Visalia Post Acute
VISALIA POST ACUTE in VISALIA, CA — inspection on September 3, 2025.
Found 3 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
attending physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition.need to alter the resident's medical treatment significantly.A significant change of condition is a major decline or improvement in the resident's status that.will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/03/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Visalia Post Acute
1925 E.
Houston Ave Visalia, CA 93292
SUMMARY STATEMENT OF DEFICIENCIES
Based on interview and record review, the facility failed to reevaluate wounds when the treatment orders were ending for one of three sampled residents (Resident 1).
This failure had the potential to result in worsening of Resident 1's wounds and going untreated.Findings:During a review of Resident 1's Progress Notes (PN) dated 6/25/25 at 4 p.m. the PN indicated, Resident is sitting up in w/c (wheelchair) just arrived from (hospital name) appointment.skin assessment done, noted to have dry blood on the left foot sock, removed sock to left foot 2nd toe left toe noted nail is not intact and 2nd toe is bleeding, left 2nd toe nail was smashed, and nail is off from nail bed, notify MD (doctor of medicine).cleanse with NS (normal saline), pat dry apply bacitracin (antibiotic ointment) very (sic) shift, leave open to air.
Cleanse skin tr=ear (sic) to left lateral (side of the body part) foot, pat dry, apply bacitracin every shift, monitor for infection and worsening shift x14 days, follow up with wound Dr.During a review of Resident 1's Treatment Administration Record (TAR) dated 7/2025, the TAR indicated the last day of treatment and monitoring to the left foot 2nd toe and left lateral foot was 7/6/25 on day shift.
During an interview on 8/14/25 at 1:14 p.m. with Treatment Nurse (TN) 1, TN 1 stated when the treatment order ended on 7/6/25, the wounds should have been reevaluated to see if treatment should continue or be discontinued. TN 1 stated there should be progress notes documented when the reevaluation was completed. TN 1 was unable to provide documentation of the wounds being re-evaluated.
During a concurrent interview and record review, on 9/3/25 at 10:44 a.m. with Director of Nursing (DON), DON stated when treatment orders were ending the wounds being treated were to be reevaluated and a progress note was to be completed indicating whether the wound treatment needed to be continued or if the wound had resolved. DON was unable to provide documentation of the wound being reevaluated.
Policy requested and none provided.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/03/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Visalia Post Acute
1925 E.
Houston Ave Visalia, CA 93292
SUMMARY STATEMENT OF DEFICIENCIES
Based on interview and record review, the facility failed to follow physician orders when there was no referral to the wound care doctor and treatment was not provided to one of three sampled residents (Resident 1) when it was ordered by the podiatrist.
This failure resulted in Resident 1's wound going untreated and had the potential for Resident 1's wound to worsen.
Findings:During a review of Resident 1's Podiatry Evaluation (PE) dated 6/2/25, the PE indicated, Wound of foot.The patient presently has a wound of the lower extremities. A dressing was applied today.
Nursing was notified of the presence of the wound.
Will defer wound management to the wound care MD (Doctor of Medicine). If recommendations for wound care are requested from a podiatry standpoint please reconsult specifically for that reason.wound x1 noted to left dorsal (back part of the body part) forefoot measuring 3x3 cm (centimeters-a unit of measurement).During a concurrent interview and record review, on 9/3/25 at 11:11 a.m. with Treatment Nurse (TN) 1, Resident 1's clinical record was reviewed. TN 1 was unable to provide documentation of Resident 1 being referred to the wound doctor. TN 1 stated when the nurse was made aware of the wound, the nurse should have completed a change of condition and notified the MD. TN 1 stated Resident 1 should have been referred to the wound doctor when the podiatrist ordered it.During a concurrent interview and record review, on 9/3/25 at 10:44 a.m. with Director of Nursing (DON), Resident 1's clinical record was reviewed. DON stated he was unable to provide evidence of Resident 1 being referred to the wound doctor as ordered by the podiatrist.
During a review of the facility's policy and procedure (P&P) titled, Foot Care dated 10/22, the P&P indicated, Residents are provided with foot care and treatment in accordance with professional standards of practice.Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions.
Facility ID: