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Complaint Investigation

Sequoia Vista

Inspection Date: August 18, 2025
Total Violations 1
Facility ID 055916
Location VISALIA, CA
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Inspection Findings

F-Tag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on interview and record review, the facility failed to follow its policy and procedure for one of three sampled residents (Resident 1) when an alleged misappropriation of resident property was not reported to Department of Public Health, Ombudsman, Adult Protective Services and Law Enforcement Officials within 24 hours. This failure resulted in a delay of the investigation.Findings:During a review of the Theft & Loss Form (TLF) dated 8/10/25, the TLF indicated Date & Time of Report.8/10/25.Description of missing items.money 600 dollars.During a review of Resident 1's Progress Notes (PN) dated 8/10/25 at 2:32 p.m.,

the PN indicated, CNA (Certified Nursing Assistant) approached writer and stated that the resident said she was missing personal belongings. Upon arrival RN (registered nurse) supervisor was in residents' room helping look for belongings. Writer called daughter (daughter name) and notified. Inventory sheet was reviewed. Resident filled out theft and loss form and turned into SS (Social Services). SS aware.During a

review of the Report of Suspected Dependent Adult/Elder Abuse (SOC341) dated 8/18/25 (seven days

after the facility was aware), the SOC341 indicated, Resident report of alleged allegation of missing money.

Resident has BIMS (Brief Interview for Mental Status-used to assess cognitive function) 15/15 (indicating Resident 1 was cognitively intact).During an interview on 8/18/25 at 3:46 p.m. with Social Service Director (SSD), SSD stated when the $600 was reported missing the daughter did not want to call the police. SSD stated the incident should have been reported to the Department of Public Health, Ombudsman, Adult Protective Services and Law Enforcement Officials per facility policy.During an interview on 8/18/25 at 4:12 p.m. with Ombudsman, Ombudsman stated the facility did not report the missing money to their office.During an interview on 8/18/25 at 4:41 p.m. with Administrator, Administrator stated on 8/10/25, Resident 1 had reported she was missing $600, and an investigation was started. Administrator stated the missing $600 was not reported to Department of Public Health, Ombudsman, Adult Protective Services and Law Enforcement Officials because the amount of money missing was not adding up during the investigation. Administrator stated it should have been reported within 24 hours.During a review of the facility policy and procedure (P&P) titled, Theft/Loss Prevention dated 8/2020, the P&P indicated, When an alleged or suspected case of misappropriation of resident property is reported, the Administrator, or designee, notifies the following persons or agencies within twenty-four (24) hours of such incident.Department of Public Health/Aging.Ombudsman.Adult Protective Services.Law Enforcement Official.

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:

📋 Inspection Summary

SEQUOIA VISTA in VISALIA, CA inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

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 VISALIA, 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 SEQUOIA VISTA or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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