Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dinuba Healthcare during CMS and state inspections, most recent first.
A resident who had an unwitnessed fall and was found on the floor bleeding was later identified in the care plan as being at risk for falls related to poor balance, with an intervention for nonskid tape at the bedside. Despite this documented intervention, an observation with the DON showed the resident in bed without nonskid tape at the bedside, and the DON acknowledged it should have been in place. Facility policy states that care plan interventions are specific actions or services to be provided, but the nonskid tape intervention was not implemented.
Advance Directive Questionnaire forms for five residents were missing a required question asking whether they wanted more information on how to execute an advance directive, and the DON confirmed the omission during record review. In addition, one resident’s medical record did not contain a signed and dated ADQ or advance directive, and the DON stated there was no ADQ in the record.
CNAs were observed standing while assisting residents with feeding during lunch, including standing over a resident while feeding and placing pureed food into another resident's mouth while standing. Staff interviews confirmed that CNAs are expected to sit when feeding residents, and the ADON reviewed the facility policy stating residents who cannot feed themselves should be fed with attention to safety, comfort, and dignity, including not standing over them.
A resident on hospice care reported being taken outside by a hospice aide to smoke three times a week and smoking two cigarettes each time. The DON confirmed the resident was the only one in the facility with smoking privileges, but the MDS Section J tobacco use item was marked as no current tobacco use, and the DON stated the MDS was inaccurate.
Failure to provide communication services for a resident with limited English proficiency. A resident who spoke [NAME] and needed an interpreter per the MDS was observed communicating in her native language, but a CNA stated there was no communication board or picture board and she did not speak [NAME]. An LVN was unaware of translation services, the AD said staff used an internet search engine to translate, and the DON stated translation services were not available until Language Scientific began.
A resident with limited mobility after a motorcycle accident stated he had never been asked about activity participation. Record review with the DON showed no activity assessment or activity care plan in the MR, and the AD stated she had not completed either document. The facility policy required residents to be offered choices in activities based on their preferences, condition, and overall plan of care.
A resident on hospice care had smoking privileges and was taken outside by a hospice aide to smoke several times a week, but the facility had no smoking care plan in the resident's chart. The DON also could not find a smoking assessment in the hospice binder during review, and no IDT notes addressing the resident's smoking were found. The resident was observed with tremor-like arm movements, and the DON stated smoking should have been care planned by the facility and addressed in an IDT meeting.
Expired IV E-kit, unsecured narcotics, and unattended medication on cart. An expired IV emergency infusion e-kit was found in a hallway medication cabinet with multiple expired fluids, antibiotics, and syringes. Discontinued narcotics were stored in a single-lock drawer in the DON's office, but the office was later observed open with no one present and the ADON stated there was no second lock. In another observation, an LVN left a Pro Stat bottle on top of the med cart before locking it and walking away.
Two residents' meal trays were found unattended on bedside tables in the rehab dining area, and an RNA stated she was taking the trays to residents in their rooms. When the DM checked one tray, the pureed meat was 120 degrees F, below the facility's minimum acceptable holding temperature of 140 degrees F.
A CNA was observed carrying an oxygen e-tank by the straps of a fabric wheelchair oxygen holder in a hallway instead of using the facility’s metal stand. The CNA stated the facility uses a metal stand to transport oxygen e-tanks, and the SSD noted that two residents in the area were dependent assistance and unable to ambulate without an assistive device. The facility policy stated that a portable oxygen cylinder should be strapped to the stand.
A resident experienced a significant delay in returning from a dialysis appointment due to the facility's failure to arrange timely transportation. The resident waited for nearly five hours, resulting in emotional distress and late medication administration. Interviews and record reviews revealed a lack of communication between the dialysis center and the facility.
The facility failed to provide palatable and appetizing meals, as residents reported food being tough, dry, and lacking flavor. Observations confirmed these issues, with the Dietary Supervisor acknowledging the need for better food preparation practices.
During a meal service, a dietary staff member failed to change gloves or wash hands after handling multiple food items and opening the oven, contrary to facility policy. Interviews with staff and supervisors confirmed the breach in protocol, with expectations for proper hand hygiene not being met.
