Inspection visit
Inspection
17 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 17 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure three of 12 sampled residents
(Resident 97, Resident 34, and Resident 13) were treated with dignity when they had to wait up to two
hours for their call light request to be answered. This failure resulted in residents experiencing discomfort
and feeling upset and the potential for skin breakdown.
Findings:
During a concurrent observation and interview on 2/19/25 at 7:48 a.m. with Resident 97 in Resident 97's
room, Resident 97 was sitting up in bed. Resident 97 stated the longest she's waited for staff to answer her
call light was approximately two hours for someone to help her and she needed her brief to be changed
because she had soiled her brief. Resident 97 stated she needs two people to help her change her brief.
Resident 97 stated, It made me feel like crap.
During a review of Resident 97's admission Record, (AR) dated 3/28/24, the AR indicated Resident 97 had
a diagnosis of Unspecified Sequelae of Cerebral Infarction (Long-term complications from a stroke).
During a review of Resident 97's Minimum Data Set, (MDS - a federally mandated resident assessment
tool) dated 12/19/24, the MDS indicated Resident 97 had a (BIMS - Brief Interview for Mental Status - an
assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the
resident) score of 14 (score of 13-15 means intact cognition). The MDS indicated Resident 97 required the
assistance of two or more helpers with toileting hygiene.
During a review of Resident 97's Care Plan, (CP) dated 12/16/24, the CP indicated, Interventions: Hygiene:
Assist of substantial/maximal [total] assistance to dependent assistance.
During an interview on 2/19/25 9:06 a.m. with Resident 34, Resident 34 stated he uses his call light for help
with toileting and he had to wait more than 15 minutes for a certified nursing assistant to assist him.
Resident 34 stated he felt upset because he had too wait long for someone to assist him.
During a review of Resident 34's AR, dated 5/3/16, the AR indicated Resident 34 had a diagnosis of
Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and
slow, imprecise movements).
During a review of Resident 34's MDS dated [DATE], the MDS indicated Resident 34 had a BIMS score
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 11
Event ID:
555208
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555208
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Gardens Care Center
4525 W. Tulare Ave.
Visalia, CA 93277
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
of 13. The MDS indicated Resident 34 required, Supervision or touching assistance - Helper provides
verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity.
Assistance may be provided throughout the activity or intermittently.
During a review of Resident 34's CP, dated 1/20/25, the CP indicated, Interventions: Toileting: Assist of
supervision or touching assistance.
During an interview on 2/19/25 at 9:08 a.m. with Resident 13, Resident 13 stated she waited more than 15
minutes for her someone to answer her call light because she needed help with changing her brief.
Resident 13 stated she was mad and felt discomfort. She waited more than 15 minutes for someone to
answer her call light.
During a review of Resident 13's AR, dated 12/20/23, the AR indicated Resident 13 had a diagnosis of
Spinal Stenosis, Lumbar Region without Neurogenic Claudication (narrowing of the spinal canal in the
lower back).
During a review of Resident 13's MDS dated [DATE], the MDS indicated Resident 13 had a BIMS score of
15. The MDS indicated Resident 13 required, Partial/moderate assistance - Helper does LESS THAN HALF
the effort. Helper lifts, holds, or supports truck or limbs, but provides less than half the effort.
During a review of Resident 13's CP, dated 2/18/25, the CP indicated, Interventions: Toileting: Assist of
partial/moderate assistance with hygiene and substantial/maximal assistance with transfer.
During a review of the facility's Resident Council Minutes, (RCM) dated 12/10/24, the RCM indicated,
MEETING NOTES - RESIDENT STATED CNAS [CERTIFIED NURSING ASSISTANTS] NOT COMING TO
ROOM WHEN CALL LIGHT IS ON.
During a review of the facility's RCM dated 1/14/25, the RCM indicated, Issue(s) Identified Resident
Council: stating that CNAS [sic] don't have time.
During a review of the facility's RCM dated 2/11/25, the RCM indicated, MEETING NOTES - CNAS GO TO
LUNCH AND OTHER CNAS COVERING THE HALL DON'T WANNA TAKE CARE OF THE OTHER
GROUP TO HELP OUT.
During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated 10/2010,
the P&P indicated, Purpose: The purpose of this procedure is to respond to the resident's requests and
needs .General Guidelines: 8. Answer the resident's call as soon as possible.
