Inspection·September 3, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on observation, interview, and record review, the facility failed to assess, notify the physician and treat a change of condition for one of three sampled residents (Resident 1) when Resident 1's left foot 2nd toe was swollen, had drainage coming from it and dry crusty debris covering the top of the toe and the nail bed. These failures resulted in a delay of care and the potential for Resident 1's foot to worsen. Findings:During a concurrent observation and interview on 8/14/25 at 10:49 a.m. with Resident 1 in Resident 1's room, Resident 1 was lying on bed with her feet exposed. Resident 1's left foot appeared swollen, there were debris between the toes, a circular dried scab/skin on the inside of the foot, and the second toenail bed and top of the toe was covered with a lumpy and bumpy debris (cauliflower in appearance) that was dry, yellow, and crusty in appearance.During a review of Resident 1's Shower/Bed Bath Sheet (SBBS) dated 8/7/25 (7 days prior to the observation), the SBBS indicated, CNA: identify any skin issues.healing scab on left foot (top).Licensed Nurse: Review information and take follow-up action as indicated.Is this a new skin issue or change.Yes.No.(there was no documented response by the licensed nurse) .Follow-up action: (no documented response by licensed nurse) .(signed by LVN 2).During a concurrent observation and interview on 8/14/25 at 11:20 a.m. with Licensed Vocational Nurse (LVN) 1 and Resident 1, in Resident 1's room, LVN 1 donned gloves and began evaluating Resident 1's left foot. LVN 1 stated Resident 1's 2nd toe was swollen, dry, had drainage coming from it and looked infected. LVN 1 began cleaning and removing the debris from Resident 1's left toes. While cleaning the debris from the toes the base of the wound opened at the bottom of the 2nd and 3rd toes and LVN 1 was able to remove the debris that were covering the nail bed and top of the 2nd toe. When the debris were removed from the 2nd toe, the nail bed area was white and soft. The 2nd toe had no nail. LVN 1 stated there were no current treatments being administered to the left foot.During an interview on 8/14/25 at 11:53 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had a history of injuring her left foot during a transfer. CNA 1 stated initially the injury was red and the skin was torn back. CNA 1 stated the 2nd toe had looked like a cauliflower since the initial injury. During a concurrent interview and record review, on 9/3/25 at 12:14 p.m. with LVN 2, LVN 2 stated when there was a skin issue identified on a SBBS and there was no ongoing treatment to the area a change of condition should have been done. LVN 2 stated there was no change of condition done on 8/7/25 when the healing scab on the left foot was identified because there was ongoing treatment to the area. LVN 2 reviewed the clinical record and was unable to provide evidence of any ongoing treatment or monitoring to the left foot on 8/7/25.During an interview on 9/3/25 at 10:44 a.m. with Director of Nursing (DON), DON stated when staff were aware of Resident 1's left foot skin issues there should have been a change of condition completed, the physician should have been notified, and any new orders should have been implemented.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status dated 2/2021, the P&P indicated, The nurse will notify the resident's (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 4 Event ID: 055604 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 055604 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Visalia Post Acute 1925 E. Houston Ave Visalia, CA 93292 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)