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Complaint Investigation

Westgate Gardens Care Center

May 28, 2026 · Visalia, CA · 4525 W. Tulare Ave.
Citations 1
CMS Rating 3/5
Beds 140
Provider ID 555208
Healthcare Facility
Westgate Gardens Care Center
Visalia, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

WESTGATE GARDENS CARE CENTER in VISALIA, CA — inspection on May 28, 2026.

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

FF0550
Resident Rights Deficiencies

his or her rights.

observation, interview, and record review the facility failed to ensure care plan was implemented for

Assistant (CNA) to provide care.

This failure resulted in violation of Resident 1's rights and potential for emotional harm.Findings:During a review of Resident 1's Care Plan Report (CPR), dated [DATE], the CPR indicated, Focus RESIDENT IS REQUESTING NO MALE CNAS.

Goal REQUEST WILL BE MET.

Intervention FEMALE CNAS TO PROVIDE CARE.During a concurrent observation and interview on [DATE] at 11:28 a.m. in Resident 1's room, Resident 1 was sitting in a wheelchair. Resident 1 stated a male staff had gone in her room in the middle of the night and provide care for her. Resident 1 stated, I don't like men around me.

During an interview on [DATE] at 1:04 p.m. with Director of Nurses (DON), DON stated CNA 1 (male staff) had provided care for Resident 1 on [DATE] and [DATE].During a concurrent interview and record review on [DATE] at 12:25 p.m. with DON, DON reviewed Resident 1's CPR, dated [DATE]. DON stated Resident 1's CPR indicated NO MALE CNAS were to provide care. DON stated CNA 1 shouldn't have provided care for Resident 1.During an interview on [DATE] at 12:31p.m. with Director of Staff Development (DSD), DSD stated CNA 1 shouldn't have been assigned [to Resident 1].

During an interview on [DATE] at 4:28 p.m. with CNA 1, CNA 1 confirmed working with Resident 1 on [DATE] and [DATE] as well as I had worked with her [Resident 1] ever since she was admitted [[DATE]].During a review of the facility's policy and procedure (P&P) titled Resident's Rights, dated [DATE], the P&P indicated Policy Interpretation and Implementation . 2.

Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3.

Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated [DATE], the P&P indicated Policy Interpretation and Implementation . 4.

Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to . g. receive the services and/or items included in the plan of care .

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

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.


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About This Inspection Report

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.