During a review of the facility's P&P titled, Dignity, dated 1/2021, the P&P indicated, Policy Statement: Each
resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of
satisfaction with life, and feeling of self-worth and self-esteem .12. Demeaning practices and standards of
care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for
example: b. promptly responding to resident's request for toileting assistance .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555208
If continuation sheet
Page 2 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555208
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Gardens Care Center
4525 W. Tulare Ave.
Visalia, CA 93277
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure call lights were within reach
for two of 64 sampled residents (Resident 42 and Resident 101). This failure had the potential to result in
residents' needs not being met.
Residents Affected - Few
Findings:
During a concurrent observation and interview on 2/18/25 at 10:14 a.m. with Resident 42 in Resident 42's
room, the call light was tied to the right side rail close to the top of the bed. When Resident 42 was asked
how she would call for assistance, Resident 42 tried to reach the call light but could not. Resident 42 stated
she could not reach the call light.
During a concurrent observation and interview on 2/18/25 at 10:15 a.m. with Certified Nursing Assistant
(CNA) 1 in Resident 42's room, Resident 42's call light tied to the right side rail close to the top of the bed.
CNA 1 stated Resident 42 could not reach the call light. CNA stated the call light should be within reach.
During an observation 2/18/25 at 10:19 a.m. in Resident 101's room, Resident 101's call light was attached
to the bed and not within reach.
During an interview on 2/18/25 at 10:24 a.m. with CNA 2, CNA 2 stated the call light should be within reach.
During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated 2010, the
P&P indicated, 5. When the resident is in bed or confined to a chair be sure the call light is within easy
reach of the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555208
If continuation sheet
Page 3 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555208
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Gardens Care Center
4525 W. Tulare Ave.
Visalia, CA 93277
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor 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.
Based on interview and record review, the facility failed to ensure Advance Directives (AD-a legal document
indicating resident preference on end-of-life treatment decisions) were offered and completed for two of 32
sampled residents (Resident 19 and Resident 103). This failure had the potential for residents' healthcare
wishes to not be honored.
Findings:
During a concurrent interview and record review on 2/20/25 at 9:25 a.m. with Nursing Consultant (NC), NC
was unable to provide documentation of an AD for Resident 19. NC stated there is no AD on file or no
documentation of AD being offered or discussed with Resident 19 or Resident 19's responsible party.
During a concurrent interview and record review on 2/24/25 at 11:28 a.m. with Social Services (SS),
Resident 103's Advance Directive (AD), dated 6/06/24 was reviewed. The AD indicated, on 6/06/24
Resident 103 was interested in executing an AD. SS stated Resident 103 had checked that he was
interested in the AD per the paperwork and there was no documentation on file that it was followed up.
During a review of Resident 103's Minimum Data Set (MDS- a resident assessment tool) Brief Interview for
Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and
judgement status of the resident), dated 2/14/25, the MDS indicated, Resident 103's BIMS was 13 [13-15
able to make decisions for self].
During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated September
2022, the P&P indicated, Policy Statement: The resident has the right to formulate an advance directive,
including the right to accept or refuse medical or surgical treatment. Advance directives are honored in
accordance with state law and facility policy. 1b. Advance Directive - a written instruction, such as a living
will or durable power of attorney for health care, recognized by state law (whether statutory or as
recognized by the courts of the state), relating to the provisions of health care when the individual is
incapacitated .Determining Existence of Advance Directive: 1. Prior to or upon admission of a resident, the
social services director or designee inquires of the resident, his/her family members and/or his or her legal
representative, about the existence of any written advance directives. 2. The resident or representative is
provided with written information concerning the right to refuse or accept medical or surgical treatment and
to formulate an advance directive if he or she chooses to do so.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555208
If continuation sheet
Page 4 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555208
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Gardens Care Center
4525 W. Tulare Ave.
Visalia, CA 93277
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor 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.
Based on observation, interview, and record review, the facility failed to ensure a functioning overhead light
was provided for one of eight sampled residents (Resident 37). This failure resulted in Resident 37 to not
have a light available for personal use.
Findings:
During a concurrent observation and interview on 2/18/25 at 9:44 a.m. with Resident 37 in Resident 37's
room, there was a light on the wall above Resident 37's bed, the string to turn on the light was detached.
Resident 37 stated she has been unable to turn on the light and the string had been broken for a couple of
weeks.
During a review of Resident 37's Minimum Data Set [MDS - a federally mandated resident assessment
tool], dated 1/30/25, the MDS indicated Resident 37 had a BIMS (Brief Interview for Mental Status-an
assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the
resident) score of 11 (score of 8-12 means moderate cognitive impairment).
