Visalia Post Acute
VISALIA POST ACUTE in VISALIA, CA — inspection on March 6, 2026.
Found 14 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
During an interview on 3/5/26 at 3:04 PM with Housekeeping Director
stated she recalled Resident 66 reporting multiple times about missing clothes within the last four
grievance log did not indicate Resident 66's complaint about missing clothes.
During an interview on 3/5/26 at 4:09 PM with SSA, SSA stated Resident 66 informed her about six weeks ago regarding missing clothes. SSA stated she provided the belongings inventory to HD and they found the clothes.
SSA stated she should have written down the complaints about Resident 66's missing clothes in the Grievance Log even though the clothes were found. SSA also stated residents do not receive a written record of the result of the investigation of the grievances.
During an interview on 3/5/26 at 4:01 PM with Social Services Director (SSD), SSD stated staff usually notify Social Services Department if there were any grievance reported to them by the residents. SSD reported receiving only three grievances from March 2025 to March 2026.
They log complaints as grievances only when residents label them as such; other complaints are addressed immediately but not recorded in the grievance log.
During a review of the facility policy and procedure (P&P) titled, Grievances/Complaints, Filing dated April 2017, the P&P indicated, Residents . have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances.
The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident. 1.
Any resident . may file a grievance or complaint concerning care, treatment . staff members, theft of property, or any other concerns regarding his or her stay at the facility. 2.
Residents . have the right to voice or file grievances. 3.
All grievances, complaints or recommendations stemming from resident . concerning issues of resident care in the facility will be considered.
Actions on such issues will be responded to in writing, including a rationale for the response. 7.
The administrator has delegated the responsibility of grievance and/or complaint investigation to the grievance officer who is Social Services Department. 8.
Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator withing five (5) working days of receiving the grievance and/or complaint. 3.
During a review of Resident 120's admission Record, from 10/22/24 shows that Resident 120 was first admitted to the facility on [DATE] and then re-admitted on [DATE] with diagnosis including spinal stenosis (narrowing of the spinal canal) of the neck and upper back area.
During a review of Resident 120's Quarterly MDS/CAA: (a comprehensive and mandatory nursing home assessment process utilized to evaluate a resident's functional, medical, and psychosocial status) dated 2/12/26, indicated that the Brief Interview for Mental Status (BIMS: a standardized 15-point screening tool primarily used to assess cognitive function) for Resident 120 was scored at 15.
During an interview on 3/5/26 at 3:38 PM with Resident 120, Resident 120 stated she spoke with Social Services Assistant (SSA) about getting assistance with scheduling neck surgery since she was admitted on [DATE]. Resident 120 also stated the surgery was not something she could schedule herself and asked the assistance from Social Services Department multiple times but gave up asking because social services did not follow through.
055604 03/06/2026
Visalia Post Acute 1925 E.
Houston Ave Visalia, CA 93292
During an interview with Administrator and Assistant Director of Nursing (ADON) 2 on 3/4/2026 at 4:00PM, Administrator stated that she was the Abuse Coordinator.
The Administrator stated resident to resident physical abuse was reported immediately to Ombudsman and the Law Enforcement, but not to the California Department of Public Health (CDPH).
Administrator was unaware of the requirement to report all resident-to-resident abuse to CDPH and confirmed CDPH was not notified of the incident between Resident 153 and Resident 22.
During a record review of Incident: Physical Aggression report, dated 3/2/2026, with Assistant Director or Nursing (ADON) 2, on 3/5/2026 at 9:56AM, the report indicated that Resident 153 had an altercation with another resident. Resident 153 tugged at Resident 22's hair.
The report did not indicate that CDPH was notified of the incident.
During a record review of the facility's policy and procedures titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating revised September 2022, the policy indicated, All reports of resident abuse (including injuries if unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management.
Findings of all investigations are documented and reported.
055604 03/06/2026
Visalia Post Acute 1925 E.
Houston Ave Visalia, CA 93292
resident's discharge goals and needs that must be addressed before the resident can be safely
055604 03/06/2026
Visalia Post Acute 1925 E.
Houston Ave Visalia, CA 93292
During an interview with Licensed Vocational Nurse (LVN) 1 on 3/4/2026 at 12 PM, LVN 1 was asked if she would be checking Resident 111's blood sugar prior to lunch. LVN 1 stated that she had already checked Resident 111's blood sugar at 11:00AM and administered Lispro Insulin to the resident.
During a concurrent observation and interview with the Speech Therapist (ST) in Unit 3 dining room on 3/4/26 at 12:10 PM, Resident 111 was observed beginning to eat his lunch meal with staff assistance. ST stated Resident 111 received his lunch tray and began eating his lunch at 12:05 PM.
