Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palm Village Retirement Comm. during CMS and state inspections, most recent first.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A staff member was observed using a regular metal teaspoon instead of a standardized portioning utensil to serve cottage cheese for a resident with specific dietary orders, despite the availability of proper measuring tools and facility policies requiring their use. This resulted in the resident not receiving the ordered portion size as specified in their care plan.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, as identified during the survey.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve complaints.
Three residents had inaccurate MDS assessments, including one whose history of fall and surgery was not documented, and two whose use of restraints or bed alarms was incorrectly coded. Staff interviews and record reviews confirmed these errors, and facility leadership acknowledged the responsibility for ensuring accurate resident assessments.
A resident admitted with multiple diagnoses, including dementia and a recent respiratory issue, was prescribed an antibiotic, but staff did not develop a baseline care plan within 48 hours to address the new medication. Nursing staff and the DON confirmed that a care plan should have been initiated to monitor for side effects and effectiveness, as required by facility policy.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
Multiple residents did not receive care in accordance with professional standards, including failures to assess and document a skin injury, administer oxygen therapy as ordered, and carry out a prescribed medication order. Nursing staff did not complete required assessments or follow physician orders for oxygen and medication administration, as confirmed by staff interviews and record reviews.
Surveyors identified that the facility's medication error rate was 5 percent or greater, indicating a failure to maintain medication administration accuracy within regulatory limits.
Surveyors identified infection control deficiencies when an LVN failed to perform hand hygiene after disposing of a soiled wound dressing, and when two residents' nasal cannulas were not properly stored in designated bags, leaving the equipment exposed to contamination. Staff interviews and facility policies confirmed that these actions did not meet infection prevention standards.
A resident with a Foley catheter had their drainage bag left uncovered and visible to others, despite being cognitively intact and having multiple medical conditions. Staff and the DON confirmed that the catheter bag should have been covered with a dignity bag at all times, in accordance with facility policy to protect resident privacy and dignity.
A resident was admitted with diagnoses of anxiety, dementia, and Alzheimer's disease, and was prescribed psychotropic medications. The facility did not complete a new PASARR Level I screening after the initial assessment from the hospital failed to include the anxiety diagnosis and medication use. Staff interviews confirmed that the PASARR was not reviewed for accuracy upon admission, contrary to facility policy requiring such review for all new admissions.
The facility did not notify the appropriate authorities when a resident with MD or ID services experienced a significant change in condition, as required.
Two residents received pain medications that were not administered according to physician orders or facility protocols. One resident was given an opioid combination medication for moderate or no pain instead of only for severe pain as prescribed, while another was given acetaminophen for pain when it was only ordered for elevated temperature. These actions were confirmed through record review and staff interviews, showing a failure to follow medication administration instructions.
A resident with dementia, psychosis, and osteoporosis, identified as a fall risk and requiring substantial assistance with transfers, did not have a non-skid mat on her wheelchair as required by her care plan. An LPN confirmed during observation and interview that the mat was not in place, despite facility policy and the intervention being documented.
A facility failed to provide a written transfer notice to a resident and their representative when the resident was transferred to the hospital. The facility's policy requires that such notices be given in writing and in a language and manner understood by the resident and their representative. The Social Worker confirmed that the notice was not provided to the resident or their representative, although it was sent to the ombudsman.
A facility failed to provide a written bed hold notice to a resident or their representative when the resident was transferred to the hospital, as required by their policy. The facility's policy mandates written notification of the bed hold provision and state policy at the time of admission and transfer. Interviews revealed that the facility was unaware of the requirement to issue written notices, and had only been providing verbal notices.
The facility did not ensure RN coverage for eight consecutive hours daily, as required by policy. Nursing schedules revealed multiple dates without documented RN coverage, confirmed by the Administrator. Despite efforts to hire RNs and support LPNs transitioning to RNs, the facility struggled to maintain consistent RN staffing.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions constitute a failure to follow proper labeling and storage protocols for medications and biologicals within the facility.