During an interview on 2/18/25 at 9:57 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the string
to turn on the light should be longer for the resident to use.
During an interview on 2/18/25 10:02 a.m. with Maintenance Assistant (MA), MA stated the light should
have had a longer string for the resident to use.
During a review of the facility's Maintenance Log, (ML) dated 2/17/25, the ML indicated, Area of Deficiency:
39A, Description of Deficiency: overhead light switch, Reported By (NAME) LVN (LVN 1), Date Corrected:
2/17/25 (day prior to observation).
During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated December
2009, the P&P indicated, 1. The Maintenance Department is responsible for maintaining the buildings,
grounds, and equipment in a safe and operable manner at all times . 2b. Maintaining the building in good
repair .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555208
If continuation sheet
Page 5 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555208
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Gardens Care Center
4525 W. Tulare Ave.
Visalia, CA 93277
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on observation, interview, and record review, the facility failed to follow one of eight sampled
residents (Resident 103) care plan for smoking. This failure had the potential to result in Resident 103 to
not meet his psychosocial (a person's well-being) needs.
Findings:
During a review of the facility's Smoking Times and Location (STL), (undated), the STL indicated, Smoking
Times are 9:00 a.m. - 9:10 a.m. (CNA St [station] 1), 11:00 a.m. - 11:10 a.m. (CNA St 2), 1:15 p.m. - 1:25
p.m. (CNA St 3), 4:30 p.m. - 4:40 p.m. (CNA St 2), 8:00 p.m. - 8:10 p.m. (CNA St 3). Resident will need to be
by the smoking door ready to go out at smoking times.
During a concurrent observation and interview on 2/19/25 at 10:44 a.m. with Resident 103 in Resident
103's room, Resident 103 was dressed and lying in bed. A wheelchair was parked on the left side of bed.
Resident 103 stated, No one has come to offer to get me ready for a smoke break.
During a concurrent observation and interview on 2/19/25 at 11:07 a.m. with Resident 103 in Resident
103's room, Resident was dressed and still lying in bed. Resident 103 stated, No one has come to offer to
get me ready for a smoke break.
During a review of Resident 103's Minimum Data Set (MDS - a federally mandated resident assessment
tool) Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify
memory, orientation, and judgement status of the resident), dated 2/14/25, the MDS indicated, Resident
103's BIMS is 13 (13-15 able to make decisions for self).
During a concurrent observation and interview on 2/19/25 at 11:13 a.m. with Activities Staff (AS) in the
smoking area, there was one resident in the smoking area. AS stated, It is the CNAs [Certified Nursing
Assistant's] job to get the residents ready and coordinate to get them (residents) here.
During a concurrent observation and interview on 2/19/25 at 11:21 a.m. with CNA 3 outside Resident 103's
room, Resident 103 was waiting in bed for a staff member to assist him to the smoking area. CNA 3 stated,
I have not personally offered the smoking break to the residents in hallway 3.
During a review of Resident 103's Facesheet, (FS) dated June 2024, the FS indicated, Resident 103 was
diagnosed with muscle weakness, abnormalities of gait and mobility [unsteady on feet].
During a review of Resident 103's Care Plan (CP), dated February 2025, the CP indicated, Resident 103's
Activities CP indicated Resident 103 was a smoker and needed to be assisted to and from activity location.
During a review of the facility's policy and procedure (P&P) titled, Smoking Policy - Residents, dated
October 2023, the P&P indicated, 2. Smoking is only permitted in designated resident smoking areas,
which are located outside of the building.
During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated March
2022, the P&P indicated, A comprehensive, person-centered care plan . to meet the resident's physical,
psychosocial and functional needs .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555208
If continuation sheet
Page 6 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555208
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Gardens Care Center
4525 W. Tulare Ave.
Visalia, CA 93277
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure 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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure medications were properly labeled for
one of seven residents (Resident 83) when two of Resident 83's medications were labeled with the wrong
type of insulin and the wrong resident's name. These failures had the potential for Resident 83 to receive
the wrong insulin, another resident's insulin or another resident to receive a medication without a physician
order.
Findings:
During a review of Resident 83's admission Record (AR), dated 2/24/25, the AR indicated Resident 83 was
admitted on [DATE] with diagnoses including diabetes mellitus (inability to control blood sugar levels).
