/27/23
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

1/10/231/27/23
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

12/27/221/27/23
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

7/29/218/30/21
2 - Minimal harm or potential for actual harm
Few
Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

7/29/218/30/21
2 - Minimal harm or potential for actual harm
Few
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.

7/29/218/30/21
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

7/29/218/30/21
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

7/29/218/30/21
2 - Minimal harm or potential for actual harm
Some

Reasonably accommodate the needs and preferences of each resident.

7/29/218/30/21
2 - Minimal harm or potential for actual harm
Some

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

6/24/227/30/22
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

7/29/218/30/21
2 - Minimal harm or potential for actual harm
Few

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

7/29/218/30/21
2 - Minimal harm or potential for actual harm
Many

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

7/29/218/30/21
2 - Minimal harm or potential for actual harm
Some

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

7/29/218/30/21
2 - Minimal harm or potential for actual harm
Few
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

2/16/233/16/23
2 - Minimal harm or potential for actual harm
Few

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

7/29/218/30/21
2 - Minimal harm or potential for actual harm
Some

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

7/29/218/30/21
2 - Minimal harm or potential for actual harm
Few

Ensure medication error rates are not 5 percent or greater.

7/29/218/30/21
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Protect each resident from the wrongful use of the resident's belongings or money.

3/4/243/21/24
2 - Minimal harm or potential for actual harm
Few

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

11/18/2412/17/24
2 - Minimal harm or potential for actual harm
Few

Ensure services provided by the nursing facility meet professional standards of quality.

5/30/247/26/24
2 - Minimal harm or potential for actual harm
Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

8/20/249/20/24
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

11/18/2412/17/24
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

7/29/248/31/24
2 - Minimal harm or potential for actual harm
Few

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

7/17/248/17/24
2 - Minimal harm or potential for actual harm
Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

10/11/2310/31/23
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

2/21/243/5/24
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate dialysis care/services for a resident who requires such services.

12/28/231/28/24
2 - Minimal harm or potential for actual harm
Few

Provide medically-related social services to help each resident achieve the highest possible quality of life.

12/28/231/28/24
2 - Minimal harm or potential for actual harm
Few

Ensure services provided by the nursing facility meet professional standards of quality.

10/18/2311/18/23
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

1/22/242/20/24
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

8/1/238/10/23
2 - Minimal harm or potential for actual harm
Few

Plan the resident's discharge to meet the resident's goals and needs.

7/10/237/31/23
2 - Minimal harm or potential for actual harm
Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

3/14/234/14/23
2 - Minimal harm or potential for actual harm
Few

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

9/22/2310/10/23
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

6/15/227/15/22
3 - Actual harm
Few

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

6/15/227/15/22
2 - Minimal harm or potential for actual harm
Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

1/10/231/27/23
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

1/10/231/27/23
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

12/27/221/27/23
2 - Minimal harm or potential for actual harm
Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

6/24/227/30/22
2 - Minimal harm or potential for actual harm
Few

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

2/16/233/16/23
2 - Minimal harm or potential for actual harm
Few
Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.
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