Inspection·June 24, 2025

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Based on observation, interview, and record, review the facility failed to:Provide an advance written notice of a new roommate assignment for one of six sampled residents (Resident 2).Monitor compatibility (being a good match, getting along well) for one of six sampled residents (Resident 2) when Resident 3 was moved into Resident 2's room.These failures resulted in a resident-to-resident altercation between Resident 2 and Resident 3, Resident 2 unable to sleep and violation in Resident 2's rights.Findings:During a concurrent observation and interview on 6/24/25 at 12:29 p.m. with Resident 2, Resident 2 was in his room lying in bed. Resident 2 stated he was not given notification prior to Resident 3 moving into his room on 6/10/25.During an interview on 6/24/25 at 1:47 p.m. with Social Service Assistant (SSA), SSA stated on 6/10/25 Resident 3 was moved to Resident 2's room. SSA reviewed Resident 2's clinical record and was unable to find documented evidence that a notice of a new roommate was provided to Resident 2.During an interview on 6/24/25 at 2:30 p.m. with Director of Nurses (DON) and Assistant Director of Nurses (ADON), ADON stated Resident 3 was moved into Resident 2's room on 6/10/25. ADON Resident 2's clinical record and was unable to find documented evidence that a notice of a new roommate was provided to Resident 2.2. During a concurrent observation and interview on 6/24/25 at 12:29 p.m. with Resident 2, Resident 2 was in his room lying in bed. Resident 2 stated on 6/10/25, Resident 3 was moved into his room. Resident 2 stated Resident 3 made constant outburst, continuous yelling throughout day and night preventing Resident 2 from sleeping. Resident 2 stated on 6/15/25 Resident 3 kept making loud noises and would not stop. Resident 2 stated he threw his hat at Resident 3 to make him stop making loud noises. Resident 2 stated he told several staff members he was unable to sleep due to Resident 3 making loud noises. Resident 3 stated nothing was done.During a concurrent observation and interview on 6/24/25 at 12:36 p.m. with Certified Nursing Assistant (CNA 3), CNA 3 was observed feeding Resident 3 in his room. CNA 3 stated Resident 3 was confused and would have outburst continuous yelling. CNA 3 stated Resident 2 was calm, like watching television, and taking naps. CNA 3 stated Resident 2 and Resident 3 were not compatible being roommates.During an interview on 6/24/25 at 12:50 p.m. with Licensed Vocational Nurse (LVN 1) LVN 1 stated on 6/10/25 Resident 3 was moved into Resident 2's room. LVN 1 stated it was the facility practice to monitor for 72 hours to ensure both roommates were compatible with each other. LVN 1 reviewed the clinical records for Resident 2 and was unable to find documented evidence Resident 2 was monitored for 72 hours for having a new roommate. During an interview on 6/24/25 at 12:57 p.m. with LVN 2, LVN 2 stated Resident 2 doesn't like noise, doesn't like to hear yelling, and kept to himself. LVN 2 stated Resident 3 randomly yells and spits. LVN 2 stated Resident 2 and Resident 3 were not compatible being roommates.During an interview on 6/24/25 at 2:30 p.m. with ADON, ADON stated Resident 3 was moved into Resident 2's room on 6/10/25. ADON stated it was the facility practice to monitor both roommates for 72 hours to make sure both residents are getting along, no emotional distress. ADON reviewed Resident 2's clinical records. ADON stated Resident 2 was not (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: 055916 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 055916 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sequoia Vista 3710 West Tulare Avenue Visalia, CA 93277 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)