Failure to Use Standardized Portioning Utensils During Food Service
Penalty
Summary
Kitchen staff failed to use appropriate portioning utensils during meal preparation, as observed when a staff member used a regular metal teaspoon instead of a standardized portioning utensil to serve cottage cheese for a resident. The staff member was preparing cottage cheese and strawberry salads to accommodate special requests, and used a small, regular metal spoon to scoop and portion two scoops of cottage cheese into each container. The resident's dietary order specified an exact amount—8 ounces of cottage cheese and fruit for a morning snack—to support stable weight trends. The kitchen had measuring cups, scoops, and spoodles available, and staff interviews confirmed that regular spoons should not be used for portioning food. The resident involved had diagnoses including dementia and hypertension, but was assessed as having no cognitive impairment. Interviews with other kitchen staff, the Registered Dietitian, and the Certified Dietary Manager confirmed that recipes and dietary orders require the use of standardized portioning tools to ensure accurate and consistent meal portions. Facility policies also required the use of standard tools for portion control. The failure to use the correct utensil resulted in the resident not being served the specified portion as ordered.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident complaints in a timely and non-retaliatory manner.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the health and functional status of three residents. For one resident, the MDS assessment did not document a history of fall and surgery, despite the resident being admitted with a hip fracture following a fall and subsequent surgery. The MDS nurse acknowledged that the fall and surgery were not coded in the assessment, and both the Director of Nursing (DON) and the Administrator confirmed that their expectation was for MDS assessments to be completed accurately, with staff responsible for ensuring the accuracy of the information. Another resident's quarterly MDS assessment inaccurately indicated the use of restraints and alarms, although observations and staff interviews confirmed that the resident did not use any restraints or alarms. The MDS nurse and other staff members recognized this as an error, and the DON emphasized the importance of accurate documentation, as it reflects the resident's condition and ensures appropriate care is provided. The facility's job description for the MDS Coordinator and professional references reviewed also highlighted the requirement for assessments to accurately reflect the resident's status in accordance with state and federal guidelines. A third resident's MDS assessment failed to document the use of a bed sensor alarm, even though the alarm was observed in use and was included in the resident's care plan and provider's orders. The MDS nurse confirmed that the assessment did not accurately reflect the resident's current care needs and acknowledged the responsibility to review care plans and provider orders during assessments. The DON reiterated the expectation that the MDS should reflect the resident's current care needs and that assessments should be conducted in a timely and accurate manner.
Failure to Initiate Baseline Care Plan for Antibiotic Therapy
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was prescribed an antibiotic for a respiratory problem. Upon review, it was found that the resident, who had diagnoses including dementia, a history of falls, and hypertension, was admitted and started on an antibiotic regimen for a cough. However, no care plan was created to address the use of the antibiotic, including monitoring for side effects or the effectiveness of the therapy, during the period the medication was administered. Interviews with nursing staff and the Director of Nursing confirmed that it was the responsibility of licensed nurses to initiate a care plan immediately upon starting new medications, and that this was not done in this case. Facility policy and job descriptions reviewed also indicated that baseline care plans should be completed within 48 hours to address immediate health and safety concerns. The absence of a care plan for the antibiotic was acknowledged by staff and leadership during the survey.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on the absence of a comprehensive approach to care planning, as required, and was observed through review of the resident's records and care documentation.
Failure to Meet Professional Standards in Assessment, Documentation, and Adherence to Physician Orders
Penalty
Summary
The facility failed to meet professional standards of quality for five residents due to multiple deficiencies in assessment, documentation, and adherence to physician orders. For one resident with a history of femur fracture, muscle weakness, and severe cognitive impairment, the licensed nurse did not accurately assess or document a change in skin condition, specifically a deep tissue injury, during the weekly assessment. Interviews with nursing staff confirmed that the required comprehensive skin assessment was not completed, and the injury was not documented as per facility policy and professional standards. Another deficiency involved residents with orders for oxygen therapy. One resident with diagnoses including congestive heart failure and acute respiratory failure did not receive oxygen therapy as ordered by the physician. Observations revealed the absence of an oxygen concentrator and nasal cannula, and staff confirmed that the resident was not receiving oxygen despite an active order. Similarly, two other residents received oxygen at incorrect flow rates, with one receiving a higher flow than ordered and another not receiving oxygen as prescribed. Staff interviews and record reviews confirmed that oxygen, considered a medication, was not administered in accordance with provider orders, contrary to facility policy and professional standards. Additionally, a resident with heart failure and Alzheimer's disease did not receive a prescribed medication (Trazodone hydrochloride) as ordered by hospice. The order was filed in the resident's chart but was not carried out, and the required notifications and documentation were not completed. Staff interviews confirmed that the process for verifying and implementing medication orders was not followed, resulting in the resident not receiving the intended medication. These deficiencies were corroborated by facility policies, job descriptions, and professional references reviewed during the survey.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on the surveyors' findings that the facility did not maintain medication error rates below the regulatory threshold.
