Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to implement its own policy when an allegation of abuse for
one of three sampled residents (Resident 1) was not reported to Ombudsman, law enforcement, and state
licensing agency. This failure had the potential to put residents at risk for abuse.
Residents Affected - Few
Findings:
During a review of the admission Record (AR) dated 6/12/25, the AR indicated, Resident 1 was admitted on
[DATE] with the following diagnoses.metabolic encephalopathy (brain dysfunction due to metabolic
[chemical changes that take place in a cell or an organism] disorder).dementia (impairment of at least two
brain functions, such as memory loss and judgement).hemiplegia (paralysis on one side of the body) and
hemiparesis ( muscle weakness or partial paralysis on one side of the body that can affect the arms, legs,
and facial muscles) following cerebral infarction (blood flow to the brain is blocked, causing brain tissue to
die) affecting right dominant side.
During a review of Resident 1's Cognitive Patterns (CP) dated 3/24/25, the CP indicated, Brief Interview for
Mental Status (BIMS assesses cognitive status with scores ranging from 0 - 15, with the higher the score
the more intact the resident's cognitive status is).08 (indicating moderate cognitive [mental process involved
in knowing, learning, and understanding things] impairment) .
During a review of Resident 1's Progress Notes (PN-written by Director of Staff Development [DSD]) dated
5/21/25 at 9:50 a.m., the PN indicated, Writer received complaint from staff member in regards to a
possible altercation between CNA (Certified Nursing Assistant) and resident [1]. Resident [1] was
interviewed by ADON (Assistant Director of Nursing) and DSD in regards [sic] the altercation. Resident
stated it was just a playful banter (playful and friendly exchange of teasing remarks) and she is happy with
the CNA and would still like the CNA to assist her.
During an interview on 6/11/25 at 12:24 p.m. with Resident 1, Resident 1 stated approximately two to three
weeks ago, CNA 1 was assigned to her. Resident 1 stated when she was on the phone with Family
Member (FM) 1, CNA 1 was in the room and CNA 1 said something (unable to recall what was said) to her,
and she (Resident 1) said something back and stuck her tongue out at CNA 1. CNA 1 then popped her with
the back of her hand in the head and her head hit the side rail of the bed.
During an interview on 6/11/25 at 1:15 p.m. with DSD, DSD stated on 5/21/25 the IP (Infection
Preventionist) reported that FM 1 had made an allegation of abuse towards CNA 1 saying she had bopped
Resident 1 over the head while she was on the phone with her. DSD stated CNA 1 was suspended and the
allegation was reported to the Administrator, Human Resources (HR) and Director of Nursing (DON). DSD
stated an investigation was initiated by the ADON and HR. DSD stated she did not report the
(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 4
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
06/11/2025
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 0607
allegation to any outside entity (Ombudsman, law enforcement, state licensing agency).
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 6/11/25 at 1:28 p.m. with IP, IP stated on 5/21/25 FM 1 reported that when she was
on the phone with Resident 1, CNA 1 went into Resident 1's room and Resident 1 offered her some food.
CNA 1 declined the food and Resident 1 said oh you are going to be a diabetic today and CNA 1 said yes,
she did not want her sugar to go up. CNA 1 then walked over to do something, and Resident 1 said 'ow' and
when FM 1 asked what happened Resident 1 said CNA 1 bopped her over the head. IP stated she reported
the incident to the Administrator who immediately removed CNA 1 from resident care. IP stated the
allegation was not reported to any outside agencies and the alleged incident should have been reported
within two hours.
Residents Affected - Few
During an interview on 6/11/25 at 1:54 p.m. with DON, DON stated on 5/21/25 it was reported to her that
Resident 1 had stated CNA 1 had bopped her in the head. DON stated the allegation was not reported to
any outside agencies and it should have been.
During an interview on 6/11/25 at 4:08 p.m. with Family Member (FM) 1, FM 1 stated during a phone call
with Resident 1 on approximately 5/17/25 or 5/18/25 she heard Resident 1 offer CNA 1 some cinnamon
balls from Taco Bell and then say your going to be diabetic and then Resident 1 said 'ow'. FM 1 asked
Resident 1 what happened, and Resident 1 said CNA 1 bopped her over the head with her hand. FM 1
stated she reported the allegation to the IP. FM 1 stated she had a meeting with the Administrator, DSD and
another staff on 6/5/25 regarding the incident. FM 1 stated I think it could be abuse, think she was very
unprofessional and crossed the line.
During an interview on 6/19/25 at 11:43 a.m. with Administrator, Administrator stated on 5/21/25 the IP
informed him that FM 1 reported that CNA 1 had bopped Resident 1 on her head. Administrator stated CNA
1 was removed from resident care and an investigation was completed. Administrator stated he was aware
of the allegation, and the allegation was not reported to any outside agencies.
