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Complaint Investigation

Grand Oaks Care

September 2, 2025 · Tulare, CA · 897 North M Street
Citations 1
CMS Rating 2/5
Beds 99
Provider ID 555861
Healthcare Facility
Grand Oaks Care
Tulare, CA  ·  View full profile →
Inspection Summary

GRAND OAKS CARE in TULARE, CA — inspection on September 2, 2025.

Found 1 citation. 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.

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Inspection Findings

FF0725
Nursing and Physician Services Deficiencies
Potential for More Than Minimal Harm

During a review of LVN 1's work schedule dated 6/29 through [DATE], the work schedule indicated LVN 1 worked on 6/30, 7/5, 7/14, 7/15, 7/16, 7/17, 7/18, 7/21, 7/22, 7/23, 7/24, 7/25,7/29, 7/30, 7/31, 8/1, 8/2, 8/5, 8/6, 8/7, 8/8, and 8/9. LVN 1 worked 22 days with an expired license.

During an interview on [DATE] at 11:53 a.m. with Director of Nurses (DON), DON stated LVN 1's license had expired on [DATE]. DON reviewed LVN 1's work schedule dated 6/29 through [DATE] and confirmed LVN 1 had worked 22 days with an expired license.

DON stated LVN 1 should not have been working without a current license.During a review of the facility's job description titled, Charge Nurse dated 2023, the job description signed by LVN 1 of acknowledgment on [DATE] indicated, Required Qualifications.

Current unrestricted license as a Registered Nurse (RN) or Licensed Practical Nurse [also known as LVN] in practicing state.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TULARE, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GRAND OAKS CARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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