Inspection·April 17, 2025

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. null Based on observation, interview, and record review, the facility failed to implement the care plan (CP) for two of two sampled residents (Resident 6 and Resident 7) on Falling Star Program (fall prevention program) when:1. The call light, the remote control, and water pitcher were not within one of one sampled resident's (Resident 6) reach.2. The bowel and bladder (toileting) program every two hours was not implemented for one of one sampled resident's (Resident 7).These failures had the potential to place Resident 6 and Resident 7 at a greater fall risk. Findings:1. During a concurrent observation and interview on 6/17/25 at 10:10 am, in Resident 6's room with Assistant Director of Nursing (ADON), there was a gold star on Resident 6's name plate by the entry door. Resident 6 was in bed. Resident 6's call light and remote control were on the floor. The water pitcher was on the over bed table out of Resident 6's reach. ADON stated, I seeDuring a concurrent observation and interview on 6/17/25, at 10:25 am, in Resident 6's room with Certified Nursing Assistant (CNA) 4, Resident 6 was in bed. Resident 6's call light and remote control were on the floor. The water pitcher was on the over bed table out of Resident 6's reach. CNA 4 stated, I don't know why the call light and remote control are on the floor. The table needs to be near him [Resident 6] because he needs the water. He [Resident 6] cannot see well.During an interview on 6/17/25, at 11:03 am, with the Director of Nursing (DON), DON stated each station has a Falling Star Program binder with the list of residents' names that had two falls in the last 30 days on the outer cover. DON stated, The updated care plan for each resident is posted in the binder for all the staff to focus on.During a concurrent interview and record review on 6/17/25, at 2:50 pm, with ADON, Resident 6's CP was reviewed, the CP indicated, Focus Falls: Resident [6] had an unwitnessed fall and is at risk for pain, recurring falls. Goal Will be compliant with fall interventions to reduce risk for additional falls. Date initiated: 2/28/2024 Revision on: 02/11/2025 Target Date: 08/17/2025. Will minimize risk for additional falls to the extent possible. Date Initiated: 2/28/2024 Revision on: 02/11/2025 Target Date: 08/17/2025 . Keep call light within reach. Date Initiated: 02/28/2024Keep personal items frequently used within reach. Date initiated: 02/28/2024ADON stated, I know, saw that.2. During a concurrent observation and interview on 6/17/25, at 9:50 am, with DON, in Resident 7's room, there was a gold star on Resident 7's name plate by the entry door. Resident 7 was not in the room. DON stated, [Resident 7] is in the activity room. DON stated, [Resident 7] is on falling star program.During a concurrent observation and interview on 6/17/25, at 3:20 p.m., in Resident 7's room with CNA 5, Resident 7 was not in his bed and stated, [Resident 7] may be in the rest room. CNA 5 stated, [Resident 7] is not on toileting bowel and bladder program every 2 hours.During a concurrent interview and record review on 6/17/25, at 3:56 pm, with ADON, Resident 7's CP was reviewed, the CP indicated Focus Fall: Resident had an unwitnessed fall and is at risk for injury. 5/8/25, Resident 7 had an unwitnessed fall no injury. Goal Will minimize for additional falls to the extent possible date initiated: 04/29/2025 Target date: 07/21/2025. Interventions/Tasks . Bowel and Bladder Q [every] 2H (continued on next page) 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 Page 1 of 5 Event ID: 055551 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055551 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sequoia Transitional Care 350 North Villa Street Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)