The home failed to provide enough nursing staff each day and ensure a licensed nurse was in charge on every shift. Cited September 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 725 — 42 CFR §483.35 — S/S: F
Nursing home report
Twin Oaks Rehabilitation & Nursing Center
Registered name: GRAND OAKS CARE
TULARE, CA · Medicare-certified · 99 beds
In good standing
For-profitChain member
Data as of July 1, 2026
3 of 5 overall
Twin Oaks Rehabilitation & Nursing Center in Tulare has an overall 3-star rating, with solid quality measures (4 stars) but weaker staffing (2 stars) and a 3-star health inspection rating. Reported nurse staffing is 4.25 hours per resident per day, slightly above the federal benchmark of 4.1, and there were no fines in the last 24 months.
Facility ratings
Health inspections
Staffing
4.2484 hrs/resident/day
Quality measures
Last inspection: March 12, 2026Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.2484.
Staffing detail
- Registered nurses
- 0.34
- Licensed practical nurses
- 1.14
- Nurse aides
- 2.77
- Weekend nursing
- 3.81
Hours per resident per day.
Total staff turnover: 50%
Registered nurse turnover: 25%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
0%4.8%Worsening
Residents with a fall causing major injury
2.6%0%Improving
Residents with pressure ulcers (bedsores)
0%0.8%Worsening
Residents with a urinary tract infection
0%0%No change
Residents who lost too much weight
5.5%10.1%Worsening
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
17.5%0%Improving
Residents whose ability to walk got worse
—20.7%—
Long-stay residents on antianxiety or sleep medication
14.8%23.2%Worsening
Short-stay residents newly given an antipsychotic
0%2.1%Worsening
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
23.3%11.2%Improving
Residents with depressive symptoms
24.2%2.6%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—100%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—100%—
Short-stay residents given the pneumonia vaccine
100%100%No change
What the inspectors found
The home failed to have an ongoing quality review group that finds problems and makes corrective plans. Cited October 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 867 — 42 CFR §483.75 — S/S: F
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited October 2022 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited February 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — S/S: E
The nursing home failed to provide services that met professional standards of quality. Cited October 2024 — limited pattern, potential for harm.
View the original federal record
F-Tag 658 — 42 CFR §483.21(b)(3) — S/S: E
Recent history
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 6 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
Operator & ownership
Recent ownership change · May 1, 2022
Now operated by Grand Oaks Care, previously Twin Oaks Rehabilitation & Nursing Center.
- Ownership
- For profit - Limited Liability company
- Chain
- Part of AJC HEALTHCARE · 14 homes · 2.2 stars avg
- Occupancy
- 93.2 residents on an average day (94% of 99 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 17 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.