The facility failed to provide the required SNF ABN Form CMS-10055 to two residents who had not exhausted their Medicare Part A skilled nursing services days. Despite having a policy in place, the facility did not document the provision of this form, and staff were unaware of the requirement. Interviews revealed that staff were familiar with the NOMNC but not the SNF ABN Form CMS-10055, leading to a deficiency in beneficiary notifications.
The facility failed to ensure accurate MDS assessments for two residents with schizophrenia, leading to discrepancies in their records. Both residents had PASRR screenings indicating serious mental illness, but their MDS assessments inaccurately reflected otherwise. Staff interviews revealed a lack of awareness of the residents' diagnoses, and the MDS Coordinator confirmed the inaccuracies.
The facility failed to post daily staffing information in a conspicuous location and did not update the postings to reflect changes due to call-ins. The staffing information was posted in an administrative hallway with limited visibility, and the postings were not updated to reflect actual staffing changes. The Staffing Coordinator was unaware of the need to update postings each shift, and the Administrator acknowledged the limited visibility and need for accurate updates.
Failure to Implement Fall-Prevention Care Plan Intervention
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as being at risk for falls following a fall incident. According to the interdisciplinary team Post Fall Review dated 2/3/26, the resident experienced an unwitnessed fall at approximately 1:47 p.m., was found on the floor bleeding, and was observed lying on her right side in a cradle position. The Post Fall Review documented a recommendation for nonskid tape at the bedside. The resident’s care plan dated 2/4/26 identified her as at risk for falls related to poor balance and included an intervention for nonskid tape at the bedside, initiated on that date. During an observation and interview in the resident’s room on 2/9/26 at 11:43 a.m. with the DON, the resident was seen lying in bed covered with a blanket, and there was no nonskid tape at the bedside as required by the care plan. The DON stated that the nonskid tape should have been placed at the bedside right away. The facility’s policy on developing and implementing care plans with the interdisciplinary team states that interventions are the specific actions or services each discipline will provide to help the resident meet their goals, but the ordered intervention of nonskid tape at the bedside was not implemented for this resident.
Advance Directive Questionnaire Missing Required Information and One Resident Lacked Signed Advance Directive
Penalty
Summary
The facility failed to ensure that the Advance Directive Questionnaire for five sampled residents contained all required regulatory elements. During record review, the questionnaires for Resident 1, Resident 10, Resident 8, Resident 76, and Resident 3 did not include a question asking whether the resident wanted more information on how to execute an advance directive. During concurrent interviews and record review with the DON, each of these residents’ questionnaires was reviewed and the DON stated that the ADQ did not ask if the resident wanted information on how to execute an advance directive. The questionnaires for these residents also indicated that they did not have an advance directive. The facility also failed to ensure that one sampled resident, Resident 13, had a signed and dated Advance Directive in the medical record. During a concurrent interview and record review with the DON, Resident 13’s medical record was reviewed and the DON stated that the resident was admitted on [DATE] and there was no ADQ in the record. The facility policy titled Advance Directives, dated 9/2022, states that prior to or upon admission the social services director or designee inquires about the existence of written advance directives and provides written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive.
Improper Feeding Assistance During Meals
Penalty
Summary
The facility failed to follow its policy and procedure titled, Assistance with Meals, when CNAs stood while assisting three sampled residents with lunch meals. During an interview, CNA 3 stated there were usually two staff members assisting in the dining room, but on the day observed she was the only one assisting. During observation, CNA 3 was standing over Resident 32 while feeding her. On another observation, CNA 4 placed a spoonful of pureed food into Resident 22's mouth while standing over her. During interviews, CNA 5 stated the process for assisting residents with feeding was to get a chair, sit, and sanitize hands between each resident, and CNA 4 stated CNAs are to be sitting when feeding a resident. Review of the facility's policy with the ADON confirmed that residents who cannot feed themselves are to be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals.
Inaccurate MDS Tobacco Use Assessment
Penalty
Summary
The facility failed to ensure the MDS assessment was accurate for one sampled resident, Resident 76, resulting in an inaccurate medical record. During interview, Resident 76 stated that a hospice aide took her outside to smoke three times a week and that she smoked two cigarettes each time she was taken out. The DON stated that Resident 76 was on hospice care and was the only resident in the facility with smoking privileges. During record review, Resident 76's MDS Section J, Health Conditions, question J1300 dated 11/20/25 was reviewed and indicated Current Tobacco Use: No. The DON stated that the tobacco use MDS assessment was inaccurate.
