Health inspection·November 14, 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:1. notify the responsible party (RP) when one of three sampled residents (Resident 1) was involved in a resident-to-resident altercation.2. assess, treat, monitor and notify the physician and the responsible party (RP) when one of three sampled residents (Resident 1) had a cut under his left eye, bruising on his left cheek and scabs to the left side of his nose and under his left eyebrow.These failures resulted in the physician and the RP being unaware of the wounds and the RP being unaware of the resident-to-resident altercation. Findings:During an interview on 11/14/25 at 8:59 a.m. with Family Member (FM/RP) 1, FM 1 stated when she was visiting Resident 1 on 11/12/25, and noted Resident 1 had a black eye and she was not made aware of the black eye or the resident-to-resident altercation Resident 1 was involved in.During a review of Resident 1's S (situation) B (background) A (appearance) R (Review and Notify) (SBAR-used to notify the physician of a change of condition) dated 11/11/25, the SBAR indicated, Resident to resident abuse.primary care clinician notified.yes.RP notified 11/11/25.9:10 p.m.During a review of Resident 1's Progress Notes (PN) dated 11/12/25, the PN indicated, RP of (Resident 1's room number) approached writer asking what had happen to residents face. Writer explained that I noticed a reden [sic] area on nose. Writer explained that there was an incident on another shift. RP asked why she was not contacted, at this point writer call ADON (Assistant Director of Nursing) and SS (Social Services).During a review of the facility's 5-day report (DR) dated 11/18/25, the DR indicated, CNA (certified nursing assistant) staff informed social services and Administrator that resident A (Resident 3) pushed Resident B (Resident 1) when he got too close to him causing resident B to stumble back.During an interview on 11/20/25 at 11:11 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was assigned to Resident 1 on 11/11/25 at the time of the resident-to-resident altercation. LVN 1 stated she documented on the Change of Condition form that the RP was notified but she was not the one that notified the RP. LVN 1 stated the Director of Nursing (DON) was supposed to notify the RP of the incident.During an interview on 11/14/25 at 2:19 p.m. with ADON, ADON stated the wife spoke with her the next day after the resident-to-resident altercation and was unaware of the incident. ADON stated the RP was upset that she was not notified. ADON stated when she talked to LVN 1 regarding notifying the RP of the resident-to-resident altercation LVN 1 told her she documented it but could not remember if she spoke with the RP.2. During an interview on 11/14/25 at 1:46 p.m. with CNA 1, CNA 1 stated she had taken care of Resident 1 for two consecutive days, and Resident 1 had a cut under his left eye, bruising on his left cheek and scabs to the left side of his nose and under his left eyebrow for the two days she had cared for him. CNA 1 stated she did not know what caused the injuries to Resident 1.During a concurrent observation and interview on 11/14/25 at 2:14 p.m. with Administrator, in Resident 1's room, Resident 1 was sitting on the bed and had a cut under his left eye, bruising on his left cheek and scabs to the left side of his nose and under his left eyebrow. Administrator stated he was not aware Resident 1 (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 2 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 11/14/2025 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)