During an interview with LVN 1 on 3/4/2026 at 4:30 PM., LVN 1 stated Resident 111's blood sugar was checked at 11 AM and she administered Lispro Insulin at that time. LVN 1 stated the resident's meal tray was served at 12:05 PM LVN 1 stated Lispro Insulin was fast acting, probably 30 minutes after given, and it lowers the blood sugar. LVN 1 stated that she should have waited a little longer to check Resident 111's blood sugar and administer insulin.
During a concurrent interview and record review on 3/5/2026 at 9:37 AM with Assistant Director of Nursing (ADON) 2, Medication Administration Record (MAR) for Insulin Lispro Injection solution was reviewed.
Resident's 111 blood sugar was checked on 3/4/2026 at 11:00 AM by LVN 1, 4 units of insulin Lispro was administered.
ADON 2 stated that Insulin Lispro was fast acting, and Resident 111's blood sugar could drop to low levels after administration. ADON 2 stated that nurse expectations are to give medications in the appropriate time. ADON 2 stated that if meal tray comes late, the doctor should be notified.
During a record review of the Provider Order Summary, dated 12/4/2025, the order summary indicated, Insulin Lispro Injection Solution, inject subcutaneously [under the skin] before meals .
During a review of the Insulin Lispro Manufacturer's Instructions, revised 9/23, the instructions indicated, Administer within 15 minutes before a meal or immediately after a meal.
During a review of the facility's policy and procedure titled, Administering Medications revised date April 2019, indicated medications were administered in accordance with prescriber orders, including any required time frame.
055604 03/06/2026
Visalia Post Acute 1925 E.
Houston Ave Visalia, CA 93292
During a review of facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated October 2022, the P&P indicated, Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after onset and reassessed as indicated until relief is obtained.
055604 03/06/2026
Visalia Post Acute 1925 E.
Houston Ave Visalia, CA 93292
Based on observation, interview, and record review, the facility failed to safely store, and label drugs
was left unlocked and unattended on station 3.Personal food items were stored in one vaccine refrigerator.
This failure had the potential to allow unauthorized access to treatment supplies by residents, staff, or visitors and maintain a controlled and sanitary environment for the storage of vaccines. 1.During an observation on 3/3/26 at 8:35 AM, Station 3's treatment cart was observed across the nurses' station.
The treatment cart was unlocked and unattended.
During a concurrent observation and interview on 3/3/26 at 8:46 AM, with Licensed Vocational Nurse (LVN) 2, the treatment cart remained located across from the nurses' station against the wall and was still unlocked and unattended. LVN 2 acknowledged the treatment cart had been left unlocked and stated the cart should be locked when unattended to prevent unauthorized access.
During a concurrent interview and record review on 3/4/26 at 3:42 PM with the Assistant Director of Nurses (ADON), the facility policy and procedure titled Storage of Medications dated 11/2020 was reviewed.
The policy indicated, the facility stores all drugs and biologicals in a safe, secure, and orderly manner and that compartments, including drawers and carts containing biologicals, must be locked when not in use.
The ADON stated the treatment cart should be locked when unattended to prevent unauthorized access to treatment supplies.
- During an observation on 3/2/26 at 5:50 PM of the infection prevention vaccine refrigerator, there
was one personal food container, one box of soft cheese, and one container of dip stored directly alongside boxes of vaccines.
During an interview with Infection Preventionist (IP) on 3/4/26 at 3:12 PM, IP stated Food should not be stored with vaccines, due to cross contamination.
During a review of the facility policy titled, Medication Storage dated 2019, the policy indicated, Other foods such as employee lunches and activity department refreshments are not stored in this refrigerator.
During a review of the facility policy titled, Storage of Medications revised November 2020, the policy indicated, Medications are stored separately from food and are labeled accordingly.
055604 03/06/2026
Visalia Post Acute 1925 E.
Houston Ave Visalia, CA 93292
During a
stated he was preparing gravy.
During an interview on 3/5/26 at 2:22 PM with the Certified Dietary
mustache not just the beard while preparing food.
During a review of the facility's policy and procedure (P&P) titled, Dress Code, dated 2023, the P&P indicated, Personal hygiene and appropriate dress are a very important part of the total appearance of the Food & Nutrition Services Department .
Proper Dress . beards and mustaches (any facial hair) must wear beard restraint.
055604 03/06/2026
Visalia Post Acute 1925 E.
Houston Ave Visalia, CA 93292
During a concurrent interview and record review on 3/5/26 at 11:09 AM with the Director of Staff Development (DSD), SSD's Employee File was reviewed.
