Health inspection·April 7, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was evaluated to self-administer medication when lidocaine (medication used to relieve pain) was left at the bedside. This failure resulted in Resident 1 having medication at bedside and the potential to self-administer medication incorrectly. Findings: During a concurrent observation and interview on 4/7/25 at 11:10 a.m. with Resident 1 in Resident 1's room, Resident 1 was holding a washcloth up to her mouth and appeared in pain. There was a medication cup with a clear gel looking substance on Resident 1's over bed table. Resident 1 stated she had a bad tooth, and was provided the lidocaine in the medication cup from the nurse so she could use it when she was in pain. During a concurrent observation and interview on 4/7/25 at 11:18 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, LVN 1 stated the medication cup that was on Resident 1's over bed table contained lidocaine. LVN 1 stated when a resident was to self-administer medication an evaluation was completed to make sure the resident was safe to administer the medication and understands the physician order. LVN 1 stated if the resident was deemed safe to self-administer medication, they will have the physician's orders at bedside and a lock box to keep the medication in. LVN 1 stated Resident 1 was not evaluated to self-administer medications. During an interview on 4/7/25 at 11:40 a.m. with LVN 2, LVN 2 stated when she administered Resident 1's medications in the morning the medication cup with the lidocaine was on the over bed table. LVN 2 stated Resident 1 will sometimes have the lidocaine at bedside so she can reapply a little over time. LVN 2 stated the lidocaine should not have been left at bedside. During an interview on 4/7/25 at 12:11 a.m. with Director of Nursing (DON), DON stated Resident 1 did not have physician orders to self-administer medications and there should not have been lidocaine at the bedside. During a review of the facility's policy and procedure (P&P) titled Self-Administration of Medications dated 2/2021, the P&P indicated, As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: a. the medication is appropriate for self-administration; b. The resident able to read and understand medication labels; c. The resident can follow directions and tell time (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 2 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 04/07/2025 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)