Nursing homeActive
Grand Oaks Care
897 North M Street, Tulare, CA 93274559687134099 certified beds · 93 residentsFor profit - Limited Liability companyMedicare and Medicaid
Surveys on file
17
since 2022
Deficiencies
55
● 0● 55● 0
Penalties · 3 yrs
—
none on file
Last survey
2026-03-12
Complaint
CMS overall
3 / 5
stars as published by CMS
CMS overall 3/5
Health 3
Staffing 2
Quality 4
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · California Department of Public Health · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-03-12 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2026-02-12 | Standard | 060 | CMS-2567 (Care Compare) | — |
| 2025-09-02 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-07-29 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-07-03 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-05-09 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-01-29 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-10-10 | Standard | 0170 | CMS-2567 (Care Compare) | — |
| 2024-06-20 | Complaint | 030 | CMS-2567 (Care Compare) | — |
| 2024-05-07 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-04-23 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-02-13 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-02-07 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2023-12-22 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2023-11-02 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2023-10-10 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2022-10-13 | Standard | 0120 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · California Department of Public Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-31Record 555861-20260312-F658
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-23Record 555861-20260212-F656
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-23Record 555861-20260212-F658
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-23Record 555861-20260212-F698
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-23Record 555861-20260212-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-02-23Record 555861-20260212-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-02-23Record 555861-20260212-F880
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-09-03Record 555861-20250902-F725
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 555861-20250729-F580
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-07-07Record 555861-20250703-F580
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-09Record 555861-20250509-F580
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-02-13Record 555861-20250129-F656
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F558
F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F578
F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F584
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F623
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F658
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F686
F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F688
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F726
F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F745
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F755
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F756
F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F761
F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F805
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F806
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F867
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F880
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-10-24Record 555861-20241010-F921
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555861-20240620-F609
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555861-20240620-F804
F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.Scope/severity EStandard
Records
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-06-21Record 555861-20240620-F837
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 555861-20240507-F580
F919Make sure that a working call system is available in each resident's bathroom and bathing area.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-08Record 555861-20240507-F919
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-04-25Record 555861-20240423-F658
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-02-29Record 555861-20240213-F658
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-02-29Record 555861-20240207-F580
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-02-29Record 555861-20240207-F755
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-22Record 555861-20231222-F655
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-22Record 555861-20231222-F658
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-12-28Record 555861-20231102-F698
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-28Record 555861-20231102-F755
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-30Record 555861-20231010-F689
F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-11-17Record 555861-20221013-F578
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-11-17Record 555861-20221013-F656
F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-11-17Record 555861-20221013-F676
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-11-17Record 555861-20221013-F677
F679Provide activities to meet all resident's needs.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-11-17Record 555861-20221013-F679
F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-11-17Record 555861-20221013-F688
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-11-17Record 555861-20221013-F698
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-11-17Record 555861-20221013-F755
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-11-17Record 555861-20221013-F804
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-11-17Record 555861-20221013-F806
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-11-17Record 555861-20221013-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-11-17Record 555861-20221013-F880
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.34
Facility
California
National
California 0.67 · National 0.69
Total nurse hours per resident day4.25
Facility
California
National
California 4.52 · National 3.86
Weekend total nurse hours3.81
Facility
California
National
California 4.09 · National 3.42
Total nursing staff turnover50%
Facility
California
National
California 37% · National 46%
Registered nurse turnover25%
Facility
California
National
California 38% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | California | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 0.4% | 4.3% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 1.8% | 1.6% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 3.3% | 12.0% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 0.0% | 1.2% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.4% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 8.7% | 10.2% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 5.8% | 4.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 20.4% | 13.7% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Swc Ca Opco 2 LLC Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Chesley, Aaron Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | — | — |
| Chesley, Aaron Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Gamett, James Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Lawrence, Michelle Individual | W-2 MANAGING EMPLOYEE | NOT APPLICABLE | — | — |
Part of a chain
Ajc Healthcare — 14 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or California.
No county cost figures on file for Tulare.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Tulare Healthcare & Wellness Center, LP Tulare | 0.1 mi | 2026-04-16 | 0560 |
| Orchards At Tulare Tulare | 0.1 mi | 2026-06-29 | 0762 |
| Westgate Gardens Care Center Visalia | 6.9 mi | 2026-05-28 | 0281 |
| Sequoia Vista Visalia | 6.9 mi | 2026-06-04 | 0872 |
| Linwood Meadows Care Center Visalia | 7.0 mi | 2025-08-05 | 0390 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |