Tulare Healthcare & Wellness Center, Lp
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Based on observation, interview, and record review, the facility failed to implement the care plan for one of three sampled resident's (Resident 1) when Resident 1's abrasion to the left shin treatment order ended and it was not re-evaluated. This resulted in Resident 1 not receiving treatment or monitoring of the abrasion and had the potential for the abrasion to worsen.Findings:During a review of Resident 1's Care Plan dated 8/10/25, the CP indicated, Altercation with roommate on 8/10/25.interventions. Abrasion to left shin. Cleanse with dermal wound spray, pat dry with 4x4 gauze, apply TAO (triple antibiotic ointment), leave open to air.Abrasion to left shin. Re-evaluate to extend or heal.During a review of the Order Summary Report (OSR) dated 8/1/25-8/31/25, the OSR indicated, Abrasion to left shin. Re-evaluate or heal.start date 8/18/25.During a review of the Treatment Administration Record (TAR) dated 8/2025, the TAR indicated, the last time the abrasion was monitored or treated was day shift on 8/18/25.During a review of Resident 1's Skin Issues (SI) dated 8/18/25 (completed 8 days after original date of injury), the SI indicated, Needs Review.left shin.abrasion.in-house acquired.During a concurrent observation and interview on 8/20/25 at 10:47 a.m. with Resident 1, in Resident 1's room, Resident 1's left shin had a scab to the lower shin and a red area to the upper shin. Resident 1 stated the skin issues occurred when Resident 2 kicked him in the shin with his house shoe on. Resident 1 stated there was no treatment being administered to his left shin.
During an interview on 8/20/25 at 11:56 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was assigned to Resident 1. LVN 1 was unaware of Resident 1 having skin issues to his left shin. LVN 1 stated 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. LVN 1 stated there was no ongoing treatment or monitoring to the left shin.During a concurrent interview and record review, on 8/20/25 at 12:04 p.m. with Director of Nursing (DON), Resident 1's clinical record was reviewed. DON stated Resident 1's abrasion order ended on 8/18/25. DON was unable to provide evidence of Resident 1's abrasion being re-evaluated and stated the abrasion should have been re-evaluated yesterday (8/19/25) and there should have been a progress note made. DON stated there was no ongoing treatment or monitoring to the left shin.During a
review of the facility's policy and procedure (P&P) tilted, Skin Integrity Management dated 7/31/24, the P&P indicated, A plan of care will be developed to provide guidelines for the treatment of skin integrity conditions to facilitate healing.
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
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
TULARE HEALTHCARE & WELLNESS CENTER, LP in TULARE, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 TULARE HEALTHCARE & WELLNESS CENTER, LP or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.