Tulare Healthcare: Wound Treatment Abandoned - CA
Resident 1 suffered an abrasion to his left shin on August 10 during what facility records described as an "altercation with roommate." The resident told inspectors his roommate "kicked him in the shin with his house shoe on."
The facility's care plan called for cleaning the wound with dermal spray, patting it dry with gauze, applying triple antibiotic ointment, and leaving it open to air. The plan also required staff to "re-evaluate to extend or heal" the abrasion.
Treatment records show staff last monitored or treated the wound during the day shift on August 18. The treatment order expired that same day.
Nobody re-evaluated the wound.
When federal inspectors visited the resident's room on August 20 at 10:47 a.m., they found a scab on his lower shin and a red area on his upper shin. The resident confirmed he wasn't receiving any treatment for his leg.
"There was no treatment being administered to his left shin," the resident told inspectors.
The Licensed Vocational Nurse assigned to his care didn't know about the wound at all. When inspectors interviewed LVN 1 at 11:56 a.m., she admitted being "unaware of Resident 1 having skin issues to his left shin."
The nurse acknowledged the breakdown in care. "When the treatment orders were ending the area should have been re-evaluated and there should have been documentation to extend or heal the area," she told inspectors. She confirmed there was "no ongoing treatment or monitoring to the left shin."
The Director of Nursing couldn't provide any evidence that staff had re-evaluated the wound after the treatment order ended on August 18. During a record review with inspectors on August 20, the DON admitted the abrasion "should have been re-evaluated yesterday and there should have been a progress note made."
Like the nurse, the DON confirmed "there was no ongoing treatment or monitoring to the left shin."
The facility had documented the wound as an in-house acquired skin issue eight days after the original injury. A skin assessment completed August 18 marked the abrasion as "Needs Review" but no review occurred.
Federal inspectors found the care breakdown violated requirements for developing and implementing complete care plans with measurable actions and timetables. The facility's own policy required developing treatment plans "to facilitate healing" of skin conditions.
The inspection report noted the failure to continue wound care had "potential for the abrasion to worsen."
Two days after the treatment order expired, the resident's wound showed signs of incomplete healing. The scab and persistent red area on his shin received no medical attention while staff remained unaware of his condition.
The facility's skin integrity management policy, dated July 31, 2024, specifically required care plans for treating skin conditions. But when the resident's roommate injured him with a house shoe, the system designed to ensure his recovery failed at the most basic level.
The wound from the August 10 altercation remained untreated and unmonitored, leaving the resident to heal on his own while his assigned nurse remained unaware he had been hurt.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tulare Healthcare & Wellness Center, Lp from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
TULARE HEALTHCARE & WELLNESS CENTER, LP in TULARE, CA was cited for violations during a health inspection on August 20, 2025.
The plan also required staff to "re-evaluate to extend or heal" the abrasion.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.