Map showing the location of GRAND OAKS CARE in TULARE, California
897 NORTH M STREET, TULARE, CA, 93274

Overall Score

CMS Five-Star Quality Rating
2/5Below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • CaliforniaAbove only 16% of peers1,154 rated homes · average 3.2★
  • Tulare CountyAbove only 13% of peers16 rated homes · average 2.9★
  • United StatesAbove only 20% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.8 vs CA avg
  • StaffingCan add or remove a star2★−1.1 vs CA avg
  • Quality measuresCan add or remove a star4★−0.1 vs CA avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersCA avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 8% of peersCA avg3.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above only 24% of peersCA avg4.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff4.20hrsAbove only 47% of peersCA avg4.51Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.36hrsAbove only 25% of peersCA avg0.65Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better45%Above only 27% of peersCA avg38%RN turnover27%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$34,492Above only 23% of peersCA avg$26,970Fines · denials1 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
64citations
19inspection dates
1actual harm (G–I)
0immediate jeopardy (J–L)
Sep 2, 2025most recent

Citations by monthMar 2019 – Sep 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Sep 2, 20251 citationCycle 1worst F · no actual harm
  1. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesF · widespreadCorrected Sep 3, 2025
Jul 29, 20251 citationCycle 1worst D · no actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrection pending
Jul 3, 20251 citationCycle 1worst D · no actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Jul 7, 2025
May 9, 20251 citationCycle 1worst D · no actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected May 9, 2025
Jan 29, 20251 citationCycle 2worst D · no actual harm
  1. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Feb 13, 2025
Oct 10, 202417 citationsCycle 1worst F · no actual harm
  1. 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.Resident RightsE · patternCorrected Oct 24, 2024
  2. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Oct 24, 2024
  3. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Oct 24, 2024
  4. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Oct 24, 2024
  5. 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.Quality of Life and CareE · patternCorrected Oct 24, 2024
  6. 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.Nursing and Physician ServicesE · patternCorrected Oct 24, 2024
  7. F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareE · patternCorrected Oct 24, 2024
  8. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Oct 24, 2024
  9. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceE · patternCorrected Oct 24, 2024
  10. 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.Pharmacy ServiceE · patternCorrected Oct 24, 2024
  11. F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryD · isolatedCorrected Oct 24, 2024
  12. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Oct 24, 2024
  13. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Oct 24, 2024
  14. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Oct 24, 2024
  15. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Oct 24, 2024
  16. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsE · patternCorrected Oct 24, 2024
  17. 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.Resident RightsD · isolatedCorrected Oct 24, 2024
Jun 20, 20243 citationsCycle 2worst E · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 21, 2024
  2. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Jun 21, 2024
  3. 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.AdministrationE · patternCorrected Jun 21, 2024
May 7, 20242 citationsCycle 2worst D · no actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected May 8, 2024
  2. F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected May 8, 2024
Apr 23, 20241 citationCycle 2worst D · no actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Apr 25, 2024
Feb 13, 20241 citationCycle 2worst D · no actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Feb 29, 2024
Feb 7, 20242 citationsCycle 2worst D · no actual harm
  1. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Feb 29, 2024
  2. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Feb 29, 2024
Dec 22, 20232 citationsCycle 3worst D · no actual harm
  1. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Jan 22, 2024
  2. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jan 22, 2024
Nov 2, 20232 citationsCycle 3worst E · no actual harm
  1. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareE · patternCorrected Dec 28, 2023
  2. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Dec 28, 2023
Oct 10, 20231 citationCycle 3worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Oct 30, 2023
May 15, 20231 citationCycle 3worst G · actual harm$34,492
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Jun 22, 2023
Mar 28, 20231 citationCycle 3worst D · no actual harm
  1. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Mar 29, 2023
Feb 23, 20231 citationCycle 3worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Mar 23, 2023
Oct 13, 202212 citationsCycle 2worst F · no actual harm
  1. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Nov 17, 2022
  2. 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.Resident RightsD · isolatedCorrected Nov 17, 2022
  3. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Nov 17, 2022
  4. F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareE · patternCorrected Nov 17, 2022
  5. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Nov 17, 2022
  6. F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Nov 17, 2022
  7. 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.Quality of Life and CareD · isolatedCorrected Nov 17, 2022
  8. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareE · patternCorrected Nov 17, 2022
  9. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Nov 17, 2022
  10. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Nov 17, 2022
  11. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Nov 17, 2022
  12. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Nov 17, 2022
Mar 21, 201913 citationsCycle 3worst E · no actual harm
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Apr 29, 2019
  2. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Apr 29, 2019
  3. F567Honor the resident's right to manage his or her financial affairs.Resident RightsD · isolatedCorrected Apr 29, 2019
  4. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 29, 2019
  5. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected Apr 29, 2019
  6. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 29, 2019
  7. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Apr 29, 2019
  8. 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.Pharmacy ServiceD · isolatedCorrected Apr 29, 2019
  9. F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Nutrition and DietaryE · patternCorrected Apr 29, 2019
  10. F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryD · isolatedCorrected Apr 29, 2019
  11. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryE · patternCorrected Apr 29, 2019
  12. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Apr 29, 2019
  13. F908Keep all essential equipment working safely.EnvironmentalE · patternCorrected Apr 29, 2019

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.20hrsAbove only 47% of peers−0.31 vs CA avg
  • Registered nursesRN hours only0.36hrsAbove only 25% of peers−0.29 vs CA avg
  • Licensed practical nursesLPN hours1.06hrs
  • Nurse aidesCNA hours2.78hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.86hrs
  • California average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better45%Above only 27% of peersCA avg 38%
  • RN turnoverRegistered nurses only27%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy99 certified beds · ~92 residents a day93%Above 59% of peersCA avg 88%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $34,492In fines
  • 1Fine
  • 0Payment denials
  • $26,970CA avg in fines
Above only 23% of peersFewer fines than 23% of rated homes in California

Actions on record

  1. May 15, 2023Civil money penalty$34,492

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Ajc Healthcare14 facilities in the chain2.2★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Swc Ca Opco 2 LLC
Indirect owners (5%+)
  • Ajc Healthcare LLC
  • Jbg Partners LLC
  • Aaron Chesley
  • James Gamett
Corporate officers
  • Aaron Chesley
  • James Gamett
Managing employees
  • Michelle Lawrence

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 555861 · 897 NORTH M STREET, TULARE, CA, 93274.
  • Percentiles compare this facility with every rated nursing home in California and Tulare County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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