Failure to Provide Communication Services for a Resident with Limited English Proficiency
Penalty
Summary
The facility failed to ensure communication services were available for a resident who did not speak English and preferred [NAME] as documented on the MDS. During a concurrent observation and interview, the resident was speaking in her native language, and a CNA stated the resident speaks [NAME]. The CNA also stated there was no communication board or picture board to understand what the resident was saying and that she did not speak [NAME]. During interviews and record review, an LVN stated she was not aware of any translation services offered by the facility, and an Activities Director stated staff used an internet search engine to translate and that she only knew two words to communicate with the resident. The DON reviewed the Language Scientific dated 1/6/26 and stated it had been started on 1/6/26, with no translation services available before that date. The facility policy stated its language access program would ensure individuals with limited English proficiency had meaningful access to information and services provided by the facility.
Missing Activity Assessment and Care Plan
Penalty
Summary
The facility failed to ensure an activity assessment and activity care plan were completed for one sampled resident, Resident 10. During an interview, Resident 10 stated he had never been asked if he wanted to participate in any activities. He also stated he could not voluntarily move his arms or legs due to a motorcycle accident and could only shrug his shoulders. During record review with the DON, the resident's medical record did not contain an activities assessment or an activities care plan, and the DON stated the Activities Director was responsible for completing them. During a separate interview, the Activities Director stated she had not completed an activities assessment or an activities care plan. The facility policy stated residents shall have the right to choose the types of activities and social events in which they wish to participate, and that the interdisciplinary care team will evaluate the resident's personal history and preferences, medical condition, and prognosis when identifying relevant activities.
Smoking care planning and assessment were missing for a hospice resident
Penalty
Summary
The facility failed to complete a smoking care plan for one resident who had smoking privileges and was on hospice care. During observation, the resident stated that a hospice aide took her outside to smoke three times a week and that she smoked two cigarettes each time. The resident was observed with shaking, tremor-like movements of both arms, and she stated she did not have Parkinson's disease and that her tremors were caused by too much chemotherapy. During interview, the DON stated the facility did not participate in the resident's smoking activities and that smoking was handled through the hospice agency, but the resident's facility care plan did not contain a smoking care plan. The facility also did not have a smoking assessment available to staff in the resident's hospice binder at the time of review. The DON reviewed the binder and found no smoking assessment, then contacted the hospice agency, which stated the completed smoking assessment would be sent to the DON. Later that day, the DON provided a copy of the resident's admission Smoking Assessment dated 10/16/25 and stated it had not been sent to the facility before then. In addition, the DON was unable to find IDT notes addressing the resident's smoking, and stated the resident's smoking should have been care planned by the facility and addressed in an IDT meeting. The facility policy stated that smoking-related privileges, restrictions, and concerns should be noted on the care plan and that all personnel caring for the resident should be alerted to these issues.
Expired IV E-kit, unsecured discontinued narcotics, and unattended medication on cart
Penalty
Summary
The facility failed to ensure safe medication administration when an IV Emergency Infusion Supply (e-kit) stored in a hallway medication cabinet was found expired during a concurrent observation and interview with the ADON. Review of the e-kit showed multiple expired items, including D5W 1000 mL, several NACL solutions in different volumes and concentrations, D5W-1/2 NS with 20 meq potassium, ceftriaxone 1 GM, vancomycin 1 GM, heparin lock 10U/mL 5 mL prefilled, SOD CHL 0.9% 10 mL prefilled syringe, and SOD CHL 0.9% 100 mL. The ADON stated the e-kit was expired, and the pharmacist stated the facility should contact the pharmacy when the e-kit was close to expiring or opened, but the pharmacy had not received any request to replace it. The facility also failed to store discontinued narcotic medications safely and to keep medication secure during administration. During observation and interview with the DON, discontinued narcotics were stored in a single-lock drawer in the DON's office, and the DON stated the office door lock was the second lock. Later, the DON's office door was observed open with no one present, and the ADON stated there was no second lock for narcotics. In a separate observation, an LVN removed a Pro Stat bottle and left it on top of the medication cart before locking the cart and walking into a resident's room; the LVN stated she should not have left the medication unattended and should have placed it inside the locked cart. The facility policy stated medications must be stored in a safe, secure, orderly manner, compartments containing drugs and biologicals must be locked when not in use, and no medications are to be kept on top of the cart.
