Facility WatchInspection records for every certified US nursing home
Grand Oaks Care
897 North M Street Tulare, CA 93274 (559) 687-1340
CCN
555861
Certified beds
99
Ownership
For profit - Limited Liability company
Chain
AJC Healthcare
Nurse staffing
3.38
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.32 hours per resident per day
Nursing staff turnover: 50% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected March 12, 2026
1 citation · from a complaint investigation · Health
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected March 31, 2026
Inspected February 12, 2026
6 citations · Health
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected February 23, 2026
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected February 23, 2026
D
F0698No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected February 23, 2026
D
F0761No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected February 23, 2026
D
F0812No actual harm with potential for more than minimal harm · Isolated
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected February 23, 2026
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected February 23, 2026
Inspected September 2, 2025
1 citation · from a complaint investigation · Health
F
F0725No actual harm with potential for more than minimal harm · Widespread
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Deficient, Provider has date of correction · corrected September 3, 2025
Inspected July 29, 2025
1 citation · from a complaint investigation · Health
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Past Non-Compliance
Inspected July 3, 2025
1 citation · from a complaint investigation · Health
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected July 7, 2025
Inspected May 9, 2025
1 citation · from a complaint investigation · Health
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected May 9, 2025
Inspected January 29, 2025
1 citation · from a complaint investigation · Health
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected February 13, 2025
Inspected October 10, 2024
17 citations · Health
D
F0584No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected October 24, 2024
D
F0623No actual harm with potential for more than minimal harm · Isolated
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Deficient, Provider has date of correction · corrected October 24, 2024
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected October 24, 2024
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected October 24, 2024
D
F0805No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Deficient, Provider has date of correction · corrected October 24, 2024
D
F0806No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Deficient, Provider has date of correction · corrected October 24, 2024
E
F0558No actual harm with potential for more than minimal harm · Pattern
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected October 24, 2024
E
F0578No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected October 24, 2024
E
F0658No actual harm with potential for more than minimal harm · Pattern
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected October 24, 2024
E
F0688No actual harm with potential for more than minimal harm · Pattern
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Deficient, Provider has date of correction · corrected October 24, 2024
E
F0726No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected October 24, 2024
E
F0745No actual harm with potential for more than minimal harm · Pattern
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Deficient, Provider has date of correction · corrected October 24, 2024
E
F0756No actual harm with potential for more than minimal harm · Pattern
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected October 24, 2024
E
F0761No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected October 24, 2024
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected October 24, 2024
E
F0921No actual harm with potential for more than minimal harm · Pattern
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected October 24, 2024
F
F0867No actual harm with potential for more than minimal harm · Widespread
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Deficient, Provider has date of correction · corrected October 24, 2024
Inspected June 20, 2024
3 citations · from a complaint investigation · Health
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected June 21, 2024
E
F0804No actual harm with potential for more than minimal harm · Pattern
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected June 21, 2024
E
F0837No actual harm with potential for more than minimal harm · Pattern
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Deficient, Provider has date of correction · corrected June 21, 2024
Inspected May 7, 2024
2 citations · from a complaint investigation · Health
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected May 8, 2024
D
F0919No actual harm with potential for more than minimal harm · Isolated
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected May 8, 2024
Inspected April 23, 2024
1 citation · from a complaint investigation · Health
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected April 25, 2024
Inspected February 13, 2024
1 citation · from a complaint investigation · Health
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected February 29, 2024
Inspected February 7, 2024
2 citations · from a complaint investigation · Health
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected February 29, 2024
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected February 29, 2024
Inspected December 22, 2023
2 citations · from a complaint investigation · Health
D
F0655No actual harm with potential for more than minimal harm · Isolated
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Deficient, Provider has date of correction · corrected January 22, 2024
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected January 22, 2024
Inspected November 2, 2023
2 citations · from a complaint investigation · Health
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected December 28, 2023
E
F0698No actual harm with potential for more than minimal harm · Pattern
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected December 28, 2023
Inspected October 10, 2023
1 citation · from a complaint investigation · Health
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected October 30, 2023
Inspected October 13, 2022
12 citations · Health
D
F0578No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected November 17, 2022
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected November 17, 2022
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected November 17, 2022
D
F0688No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Deficient, Provider has date of correction · corrected November 17, 2022
D
F0806No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Deficient, Provider has date of correction · corrected November 17, 2022
E
F0676No actual harm with potential for more than minimal harm · Pattern
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Deficient, Provider has date of correction · corrected November 17, 2022
E
F0679No actual harm with potential for more than minimal harm · Pattern
Provide activities to meet all resident's needs.
Deficient, Provider has date of correction · corrected November 17, 2022
E
F0698No actual harm with potential for more than minimal harm · Pattern
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected November 17, 2022
E
F0755No actual harm with potential for more than minimal harm · Pattern
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected November 17, 2022
E
F0804No actual harm with potential for more than minimal harm · Pattern
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Deficient, Provider has date of correction · corrected November 17, 2022
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected November 17, 2022
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected November 17, 2022
Ownership transfers
Effective
Seller
Buyer
05/01/2022
Twin Oaks Rehabilitation & Nursing
Grand Oaks Care LLC
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.