The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited May 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
GRAND OAKS CARE
TULARE, CA · Medicare-certified · 99 beds
In good standing
For-profitChain member
2 of 5 overall
GRAND OAKS CARE (TULARE, CA) has an overall rating of 2 out of 5 stars. Its health inspection and staffing ratings are both 2 stars, quality measures are 4 stars, reported nurse staffing is 4.10 hours per resident per day, matching the federal benchmark of 4.1, and there were no fines in the last 24 months.
Facility ratings
Health inspections
Staffing
4.1045 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 4.1045.
Staffing detail
- Registered nurses
- 0.39
- Licensed practical nurses
- 1.02
- Nurse aides
- 2.70
- Weekend nursing
- 3.76
Hours per resident per day.
Total staff turnover: 50%
Registered nurse turnover: 30%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
3.1%Improving
Residents with a fall causing major injury
2.2%Worsening
Residents with pressure ulcers (bedsores)
0.2%Worsening
Residents with a urinary tract infection
0%Steady
Residents who lost too much weight
4.4%Improving
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
11.1%Improving
Residents whose ability to walk got worse
16%Steady
Show all measures
Long-stay residents on antianxiety or sleep medication
18.6%Worsening
Short-stay residents newly given an antipsychotic
0.4%Worsening
Residents with a long-term catheter
0%Steady
Residents with new or worsening incontinence
18.9%Improving
Residents with depressive symptoms
7.3%Improving
Long-stay residents given the seasonal flu vaccine
100%Steady
Long-stay residents given the pneumonia vaccine
100%Steady
Short-stay residents given the seasonal flu vaccine
100%Steady
Short-stay residents given the pneumonia vaccine
99.7%Improving
What the inspectors found
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
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.
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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
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
- Ownership
- For profit - Limited Liability company
- Chain
- Part of AJC HEALTHCARE · 14 homes · 2.3 stars avg
- Occupancy
- 92.6 residents on an average day (94% of 99 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 16 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.