Meal trays left unattended and food temperature below policy standard
Penalty
Summary
The facility failed to ensure food was served according to its policy and procedure for two sampled residents, Resident 84 and Resident 92. During an observation in the B-Wing hallway rehab dining room, two meal trays were found on bedside tables with no staff or residents present in the rehab dining room, and the tray identification tickets showed the trays belonged to Resident 84 and Resident 92. During a concurrent observation and interview, the RNA stated she had just taken a resident back to their room and that the two trays belonged to residents in their bedrooms and she was going to take them to the residents. At the same time, the DM arrived and checked the temperature of Resident 92's meal tray, finding the pureed meat at 120 degrees Fahrenheit. The facility policy titled Proper Temperatures for All Meals and Services listed minimum acceptable holding temperatures of 140 degrees Fahrenheit for ground beef, pork, and vegetables.
Unsafe Transport of Oxygen E-Tank
Penalty
Summary
The facility failed to ensure that one oxygen e-tank was transported in a safe and secure manner by staff. During an observation on the B-wing hallway, a CNA was seen walking down the hallway carrying an oxygen e-tank by the straps of the fabric wheelchair oxygen e-tank holder. When interviewed at the time of the observation, the CNA stated that the facility has a metal stand used to transport oxygen e-tanks. The SSD stated that both residents present in the hallway were dependent assistance and were unable to ambulate without an assistive device, meaning they could not move without staff assistance in the event of an emergency. The facility policy titled Oxygen Administration stated that a portable oxygen cylinder should be strapped to the stand.
Failure to Arrange Timely Transportation for Dialysis Appointment
Penalty
Summary
The facility failed to arrange timely transportation for a resident to return from a dialysis appointment, resulting in the resident waiting for almost five hours. The resident, who relies on dialysis due to kidney failure, was left at the dialysis center from 5 p.m. until 9:51 p.m. without transportation back to the facility. This delay led to the resident experiencing emotional distress, as evidenced by crying, and resulted in late administration of medication and feeding through a feeding tube. The deficiency was identified through observations, interviews, and record reviews. The facility's Dialysis Transportation Log indicated the resident left for the appointment at 2:30 p.m., but there was no established communication system between the dialysis center and the facility. Interviews with staff, including the Social Services representative, Licensed Vocational Nurses, and the Director of Nursing, revealed a lack of communication and coordination regarding the resident's transportation. The Dialysis Center Supervisor reported multiple unsuccessful attempts to contact the facility, further highlighting the communication breakdown.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature, as required by their policy. This deficiency was identified through observations, interviews, and reviews of records and facility documents. The facility's policy on Food and Nutrition Services, revised in October 2017, mandates that food trays be inspected to ensure meals are correct, palatable, attractive, and served at appropriate temperatures. However, residents consistently reported dissatisfaction with the food quality during Resident Council meetings in May and June 2024, citing issues such as food being too tough, dry, cold, and lacking taste. On July 15, 2024, interviews with three cognitively intact residents revealed complaints about the food quality, specifically mentioning that the meat was tough and the food was generally not good. A test tray observation on July 16, 2024, confirmed these complaints, with the Dietary Supervisor noting that the chicken was dry and the rice lacked flavor. The Dietary Supervisor acknowledged that the cook should have added broth to the chicken to maintain moisture. The facility administrator expressed an expectation for the food's taste and presentation to be acceptable, indicating a disconnect between expectations and the actual food quality provided to residents.
Improper Hand Hygiene by Dietary Staff During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by dietary staff during meal service, as observed on 07/16/2024. A staff member, identified as [NAME] #1, was seen using the same gloved hand to open the oven and then handle food items such as grilled cheese sandwiches, tater tots, chicken breasts, and rolls without changing gloves or washing hands. This practice was contrary to the facility's policy, which mandates that gloves be changed between tasks and that bare hand contact with food is prohibited. The policy also specifies that food and nutrition services staff must wash their hands before serving food to residents. Interviews conducted with the dietary staff, the Dietary Supervisor, the Director of Nursing (DON), and the Administrator confirmed the breach in protocol. [NAME] #1 admitted to not changing gloves after touching multiple items, acknowledging the oversight. The Dietary Supervisor stated that the cook should have requested assistance to open the oven and should have changed gloves after handling the oven and food items. The DON and the Administrator both expressed expectations that dietary staff adhere to proper hand hygiene practices, highlighting the failure to follow established guidelines.