During a review of Resident 83's Order Details (OD), order date 11/21/24, the OD indicated the following
medication order: HumaLOG Kwikpen Subcutaneous [under the skin] Solution Pen-Injector 100 UNIT/ML
(Insulin Lispro) [a fast acting insulin] Inject subcutaneously before meals for DM [Diabetes Mellitus].
During a review of Resident 83's OD, order date 1/9/25, the OD indicated the following medication order:
Insulin NPH (Human) (Isophane) Subcutaneous Suspension 100 UNIT/ML (Insulin NPH (Human )
(Isophane) [an intermediate acting insulin] Inject 18 units subcutaneously at bedtime for DM .
During a concurrent observation and interview on 2/20/25 at 12:05 p.m. with Licensed Vocational Nurse
(LVN) 1, LVN 1 stated she was going to administer Insulin Lispro to Resident 83. LVN 1 removed a plastic
bag from the medication cart with an insulin pen. The plastic bag had a label with Resident 83's name
indicating Insulin NPH. The insulin pen inside the bag had a label indicating Insulin Lispro. LVN 1 stated
Resident 83's insulin was mislabeled and discarded it. LVN 1 obtained a new Insulin Lispro pen for
Resident 83 from the medication room. The plastic bag containing the new Insulin Lispro pen was labeled
with Resident 83's name. The insulin pen inside the bag was labeled with another resident's name. LVN 1
stated this new insulin pen was also mislabeled.
During an interview on 2/24/25 at 11:15 a.m. with the Director of Nursing (DON), the DON stated the labels
on insulin bags and pens should match to prevent residents receiving the wrong type of insulin or another
resident's insulin.
During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage,
(undated), the P&P indicated, Medication Labeling .Labeling of medications and biologicals dispensed by
the pharmacy is consistent with applicable federal and state requirements and currently accepted
pharmaceutical practices .if medication containers have missing, incomplete, improper or incorrect labels,
contact the dispensing pharmacy for instructions regarding returning or destroying these items.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555208
If continuation sheet
Page 7 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555208
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Gardens Care Center
4525 W. Tulare Ave.
Visalia, CA 93277
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Based on observation, interview, and record review, the facility failed to ensure two of eight sampled
residents (Resident 93 and Resident 103) meal consumption percentages were documented accurately.
This failure had the potential to resulted in Resident 93 and Resident 103 to experiencing unplanned weight
loss or weight gain.
Findings:
During a concurrent observation and interview on 2/18/25 at 11:41 a.m. with Resident 93, Resident 93 was
sitting in bed eating her lunch in her room. Resident 93 stated, There has not been anything on the food
menu that has been tasteful. I end up with those chicken nuggets all the time and I am tired of it. I have
never eaten 80% of my meals.
During a review of Resident 93's Minimum Data Set [MDS - a resident assessment tool] Brief Interview for
Mental Status [BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and
judgement status of the resident], dated 12/18/24, the MDS indicated Resident 93's BIMS was 15 [13-15
able to make decisions for self].
During an observation on 2/18/25 at 12:24 p.m. in Resident 93's room, Resident 93 was served lunch with
six chicken nuggets, milk, punch, ½ cup sherbet, and salad with dressing.
During a concurrent observation and interview on 2/18/25 at 12:41 p.m. with Resident 93, Resident 93 was
sitting in her bed in her room with her table pushed away from her body. Resident 93 stated she was done
eating. On Resident 93's plate was five full chicken nuggets, full cup of punch, milk opened but not emptied,
sherbet eaten, and salad with dressing eaten.
During a concurrent interview and record review on 2/19/25 at 2:33 p.m. with Director of Staff Development
(DSD) and Infection Preventionist Consultant (IPC), Resident 93's amount eaten percentage chart dated
2/18/25 was reviewed. The amount eaten percentage chart indicated Resident 93 ate 76-100% of meal.
The DSD and IPC reviewed both pictures of the meals prior to eating and after Resident 93 was finished
with her tray. The DSD and IPC stated she would have documented 25% of meal consumed.
During an observation on 2/18/25 at 12:26 p.m. with Resident 103 in his room, Resident 103's lunch tray
contained meatloaf/ketchup, scalloped potatoes, tossed salad with dressing, bread with butter, pound cake
with chocolate sauce, milk and apple juice.
During an observation on 2/18/25 at 12:45 p.m. with Resident 103 in his room, Resident 103 had eaten the
bread, pound cake, milk and a few bites of meatloaf/ketchup with scalloped potatoes. Resident 103 did not
eat tossed salad with dressing and apple juice.
