Health inspection·June 4, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the staff used the Hoyer lift (mechanical device designed to assist individuals with limited mobility in safely transferring from one place to another) properly when the legs (base) of the Hoyer lift were not open during a transfer for one of three sampled residents (Resident 1). This failure resulted in the Hoyer lift tilting over causing Resident 1 to fall to the floor, sustaining a mild displaced (bone fragments are no longer together) distal (away from the point of attachment) coccygeal (tailbone) segment (completely detached from surrounding bone) fracture (break in a bone).Findings:During a review of Resident 1's admission Record (AR) dated 6/10/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including paraplegia (loss of impairment of motor (movement of body parts) and sensory (sensation) functions in the lower half of the body).neuralgia (nerve pain) and neuritis (inflammation of a nerve).congestive heart failure (heart does not pump blood well).During a review of Resident 1's Minimum Data Set (quarterly MDS - comprehensive assessment tool) dated 5/23/25, under the section Brief Interview for Mental Status (BIMS- an assessment of cognition [how well a person thinks, remembers, and learns]), the BIMS indicated, Resident 1 had a score of 13 (cognition intact). The MDS under the section GG (an assessment of the level a care a resident required), indicated, Resident 1 was dependent on staff for transferring from bed to chair/chair to bed.During a review of Resident 1's Fall Risk Observation/Assessment (FROA) dated 5/18/25, the FROA indicated, Score 22 (high risk for falls).During a review of Resident 1's Progress Notes (PN) dated 5/31/25 at 3:50 p.m., the PN indicated, Staff reported this writer that the resident had a fall during a transfer from bed to wheelchair using a Hoyer lift. Upon arrival, res (Resident 1) was found on the floor in between Hoyer lift and closet, having landed on buttocks with sling underneath. Incident occurred when staff attempted to move the res with Hoyer lift legs in the closed position and turned the resident, causing the lift to tip and res to fall.Resident c/o (complained of) pain right wrist.During a review of Resident 1's S (Situation) B (Background) A (Appearance) R (Review and Notify) Communication Form (SBAR - a communication tool used between healthcare professionals i.e. between the nurse and physician) dated 5/31/25, the SBAR indicated, Witnessed fall.Recommendations of Primary Clinicians.X-ray (medical imaging technique that uses radiation to create a picture of the inside of the body) Sacrum (triangular bone in the lower back) bone & Coccyx (tailbone) Bilateral Hips X-ray right wrist.During a review of Resident 1's PN dated 5/31/25 at 10:26 p.m., the PN indicated, (Physician name) notified of.mild displaced distal coccygeal segment fracture.MD (Medical Doctor) confirmed of res (resident) to already have Norco (narcotic pain [no dosage indicated] medication) and Tylenol (no dosage indicated) pain medication ordered. NNO (no new orders) at this time.During a review of Resident 1's Radiology Interpretation (RI - X-ray performed at the facility) dated 5/31/25, the RI indicated, mild displaced distal coccygeal segment fracture.During an interview on 6/4/25 at 12:35 p.m. with Resident 1, Resident (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 06/04/2025 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)