The file indicated SSD has a high school diploma. DSD stated SSD had a performance evaluation completed by the Facility Administrator on 6/2/25.
During a concurrent interview and record review on 3/5/26 at 11:03 AM with the Human Resources Director (HRD), SSD's Position History was reviewed.
The history indicated SSD started the social services director role on 6/6/11. HRD stated that SSD had not held any other positions since then.
During a review of Job Description: Social Services Director, dated February 2024, the job description indicated, Qualification Education and/or Experience Bachelor's Degree in Social Work or in Human Services and 2 years of supervised social work experience . MSW 's (Master's of Social Work) preferred.
During an interview on 3/4/26 at 2:39 PM with Social Services Assistant (SSA), SSA stated she had no degree, just a high school diploma. SSA stated she started as full-time SSA around 2023.
During a concurrent interview and record review on 3/5/26 at 10:56 AM with the DSD, SSA's Employee File was reviewed.
The file indicated SSA had a high school diploma. DSD stated SSA was originally hired at the facility on 3/8/17 for a different position.
During a concurrent interview and record review on 3/5/26 at 11:03 AM with the HRD, SSA's Position History was reviewed.
The history indicated SSA started the social services assistant role on 10/15/23.
During a review of Job Description: Social Services Assistant, dated November 2016, the job description indicated, Qualification Education and/or Experience Bachelor's Degree in Social Work or related major and 1 year of supervised social work experience .
During an interview on 3/4/26 at 2:49 PM with the Facility Administrator, the administrator stated she was aware of the requirements of social services to have a minimum of bachelor's degree in social services or related field.
The administrator stated that neither the SSD nor the SSA had a bachelor's degree.
During a review of Facility Assessment Tool, dated June 2025 through December 2025, the tool indicated, Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies .
Social Services Department - Social Services Director and Assistant (Discharge Planning, Grievances, and Psychosocial needs) .
Education Required for the position .
Social Services Director: The individual must have a bachelor's degree in social work or other related field from an accredited school with experience in SNF's.
055604 03/06/2026
Visalia Post Acute 1925 E.
Houston Ave Visalia, CA 93292
During a concurrent interview and record review on 3/5/26 at 10:56 AM with the DSD, SSA's Employee File was reviewed.
The file indicated SSA had a high school diploma.
DSD stated SSA was originally hired at the facility on 3/8/17 for a different position.
During a concurrent interview and record review on 3/5/26 at 11:03 AM with the Human Resources Director(HRD), SSA's Position History was reviewed.
The history indicated SSA started the social services assistant role on 10/15/23.
During an interview on 3/4/26 at 2:49 PM with the Facility Administrator (Adm), the Adm stated she was aware of the requirements of social services to have a minimum of bachelor's degree in social services or related field.
During a review of Job Description: Social Services Assistant, dated November 2016, the job description indicated, Qualification Education and/or Experience bachelor's degree in social work or related major and 1 year of supervised social work experience .During a record review of the facility document titled Quality Assurance Performance Improvement Plan the plan indicated, .QAPI is integrated into the responsibilities and accountability of all facility leadership.
However, the issue of the SSD and SSA not meeting the regulatory required qualifications had not been identified or addressed through the facility's QAPI program.
During an interview on 03/06/26 at 9:15 AM with the Adm, the Adm was asked whether the issue of the Social Services Director and the Social Services Assistant qualifications had been addressed through the facility's QAPI program.
The Adm confirmed the issue had not previously been addressed.
055604 03/06/2026
Visalia Post Acute 1925 E.
Houston Ave Visalia, CA 93292
corrective plans of action.
Quality Assurance and Performance Improvement (QAPI) program (the facility's program for
consistently identified, documented, tracked, and analyzed through the QAPI process.This failure had the potential to prevent the facility from identifying systemic issues (problems that affect more than one resident or area of the facility), implementing corrective actions, and improving the quality of care and services provided to residents.On 03/04/2026 at 12:00 PM during a reviewed Facility Grievance Log there were only three grievances listed since March 2025.
The log did not indicate what the grievance was about, the actions taken by the facility to investigate, a conclusion, the remedies the facility took to resolve the grievance, nor the date a written response was sent to the resident or representative. On 03/05/26 at 4:00 PM, during an interview with the Grievance Committee consisting of the Administrator (Adm), Social Service Director (SSD) and the Social Services Assistant (SSA), the SSD stated complaints were not the same as grievances and stated, I don't put all complaints on the grievance log.
The SSD stated the facility maintained a theft and loss log to track missing items, but those complaints are not considered grievances.
