Sequoia Vista
Inspection Findings
F-Tag F0585
F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Based on observation, interview, and record review the facility failed to follow its own policy and procedure (P&P) titled, Resident and Family Grievances, when no investigation was done for one of six sampled residents' (Resident 1) grievance. This failure resulted in no resolution in Resident 1's grievance and violation of Resident 1's rights.Findings:During an interview on 12/1/25 at 2:16 p.m. with Director of Staff Development (DSD), DSD stated on 11/15/25 Resident 1's Responsible Party (RP) had filed a grievance regarding Resident 1 not being provided with a personal bag and a sack lunch when transported to dialysis center (outpatient clinic that provide life-sustaining treatment) and bandage on Resident 1's dialysis port site (surgical access point) was not removed after returning from dialysis center. DSD stated Director of Nurses (DON) was made aware of the grievance. DSD stated, I did tell DON about it, and she said she was going to follow up on it.During a review of the facility report titled Concern/Grievance Log dated 11/15/25 indicated unhappy w/ [with] nursing staff. Responsible for investigation DON (Director of Nurses).During an
interview on 12/1/25 at 2:47 p.m. with DON, DON stated she was made aware of the grievance made by Resident 1's RP. DON stated no follow-up was done and no investigation was completed. DON stated Resident 1's grievance should have been investigated.During a review of the facility's policy and procedure (P&P) titled, Resident and Family Grievances, dated 2025, the P&P indicated, d. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility.
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:
SEQUOIA VISTA in VISALIA, 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 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.