Westgate Gardens Care Center
WESTGATE GARDENS CARE CENTER in VISALIA, CA — inspection on December 22, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.