Infection Control Failures in Hand Hygiene and Oxygen Equipment Storage
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices involving two residents. In one instance, a Licensed Vocational Nurse (LVN) was seen exiting a resident's room after performing a wound dressing change, carrying the soiled dressing in her bare hands. The LVN disposed of the dressing in a trash can outside the room and then moved the wound cart without performing hand hygiene. Interviews with the LVN, Director of Nursing (DON), Director of Staff Development (DSD), and Infection Preventionist (IP) confirmed that this action did not follow facility policy or infection control protocols, as hand hygiene should have been performed after handling soiled dressings to prevent cross contamination. Additionally, the same resident did not have a storage bag available for their nasal cannula (NC) in the room. Observations and interviews with the DON, DSD, and IP confirmed that a storage bag should have been present and used to store the NC when not in use, as per facility policy and manufacturer recommendations. The absence of a storage bag meant the NC could have been exposed to unclean surfaces, increasing the risk of contamination. A separate observation found another resident's oxygen NC tubing lying unbagged on a bedside table next to used tissues and a trash can. Staff interviews confirmed that the NC should have been stored in a designated bag when not in use, and that the tubing is changed weekly and should be labeled. The IP and DON both validated that the observed practice did not align with facility policy, and that the NC was at risk of contamination due to improper storage. Facility policies and professional references reviewed by surveyors supported the expectation for proper storage and handling of respiratory equipment to prevent infection.
Failure to Maintain Resident Dignity by Not Covering Catheter Bag
Penalty
Summary
A deficiency occurred when a resident's urinary catheter drainage bag was left uncovered and visible to other residents and visitors, contrary to facility policy and expectations. The resident, who was cognitively intact and had diagnoses including Parkinson's disease, diabetes mellitus, obstructive and reflux uropathy, and malignant neoplasm of the prostate, had a physician's order for a Foley catheter to gravity drainage. During an observation, the catheter bag was not covered by a dignity bag as required. Staff interviews confirmed that the catheter bag should have been covered at all times to maintain the resident's dignity and privacy. Both a Licensed Vocational Nurse and the Director of Nursing acknowledged that the lack of a dignity bag violated the resident's right to privacy and dignity, as outlined in the facility's policy. The facility's policy specifically states that staff must help residents keep urinary catheter bags covered to promote dignity and respect.
Failure to Complete Accurate PASARR Assessment for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a new Preadmission Screening and Resident Review (PASARR) Level I screening for a resident when the initial PASARR, completed prior to admission in a general acute care hospital, did not include the resident's diagnosis of anxiety or the use of psychotropic medications. Upon admission, the resident's records indicated diagnoses of anxiety, dementia, and Alzheimer's disease, and the resident was prescribed medications such as lorazepam and quetiapine fumarate. Despite these findings, the PASARR Level I assessment was not updated or reviewed for accuracy by the Admission Coordinator/Minimum Data Set Nurse (AC/MDSN), who acknowledged responsibility for ensuring accurate PASARR assessments for new admissions. Interviews with facility staff, including the AC/MDSN and the Director of Nursing (DON), confirmed that the PASARR assessment was not reviewed for accuracy upon admission, and a new assessment was not completed despite discrepancies in the resident's diagnoses and medication use. Facility policy requires a PASARR Level I screening for each resident upon admission and mandates review for accuracy, especially when there are significant changes in a resident's physical or mental condition. The failure to complete an accurate PASARR assessment had the potential to impact the resident's receipt of appropriate services related to their mental health diagnosis and medication regimen.
Failure to Notify Authorities of Significant Change for MD/ID Residents
Penalty
Summary
The facility failed to notify the appropriate authorities when residents receiving services for mental disorders (MD) or intellectual disabilities (ID) experienced a significant change in condition. This deficiency was identified based on the observation that required notifications were not made as mandated when such changes occurred for these residents.
