Westgate Gardens Care Center
Inspection Findings
F-Tag F0656
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 interview and record review, the facility failed to develop a comprehensive person-centered care plan for cognition (a mental process of knowing and understanding) for one of three sampled residents (Resident 1) who had impaired cognition. This failure had the potential for staff unaware of Resident 1's cognitive impairment and not having his needs met.Findings:During a review of Resident 1's admission Record, dated 12/23/2025, the admission Record indicated Resident 1 has diagnoses of Parkinson's Disease (brain disorder that slows you down and makes you shake) and panic disorder (recurring, unexpected, sudden, and intense episodes of fear with physical symptoms like a racing heart, shortness of breath, and dizziness, often feeling like a medical emergency). During a review of Resident 1's Brief
Interview for Mental Status (BIMS- a quick, 15-point test used in nursing homes to get a snapshot of someone's thinking and memory by asking them to recall words, identify the date/place, and remember those words later, helping staff spot potential cognitive decline and know when to get a doctor involved), dated 11/17/25, the BIMS indicated Resident 1's score is 3 (score of 0-7 means severe cognitive impairment). During a concurrent interview and record review on 12/22/25 at 3:03 p.m. with Director of Nursing (DON), DON reviewed Resident 1's care plan. DON stated due to his cognitive impairment, a care plan should be developed to set care for him which helps set specific goals and interventions. DON stated there was no care plan developed for Resident 1's cognitive impairment. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person- Centered, dated March 2022, the P&P indicated, The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.includes measurable objectives and timeframes.maintain the resident's highest practicable physical, mental, and psychosocial (mind/emotions) well-being.Care plan interventions are chosen only
after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.
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
Event ID:
WESTGATE GARDENS CARE CENTER in VISALIA, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in VISALIA, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WESTGATE GARDENS CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.