The SSD further stated complaints, theft, or lost property complaints were not processed as grievances. It's always been like that since I've been here.On 03/06/26 at 9:15 AM, during an interview with the Administrator (Adm), the Adm confirmed that not all complaints were documented on the grievance log.
The Adm acknowledged that complaints and grievances are the same.
The Adm stated, To be quite honest, if they state that they want to file a formal grievance, that's when we actually put it on the grievance log and complete the paperwork for a formal grievance.The Adm further acknowledged that other complaints may or may not be documented.
The Administrator stated, When a resident or family member has a complaint, they don't all get documented.
Some of it gets documented in the resident's chart in the progress notes, but some of it doesn't.The Adm also indicated there was not a consistent process guiding documentation of complaints.
The Adm stated, There's no real guideline as to what gets documented and what doesn't. It kind of depends on how quickly we're able to resolve it.A review of the facility's QAPI Plan dated June 2, 2025, IV.
Feedback, Data System and Monitoring section b, indicated, The following data is monitored through QAPI.v.
Complaints/Grievances.
055604 03/06/2026
Visalia Post Acute 1925 E.
Houston Ave Visalia, CA 93292
The IP further stated housekeeping is responsible for cleaning the filters and licensed nurses are
055604 03/06/2026
Visalia Post Acute 1925 E.
Houston Ave Visalia, CA 93292
single resident rooms.
minimal harm NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide the minimum square footage required by
41-51 did not meet the required minimum square footage of 80 square feet per resident.room [ROOM NUMBER]: 227.2 sq. ft. (3 residents)room [ROOM NUMBER]: 219.2 sq. ft. (3 residents)Rooms 43-51: 234.5 sq. ft. (3 residents)
During an interview on 3/6/26 at 9:15 AM with the Administrator (Adm), the resident room size waiver was discussed.
The Adm acknowledged that rooms 41-51 did not meet regulatory requirements.
During an observation on 3/2/26 at 2:45 PM in room [ROOM NUMBER] bathroom, the call light system was observed with missing pull cord.
During an interview on 3/3/26 at 2:50 PM with Certified Nursing Assistant (CNA) 3, CNA 3 confirmed the call light pull cord was missing.2.
During an observation on 3/2/26 at 3 PM in room [ROOM NUMBER] bathroom, the call light system was observed to be broken with missing call light button.
During an interview on 3/2/26 at 3:05 PM with CNA 4, CNA 4 confirmed the call light was not working and had a missing button.
During an interview on 3/3/26 at 10:30 AM with the Maintenance Director, the Maintenance Director stated he was not notified of the call light issues. He stated staff were supposed to report any maintenance issues by documenting on the maintenance logbook in the nurse's station.
The Maintenance Director confirmed the broken call lights had not been reported on the maintenance logbook.
During a review of the facility's policy and procedure (P&P) titled, Environmental Services Inspection with a revision date of February 2023, the P&P indicated, It is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis.
Policy Explanation and Compliance Guidelines:The Director of Environmental Services will perform random and/or routine inspections.All opportunities will be corrected immediately by environmental services personnel.Each environmental service personnel will be informed of their performance and re-trained on any opportunities as needed.Follow up inspections or spot checks will be conducted as needed to ensure that corrections have been made.
055604 03/06/2026
Visalia Post Acute 1925 E.
Houston Ave Visalia, CA 93292
During an observation on 3/2/26 at 2:20 PM in room [ROOM NUMBER], multiple large scuff marks and visible damage on the walls were observed.
The wall surfaces appeared worn and need of repair.2.
During observation on 3/2/26 at 2:45 PM in room [ROOM NUMBER], the vinyl flooring in the resident bathroom was lifted and separating from the floor surface near the bathroom entryway.
The raised vinyl flooring created an uneven surface.During a concurrent observation and interview on 3/3/26 at 10:30 AM with the Maintenance Director, the Maintenance Director confirmed the condition of the walls and vinyl flooring.
Stated staff were supposed to report any maintenance issues by logging in the maintenance log in the nursing station.
The Maintenance Director confirmed the issues had not been reported for repairs.During a review of the facility's policy and procedure (P&P) titled, Environmental Services Inspection with a revision date of February 2023, the P&P indicated, It is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis.
Policy Explanation and Compliance Guidelines:The Director of Environmental Services will perform random and/or routine inspections.All opportunities will be corrected immediately by environmental services personnel.Each environmental service personnel will be informed of their performance and re-trained on any opportunities as needed.Follow up inspections or spot checks will be conducted as needed to ensure that corrections have been made.
055604 03/06/2026
Visalia Post Acute 1925 E.
Houston Ave Visalia, CA 93292
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.