During a concurrent interview and record review on 2/19/25 at 2:37 p.m. with DSD and IPC, Resident 103's
amount eaten percentage chart dated 2/18/25 was reviewed. The amount eaten percentage chart indicated
Resident 103 ate 76-100% of meal. The DSD and IPC reviewed both pictures of the meals prior to eating
and after Resident 103 was finished with her tray. The DSD and IPC stated she would have documented
25% of meal consumed.
During a review of the facility's Dietary Intake Guide, (DIG) (undated), the DIG indicated, staff
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555208
If continuation sheet
Page 8 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555208
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Gardens Care Center
4525 W. Tulare Ave.
Visalia, CA 93277
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
should accurately record the amount of the total meal consumed.
Level of Harm - Minimal harm
or potential for actual harm
During a review of the facility's policy and procedure (P&P) titled Charting and Documenting, dated July
2017, the P&P indicated, 3. Documentation in the medical record will be objective (not opinionated or
speculative), complete, and accurate.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555208
If continuation sheet
Page 9 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555208
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Gardens Care Center
4525 W. Tulare Ave.
Visalia, CA 93277
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0847
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to ensure its arbitration agreement explicitly
indicated that the resident or his or her representative had the right to rescind the agreement within 30
calendar days of signing the arbitration agreement. This failure had the potential for 92 of 138 residents who
signed arbitration agreements not to understand their right to rescind the arbitration agreement within 30
days.
Residents Affected - Some
Findings:
During a concurrent interview and record review on 2/24/25 at 9:30 a.m. with the Admissions Director (AD),
the facility's list of current residents who signed arbitration agreements was reviewed. A review of the list of
current residents who signed arbitration agreements indicated 92 of 138 residents had signed it. The AD
stated the facility offered arbitration agreement to all its residents.
During a concurrent interview and record review on 2/24/25 at 11:34 a.m. with the Administrator, the
facility's Arbitration Agreement (Agreement) (undated) was reviewed. The Agreement indicated, This
Agreement may be rescinded by written notice within thirty (30) days of signature. The Agreement did not
explicitly indicate that the resident or his or her representative had the right to rescind it within 30 days of
signing it. The Administrator stated the Agreement should explicitly indicate that the resident or his or her
representative had the right to rescind it within 30 days of signing it.
During a review of the facility's policy and procedure (P&P) titled, Binding Arbitration Agreements, dated
November 2023, the P&P indicated, Residents (or representatives) are provided 30 days after signing to
fully review and rescind any agreement not understood at the time of admission.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555208
If continuation sheet
Page 10 of 11
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555208
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Gardens Care Center
4525 W. Tulare Ave.
Visalia, CA 93277
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to document the attendance of Quality Assurance
and Performance Improvement (QAPI) committee meetings during ten of 12 meetings in 2024. This failure
prevented the verification of attendance of the required QAPI committee members (Administrator, Director
of Nursing, Medical Director, and Infection Preventionist).
Residents Affected - Some
Findings:
During a concurrent interview and record review on 2/24/25 at 3:22 p.m. with the Administrator, the facility's
QAPI committee meeting minutes (the minutes) for 2024 were reviewed. The minutes indicated monthly
meetings during 2024 but attendance sheets only for the November 2024 and December 2024 meetings.
There was no documentation of who attended the meetings held from January 2024 to October 2024. The
Administrator stated the facility started documenting the attendance of QAPI committee meetings in
November 2024. The Administrator stated there was no documentation of who attended the meetings from
January 2024 to October 2024.
During a review of the facility's policy and procedure (P&P) titled, Quality Assurance Performance
Improvement Plan, (undated), the P&P indicated, Minutes of all meetings - QAPI Administrator is
responsible for maintaining documentation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555208
If continuation sheet
Page 11 of 11
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Back to topCitations
17 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
- 0521GeneralS&S Epotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor 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.
F584 - Safe Environment
Honor 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.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F761 - Labeling of Drugs and Biologicals
Ensure 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.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F847 - Entering Into Binding Arbitration Agreements
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
FAQ · About this visit
Common questions about this visit
What happened during the February 24, 2025 survey of WESTGATE GARDENS CARE CENTER?
This was a inspection survey of WESTGATE GARDENS CARE CENTER on February 24, 2025. The surveyor cited 17 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WESTGATE GARDENS CARE CENTER on February 24, 2025?
Yes, 17 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have approved installation, maintenance and testing program for fire alarm systems."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.