Failure to Provide SNF ABN Form CMS-10055
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN), CMS Form 10055, to residents who had not exhausted their Medicare Part A skilled nursing services days and planned to remain in the facility. This deficiency affected two residents who were reviewed for beneficiary notifications. The facility's policy required that residents be informed in advance when changes would occur to their bills, specifically when Medicare would not cover certain services. However, the facility did not adhere to this policy, as evidenced by the lack of documentation of the SNF ABN Form CMS-10055 in the medical records of the affected residents. Resident #57, who had severe cognitive impairment, was admitted to the facility and had 21 covered Part A skilled services days remaining at the time of the survey. Despite this, there was no evidence in the resident's medical record that a SNF ABN Form CMS-10055 was provided or signed by the resident or their representative. Similarly, Resident #61, also with severe cognitive impairment, had 49 covered Part A skilled services days remaining, yet there was no documentation indicating that the SNF ABN Form CMS-10055 was provided to the resident or their responsible party. Interviews with facility staff, including the Social Service Director, Director of Rehabilitation Services, Director of Nursing, and the Administrator, revealed a lack of awareness and understanding regarding the requirement to issue the SNF ABN Form CMS-10055. Staff members were familiar with providing the Notice of Medicare Non-Coverage (NOMNC) but did not know that the SNF ABN Form CMS-10055 was required for residents who remained in the facility with Part A benefit days remaining. The Administrator acknowledged that the facility had not focused on the SNF ABN Form CMS-10055 and had relied on the NOMNC instead.
Inaccurate MDS Assessments for Residents with Schizophrenia
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, both diagnosed with schizophrenia, leading to discrepancies in their records. Resident #41 was admitted with a medical history of schizophrenia, and their Preadmission and Resident Review (PASRR) Level I Screening indicated a serious mental illness, requiring a Level II evaluation. Despite this, the annual MDS assessment inaccurately reflected that the resident was not considered to have a serious mental illness by the state Level II PASRR process. Similarly, Resident #63, also diagnosed with schizophrenia, had a PASRR Level I Screening that was positive for a serious mental illness, necessitating a Level II evaluation. However, their MDS assessment also inaccurately indicated the absence of a serious mental illness. Interviews with facility staff revealed a lack of awareness regarding the residents' diagnoses. The MDS Coordinator confirmed the inaccuracies in the assessments, acknowledging that Section A1500 should have been coded to reflect the presence of a serious mental illness as determined by the state Level II PASRR process. Both the Director of Nursing and the Administrator expressed expectations for accurate MDS assessments, highlighting a failure in the facility's processes to ensure the accuracy of resident assessments.
Failure to Post and Update Daily Staffing Information
Penalty
Summary
The facility failed to post daily staffing information in a conspicuous location and did not update the postings to reflect changes in staffing due to call-ins. The facility's policy required that nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents, be posted daily in a prominent location. However, the staffing information was posted in an administrative hallway with limited visibility to residents and visitors, and the postings were not updated to reflect actual staffing changes. Observations and interviews revealed that the Staffing Coordinator was responsible for posting the daily staffing numbers but did not update them with changes due to call-ins. The Coordinator stated that she was unaware that the postings needed to be updated each shift and that the numbers posted were just projections. The HR Coordinator confirmed that the daily postings were not updated with call-ins, and the Director of Nursing (DON) acknowledged that the postings were not in a conspicuous area and that the nurses were supposed to update the forms with any changes. The Administrator admitted that the current location of the postings limited visibility to residents, visitors, and families, and agreed that the staffing sheets should be updated with call-ins per shift. The deficiency in posting accurate and updated staffing information had the potential to affect all residents residing in the facility, as the postings were not reflective of the actual staffing levels providing care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dinuba
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palm Village Retirement Comm. | 4.8 mi | ★★★★★ | 1 | 0 |
| Vineyard Care Center | 4.9 mi | ★★★★★ | 2 | 0 |
| Sierra View Homes | 5.3 mi | ★★★★★ | 18 | 0 |
| Kingsburg Center | 9.4 mi | ★★★★★ | 3 | 0 |
| Bethel Lutheran Home | 11.9 mi | ★★★★★ | 19 | 0 |
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