Failure to Administer Pain Medications According to Physician Orders and Protocols
Penalty
Summary
Two residents experienced deficiencies related to the administration of medications that were not in accordance with physician orders and facility protocols. One resident, who was cognitively intact and had a history of chronic back pain and related diagnoses, was prescribed acetaminophen-codeine to be administered for severe pain. However, nursing staff administered this medication 21 times over several days for pain levels documented as 0-6 out of 10, which corresponded to no pain, mild, or moderate pain, rather than severe pain as specified in the order. The medication administration records and interviews with nursing staff, the pharmacy consultant, and the Director of Nursing confirmed that the medication was repeatedly given outside the prescribed parameters, and the pain scale was not properly used to guide administration. Another resident, who had a history of a recent fall and was described as alert but confused, was administered acetaminophen for complaints of pain and headache. The physician's order for this medication specified it was to be given only for temperatures above 101 degrees Fahrenheit, not for pain. Despite this, nursing staff administered the medication for pain on at least two occasions. Both the pharmacy consultant and the Director of Nursing confirmed that the medication was not administered according to the physician's order, and that staff should have contacted the physician for an appropriate pain management order instead of using the medication off-label. Facility policies and procedures reviewed during the investigation emphasized the importance of assessing pain accurately, following medication administration instructions, and adhering strictly to prescriber orders. The failures identified in both cases were confirmed through interviews, record reviews, and direct observation, demonstrating that staff did not follow established protocols or physician instructions in the administration of pain medications for these residents.
Failure to Provide Non-Skid Mat as Fall Prevention Intervention
Penalty
Summary
A deficiency was identified when a resident with dementia, psychosis, and osteoporosis, who required substantial assistance with transfers and was assessed as a fall risk, did not have a non-skid mat on her wheelchair as specified in her care plan. The care plan, dated 4/5/23, included an intervention to provide a non-skid mat under the wheelchair seat cushion to reduce the risk of falls, but during observation and record review, it was found that this intervention was not implemented. A Licensed Vocational Nurse confirmed during an interview and observation that the non-skid mat, which was available in the facility, was not present under the resident's wheelchair seat cushion as required. The facility's policy on fall precautions states that assistive devices and equipment should be used appropriately to maximize resident safety, but this was not followed in the resident's case.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written transfer notice to a resident, identified as R118, and their representative when the resident was transferred to the hospital. This deficiency was identified during a review of the facility's policy on transfer and discharge notices, which mandates that residents and their representatives be notified in writing and in a language and manner they understand before a transfer or discharge occurs. The review of R118's electronic medical record revealed that the resident was transferred to the hospital on 05/09/24, but there was no evidence of a signed transfer notice by R118 or their representative. During an interview, the Social Worker confirmed that the facility did not provide the written notice of transfer/discharge to R118 or their representative at the time of the transfer. Although the facility generated the form and sent it to the ombudsman, the residents and their representatives were not given the written notice, which is a requirement according to the facility's policy.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident, identified as R118, or their representative when the resident was transferred to the hospital. According to the facility's policy titled Bed-Hold Notification, dated January 2017, residents or their representatives should be informed in writing of their right to exercise the bed hold provision and the state bed-hold policy of seven days. This policy mandates that written information be provided at the time of admission and transfer to a general acute care hospital or for therapeutic leave. However, a review of R118's electronic medical record revealed no documented evidence that such a notice was provided at the time of transfer. Interviews conducted during the investigation revealed that the Admission Director confirmed the facility's failure to provide the bed hold notices to R118 upon transfer to the hospital. The Admission Director also admitted that the facility was unaware of the requirement to issue bed hold notices upon a resident's transfer to the hospital. Furthermore, the Administrator stated that it was their expectation for bed holds to be done upon admission and upon a resident's transfer or discharge from the facility. However, the Administrator confirmed that the facility had only been providing verbal notices, not written ones, as required by their policy.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours within a 24-hour period, seven days a week, as required by their policy. This deficiency was identified through interviews, record reviews, and a review of the facility's policy titled 'Departmental Supervision, Nursing,' which was revised in August 2022. The policy mandates that an RN provides services for at least eight consecutive hours every 24 hours, seven days a week. However, the facility's nursing schedules from December 24, 2023, to August 2, 2024, showed no documented evidence of RN coverage for the specified hours on multiple dates. During an interview, the Administrator confirmed the lack of RN coverage on the listed dates and mentioned that the facility was actively searching for RNs to hire. Additionally, the Administrator noted that although the facility supported several LPNs in transitioning to RNs, they did not remain with the company.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 324 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Reedley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vineyard Care Center | 0.8 mi | ★★★★★ | 2 | 0 |
| Sierra View Homes | 1.2 mi | ★★★★★ | 18 | 0 |
| Dinuba Healthcare | 4.8 mi | ★★★★★ | 17 | 0 |
| Kingsburg Center | 7.2 mi | ★★★★★ | 3 | 0 |
| Bethel Lutheran Home | 8.4 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.