Sequoia Transitional Care
SEQUOIA TRANSITIONAL CARE in PORTERVILLE, CA — inspection on January 15, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 98's admission Record, indicated Resident 98 had diagnoses which included Type 2 Diabetes (body's inability to produce enough insulin).During a review of Resident 98's Physician Order (PO), dated 12/5/25, the PO indicated, Insulin Lispro inject as per sliding scale before meals.During medication pass observation and interview on 1/14/26 at 11:24 a.m., LVN 2 administered Lispro 4 units SQ to Resident 98 using an insulin pen. LVN 2 did not prime the insulin pen before administering the insulin to Resident 98. LVN 2 inaccurately described the process of priming the insulin pen.During a concurrent interview and record review on 1/15/26 at 11:32 a.m. with the Director of Nursing (DON) the facility policy and procedure titled, Insulin Pen Administration, dated 2019 was reviewed.
The policy indicated .To provide for the safe and accurate administration of Insulin Pen medications .Before each injection, do a safety test as follows:a.
Turn dose selector to select 2 unitsb.
Hold insulin pen upright, tap the cartridge gently a few times.c.
Press the push-button all the way ind.
The dose selector returns to 0 .The DON stated the insulin pen should be primed before each use to ensure the resident does not receive too much or too little insulin.
055551 01/15/2026
Sequoia Transitional Care 350 North Villa Street Porterville, CA 93257
one of the 30 sampled residents (Resident 57) when:Resident 57's fingernails and toenails were not
was not informed about the resident's change in condition.These failures resulted in substandard quality of care for Resident 57.Findings:During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE], with diagnoses of Parkinsonism (neurological disorder that cause movement problems), muscle weakness and dependence on wheelchair.During a concurrent observation and interview on 1/12/26 at 2:21 p.m., with Resident 57, in Resident 57's room, Resident 57 was lying in bed with his feet exposed. Resident 57 had untrimmed fingernails and toenails. Resident 57's inner area of the right great toe had three scabs (forms over a cut or wound during healing) Resident 57, who was alert and oriented, stated about a week ago when he was transferred from his bed, his left foot nail dug into his right great toe causing a cut. Resident 57 stated licensed nurses did not treat his cut. Resident 57 also stated his nails were too long, and he wished for somebody to cut his nails.During a concurrent observation and interview on 1/14/26 at 10:29 a.m., with Licensed Vocational Nurse (LVN) 5, in Resident 57's room, Resident 57 was lying in bed with his feet exposed. LVN 5 confirmed Resident 57 fingernails and toenails were untrimmed. LVN 5 confirmed Resident 57's inner right great toe had scabs. LVN 5 stated he was unaware of Resident 57's injury of unknow origin prior to the current observation and there was no treatment ordered. LVN 5 stated that Resident 57's untrimmed toenails and movement disorder could have caused the injury of unknown origin. LVN 5 also stated it was the Certified Nurse Assistants (CNA) responsibility to trim fingernails, and toenails should have been trimmed by podiatry services.During a review of Resident 57's physician current orders for 1/2026, the physician orders indicated, Podiatry care for nail treatment as indicated.
During an interview on 1/14/26 at 10:42 a.m., with Social Worker (SW), SW stated the process of scheduling podiatry was for licensed nurses to verbally tell her or place note in her in-box. SW stated that she was not informed by the LVNs that Resident 57 needed podiatry services.
During an interview on 1/15/26 at 11:33 a.m., with the Director of Nursing (DON), the DON stated it was CNAs responsibility to trim resident fingernails and podiatry services trim toenails.
The DON stated while staff were providing care they should do skin assessments.
The DON stated there should have been a change in condition completed and physician notification to monitor and treat Resident 57's right great toe laceration.During a review of the facility policy and procedure titled, Fingernails/Toenails, Care of, dated February 2018.
The policy indicated, .The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming .Proper nail care can aid in the prevention of skin problems around the nail bed .Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .During a review of the facility policy and procedure titled, Podiatry Services undated.
The policy indicated, .to ensure residents receive proper treatment and care .Employees should refer any identified need for foot care to the social worker or designer .During a review of the facility policy and procedure titled, Change in a Resident's Condition or Status, dated February 2021.
