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78/100WESTGATE GARDENS CARE CENTER Inspection Report, Violations & Safety Grade (VISALIA, California)
4525 W. TULARE AVE., VISALIA, California 93277
Phone: 5597330901
CMS Overall:4/5
Overview & Bed Count
Certified Beds
140
Avg Residents/Day
134
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Tulare
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall4/5
Health3/5
Staffing3/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | California Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.33 | 0.68 | -0.35 |
| Total Nurse Hours per Resident per Day | 4.07 | 4.54 | -0.47 |
| CMS Staffing Rating | 3/5 | 3.3/5 | - |
| Nursing Staff Turnover | 44.8% | 36.6% | - |
Health Citation History
51 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-27 | Administration Deficiencies | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | D – Moderate Harm Potential |
| 2026-05-28 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2026-04-09 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | D – Moderate Harm Potential |
| 2026-02-17 | Environmental Deficiencies | Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | D – Moderate Harm Potential |
| 2025-12-22 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-08-05 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2025-08-05 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2025-07-01 | Administration Deficiencies | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | D – Moderate Harm Potential |
| 2025-06-11 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D – Moderate Harm Potential |
| 2025-06-11 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-06-04 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2025-05-15 | Resident Rights Deficiencies | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | D – Moderate Harm Potential |
| 2025-04-07 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-03-28 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D – Moderate Harm Potential |
| 2025-02-24 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | E – Moderate Harm Potential |
| 2025-02-24 | Administration Deficiencies | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | E – Moderate Harm Potential |
| 2025-02-24 | Administration Deficiencies | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | E – Moderate Harm Potential |
| 2025-02-24 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-02-24 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | D – Moderate Harm Potential |
| 2025-02-24 | Resident Rights Deficiencies | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D – Moderate Harm Potential |
| 2025-02-24 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-02-24 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D – Moderate Harm Potential |
| 2025-02-24 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2025-01-29 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2025-01-02 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2024-09-06 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2024-05-16 | Resident Rights Deficiencies | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | D – Moderate Harm Potential |
| 2024-05-02 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2024-04-23 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2023-11-29 | Resident Rights Deficiencies | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D – Moderate Harm Potential |
| 2023-04-20 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | E – Moderate Harm Potential |
| 2023-04-20 | Resident Assessment and Care Planning Deficiencies | PASARR screening for Mental disorders or Intellectual Disabilities | E – Moderate Harm Potential |
| 2023-04-20 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | E – Moderate Harm Potential |
| 2023-04-20 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E – Moderate Harm Potential |
| 2023-04-20 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2023-04-20 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2023-04-20 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2023-04-20 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2023-04-20 | Resident Assessment and Care Planning Deficiencies | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D – Moderate Harm Potential |
| 2023-04-20 | Quality of Life and Care Deficiencies | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | D – Moderate Harm Potential |
| 2023-04-20 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2023-04-20 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2023-04-20 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2023-04-20 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2023-04-20 | Nutrition and Dietary Deficiencies | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | D – Moderate Harm Potential |
| 2019-10-24 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2019-10-24 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2019-10-24 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2019-10-24 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D – Moderate Harm Potential |
| 2019-10-24 | Nutrition and Dietary Deficiencies | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | D – Moderate Harm Potential |
Showing 50 of 51 citations.
Fire Safety Citation History
23 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-02-24 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-02-24 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2025-02-24 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2025-02-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-02-24 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | E – Moderate Harm Potential |
| 2025-02-24 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2025-02-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
| 2025-02-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2023-04-20 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | D – Moderate Harm Potential |
| 2023-04-20 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | D – Moderate Harm Potential |
| 2023-04-20 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2023-04-20 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2023-04-20 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | D – Moderate Harm Potential |
| 2023-04-20 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | D – Moderate Harm Potential |
| 2023-04-20 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | D – Moderate Harm Potential |
| 2019-10-24 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | E – Moderate Harm Potential |
| 2019-10-24 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2019-10-24 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2019-10-24 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2019-10-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2019-10-24 | Emergency Preparedness Deficiencies | List the names and contact information of those in the facility. | D – Moderate Harm Potential |
| 2019-10-24 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2019-10-24 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | D – Moderate Harm Potential |
Total Penalties & Fines
$10,317
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-05-15 | Fine | $10,317 | - |
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the VISALIA area at no cost.
Find Safe, Vetted Facilities Near VISALIA
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.