Westgate Gardens Care Center: Care Plan Ignored - CA
The resident, identified in inspection records only as Resident 1, was found sitting in a wheelchair in her room during a May 2026 inspection when she told the investigator what had happened. "I don't like men around me," she said.
Her care plan, dated before the inspection, could not have been clearer. Under Focus, it read: RESIDENT IS REQUESTING NO MALE CNAS. Under Goal: REQUEST WILL BE MET. Under Intervention: FEMALE CNAS TO PROVIDE CARE.
The request was not met.
The Director of Nurses confirmed during an interview that a male CNA, identified in records as CNA 1, had provided care for the resident on at least two specific dates. When the Director of Nurses reviewed the care plan document during that same conversation, she said CNA 1 shouldn't have provided care for the resident. The Director of Staff Development, interviewed separately, reached the same conclusion: CNA 1 shouldn't have been assigned to her.
CNA 1 didn't dispute any of it. In his own interview, he confirmed working with the resident on both dates named by the Director of Nurses, then added something that widened the scope of the problem considerably. "I had worked with her ever since she was admitted," he said.
That means the care plan preference, whatever date it was formalized, had been overridden throughout the resident's entire stay at the facility. Not a single lapse. A sustained pattern.
The inspection was triggered by a complaint and was conducted on May 28, 2026. Inspectors cited the facility for failing to implement the resident's care plan, a violation they assessed at the level of minimal harm or potential for actual harm, affecting a small number of residents.
The "minimal harm" classification is a regulatory category, not a characterization of what the experience meant to this particular resident. She was specific about her feelings. She didn't want men providing her personal care. The facility acknowledged the request was valid, documented it, assigned a goal of meeting it, and identified the intervention required to do so. Then the same facility sent a male aide into her room at night, repeatedly, without correction.
Westgate Gardens' own policies describe residents as entitled to exercise their rights and privileges to the fullest extent possible, and commit the facility to making every effort to assist each resident in exercising those rights so that the resident is always treated with respect, kindness, and dignity.
The care plan policy adds that each resident's comprehensive person-centered care plan is consistent with the resident's right to receive the services and items included in the plan of care.
Neither policy appears to have been applied here.
What the inspection record does not contain is any explanation for how a documented, written preference was ignored across multiple shifts over an extended period without anyone catching it. No supervisor flagged the assignment. No scheduling review caught the mismatch. CNA 1 worked with the resident from admission onward, and the care plan, whenever it was written, did not change what was happening in practice.
The resident learned of the violation the way residents typically do: by experiencing it herself, alone, in her room, at night.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westgate Gardens Care Center from 2026-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 8, 2026 · Our methodology
WESTGATE GARDENS CARE CENTER in VISALIA, CA was cited for violations during a health inspection on May 28, 2026.
"I don't like men around me," she said.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.