During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or
Misappropriation - Reporting and Investigating dated 2021, the P&P indicated, All reports of resident abuse
(including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property
are reported to local, state and federal agencies (as required by current regulations) and thoroughly
investigated by facility management. Findings of all investigations are documented and reported.The
administrator or the individual making the allegation immediately reports his or her suspicion to the
following persons or agencies.the state licensing/certification agency responsible for surveying/licensing the
facility.the local/state ombudsman.law enforcement officials.Immediately is defined as.within two hours of
an allegation involving abuse or result in serious bodily injury or.within 24 hours of an allegation that does
not involve abuse or result in serious bodily injury.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555208
If continuation sheet
Page 2 of 4
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
06/11/2025
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to implement the care plan for one of five sampled residents
(Resident 4) when staff witnessed Resident 4 invading Resident 5's personal space looking angry and
aggressive and did not intervene. This failure resulted in Resident 4 cussing at and hitting Resident 5 on the
left leg.
Findings:
During a review of Resident 4's Care Plan (CP) dated 11/26/24, the CP indicated, Has episodes of being
verbally abusive behaviors r/t (related to) poor impulse control.Interventions/Tasks.gentle redirection when
applicable.
During a review of Resident 4's Minimum Data Set (MDS - a standardized, comprehensive assessment tool
to evaluate the status of residents) dated 4/8/25, the MDS indicated, BIMS (Brief Interview for Mental
Status - used to assess knowledge, manipulation of information, and reasoning with score ranging from 0 15. The higher the score the more intact the resident's cognition is) Summary Score.09 (moderately
impaired cognitive status) .Behavior Symptom - Presence & Frequency.Verbal behavioral symptoms
directed toward others (e.g., threatening others, screaming at others, cursing at others).1 (behavior of this
type occurred 1 to 3 days).Impact on others.Significantly intrude on the privacy or activity of
others.1.Significantly disrupt care of living environment.1.
During a review of Resident 4's S (Situation) B (Background) A (Appearance) R (Review and Notify) dated
6/10/25 at 2 p.m., the SBAR indicated, Writer made aware by CNA's (Certified Nursing Assistant) that
resident was being verbally & physically abusive towards roommate [Resident 5]. Writer made aware that
resident was cussing, slapping her roommate's legs and throwing her belongings on the floor.
During a review of Resident 5's Progress Notes (PN) dated 6/10/25 at 6:21 p.m., the PN indicated, Writer
made aware by CNA's that resident's roommate [Resident 4] was being verbally & physically abusive
towards them. Writer made aware that roommate was cussing, slapping the resident's legs, and throwing
the resident's belongings on the floor.
During a review of Resident 5's MDS assessment dated [DATE], the MDS indicated, BIMS (Brief Interview
for Mental Status-used to assess knowledge, manipulation of information, and reasoning) Summary
Score.99 (resident was unable to complete the interview) .
During an interview on 6/11/25 at 11:12 a.m. with CNA 1, CNA 1 stated on 6/10/25 she was providing care
to a resident when CNA 2 came into the room and said Resident 4 was getting close to Resident 5 and
something was going on in the room. CNA 1 stated when she arrived in Resident 4 and Resident 5's room,
Resident 5 was laying in bed and Resident 5's blankets were on the floor and her flowers had been put in
the trash can. Resident 4 was cussing at Resident 5 and hit her leg. CNA 4 stated Resident 5 was sleeping
and hugging her baby doll. CNA 1 stated Resident 4 had acted like this before and she doesn't like
Resident 5 laying in bed. CNA 1 stated Resident 4 is always yelling at Resident 5 to get out of the room and
gets really upset.
During an interview on 6/11/25 at 11:12 p.m. with CNA 2, CNA 2 stated on 6/10/25 as she was passing
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555208
If continuation sheet
Page 3 of 4
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
06/11/2025
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
by Resident 4 and Resident 5's room, she witnessed Resident 4 in Resident 5's space looking aggressive
and angry. CNA 2 stated she did not go near Resident 4 or Resident 5 but went to the next room and told
CNA 1.
During an interview on 6/11/25 at 2:08 p.m. with Director of Nursing (DON), DON stated when CNA 2 was
walking by the room and seen Resident 4 in Resident 5's space she should have intervened right away and
removed Resident 5 from a stressful situation.
During a review of the facility's policy and procedure (P&P) titled, Behavior Management dated 12/31/15,
the P&P indicated, It is the policy of this Center to make reasonable efforts to ensure when a resident
displays mental or psychosocial adjustment difficulties, that he/she receives appropriate treatment and
services to address the identified problem(s).Behavioral interventions are individualized
non-pharmacological approaches (including direct care or activities) that are provided as part of a
supportive physical or psychosocial environment directed toward preventing, modifying, and/or relieving a
resident's distressed behavior.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555208
If continuation sheet
Page 4 of 4
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Back to topCitations
2 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.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
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.
FAQ · About this visit
Common questions about this visit
What happened during the June 11, 2025 survey of WESTGATE GARDENS CARE CENTER?
This was a inspection survey of WESTGATE GARDENS CARE CENTER on June 11, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WESTGATE GARDENS CARE CENTER on June 11, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement policies and procedures to prevent abuse, neglect, and theft."
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.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.