The policy indicated, .Our facility notifies the resident .attending physician .where there has been .accident or incident involving the resident .discovery of injuries of an unknown source .
055551 01/15/2026
Sequoia Transitional Care 350 North Villa Street Porterville, CA 93257
During a review of Resident 71's Order Summary Report, (OSR), the OSR, dated 12/5/25, indicated an order since 6/3/25 for morphine 15 mg (milligram-unit of measure) one tab every four (4) hours as needed for moderate to severe pain (level 4-9), hold if respirations less than 12 and/or oxygen saturation less than 90%.During a concurrent interview and record review on 1/15/26 at 10:06 a.m., with the Assistant Director of Nursing (ADON), Resident 71's Medication Administration Record (MAR) indicated Resident 71 received a morphine 15 mg tablet on 12/11/25 at the following times:a. 4 a.m.b. 7:19 a.m. (41 minutes early)ADON stated the second dose should have been administered every four hours as needed, and as a result the second dose of morphine was given too early.During Resident 71's medical record review, ADON confirmed Resident 71 was over sedated when she returned to the facility from her ophthalmology appointment on 12/11/25 at 10:40 a.m. ADON was unable to locate documented evidence to show the licensed nurses monitored Resident 71 for over sedation (a change in condition) starting on 12/11/25, upon her return to the facility. ADON confirmed Resident 71 was repeatedly vomiting green liquid, and she was hard to arouse on 12/12/25 at approximately 3 a.m.
ADON stated the licensed nurses identified a change in Resident 71's condition at that time, and she was transferred to the GACH for evaluation.
During an interview on 1/15/26 at 11:13 a.m., with the Director of Nursing (DON), the DON stated that licensed nurses should have implemented the facility's policies and procedures (P&P) for Administering Pain Medication and Change in a Resident's Condition or Status on 12/11/25 when Resident 71 returned to the facility over sedated from the 12/11/25 at 7:19 a.m. morphine administration.
The DON stated there should have been monitoring to prevent adverse reactions (morphine black box warning) sedation, respiratory depression, coma, and death.
During an interview on 1/15/26 at 11:55 a.m., with Pharmacy Consultant (PC), the PC stated monitoring for morphine adverse effects was a nursing measure.
The PC stated licensed nurses should monitor residents receiving morphine for adverse reactions sedation, respiratory depression, coma, and death.During a review of the facility policy titled Administering Pain Medication, dated 4/2025, the policy indicated .When opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential overdose. a.
Any resident who uses opioids for long-term management of chronic pain is at risk for opioid overdose .Administer pain medication as ordered .During a review of the facility policy titled Change in a Resident's Condition or Status, dated 2/2021, the policy indicated .The nurse will notify the resident's attending physician.when .adverse reaction to medication .The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition .
055551 01/15/2026
Sequoia Transitional Care 350 North Villa Street Porterville, CA 93257
During a concurrent observation and interview on 1/14/26 at 9:26 a.m. with the Director of Nurses (DON), South 1 and North 2 Medication Carts were observed.
The DON opened the removable lid of the pharmaceutical waste container and stated there was a risk for diversion.
The DON validated that both containers contained multiple intact medications.During a review of the facility policy and procedure (P&P) titled, Disposal of Medications and Medication-Related Supplies, dated 2019, the P&P indicated, .Controlled substances are retained in a securely locked area with restricted access until destroyed by Director of Nursing and Consultant Pharmacist.
Controlled medications given to the Director of Nursing for destruction shall be recorded in a perpetual inventory log.non-controlled medications destruction occurs only in the presence of (two) individuals .
055551 01/15/2026
Sequoia Transitional Care 350 North Villa Street Porterville, CA 93257
During a review of the facility's policy and procedure (P&P) titled, Sanitation Section 8, dated 2023, the P&P indicated,16.
Kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures and the hood over stove, which will be cleaned by the maintenance staff.22. Do not use cleaning products or sanitizers in the food preparation or food storage areas in any way that could result in contamination of exposed food items.
This includes spraying or pouring cleaning products near food items during preparation or cooking.
residente. after touching the resident's environmentg. immediately after glove removal
055551 01/15/2026
Sequoia Transitional Care 350 North Villa Street Porterville, CA 93257