Inspection citations
12’22
5’23
26’24
5’25
7’26
55 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Mar 12, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Feb 12, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Feb 12, 2026 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Feb 12, 2026 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Feb 12, 2026 | D · potential | 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. | Routine |
| Feb 12, 2026 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Feb 12, 2026 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Sep 2, 2025 | F · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Complaint |
| Jul 29, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Jul 3, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| May 9, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Jan 29, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Oct 10, 2024 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Oct 10, 2024 | E · potential | 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. | Routine |
| Oct 10, 2024 | D · potential | 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. | Routine |
| Oct 10, 2024 | D · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Routine |
| Oct 10, 2024 | E · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Oct 10, 2024 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Oct 10, 2024 | E · potential | 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. | Routine |
| Oct 10, 2024 | E · potential | 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. | Routine |
| Oct 10, 2024 | E · potential | Provide medically-related social services to help each resident achieve the highest possible quality of life. | Routine |
| Oct 10, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Oct 10, 2024 | E · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Oct 10, 2024 | E · potential | 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. | Routine |
| Oct 10, 2024 | D · potential | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Routine |
| Oct 10, 2024 | D · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Oct 10, 2024 | F · potential | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Routine |
| Oct 10, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Oct 10, 2024 | E · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
| Jun 20, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Jun 20, 2024 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Complaint |
| Jun 20, 2024 | E · potential | 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. | Complaint |
| May 7, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| May 7, 2024 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Complaint |
| Apr 23, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Feb 13, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Feb 7, 2024 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Feb 7, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Dec 22, 2023 | D · potential | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Complaint |
| Dec 22, 2023 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Nov 2, 2023 | E · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Complaint |
| Nov 2, 2023 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Oct 10, 2023 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Oct 13, 2022 | D · potential | 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. | Routine |
| Oct 13, 2022 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Oct 13, 2022 | E · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Oct 13, 2022 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Oct 13, 2022 | E · potential | Provide activities to meet all resident's needs. | Routine |
| Oct 13, 2022 | D · potential | 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. | Routine |
| Oct 13, 2022 | E · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Oct 13, 2022 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Oct 13, 2022 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Oct 13, 2022 | D · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Oct 13, 2022 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Oct 13, 2022 | E · potential | Provide and implement an infection prevention and control program. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Grand Oaks Care
897 North M Street, Tulare, CA 93274 · (559) 687-1340
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555861
- Certified beds
- 99
- Legal owner
- Grand Oaks Care LLC
- Part of
- Ajc Healthcare
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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Other nursing homes in Tulare
- Tulare Healthcare & Wellness Center, LP2 of 5 stars overall
- Orchards at Tulare2 of 5 stars overall