Inspection citations
6’19
16’23
4’24
21’25
4’26
51 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jul 27, 2026 | D · potential | 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. | Complaint |
| May 28, 2026 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| Apr 9, 2026 | D · potential | Keep residents' personal and medical records private and confidential. | Complaint |
| Feb 17, 2026 | D · potential | 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. | Complaint |
| Dec 22, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Aug 5, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Aug 5, 2025 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Complaint |
| Jul 1, 2025 | D · potential | 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. | Complaint |
| Jun 11, 2025 | D · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Complaint |
| Jun 11, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Jun 4, 2025 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| May 15, 2025 | D · potential | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | Complaint |
| Apr 7, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Mar 28, 2025 | D · potential | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Complaint |
| Feb 24, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Feb 24, 2025 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Feb 24, 2025 | E · potential | 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. | Routine |
| Feb 24, 2025 | D · potential | 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. | Routine |
| Feb 24, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Feb 24, 2025 | D · potential | 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. | Routine |
| Feb 24, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Feb 24, 2025 | E · potential | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Routine |
| Feb 24, 2025 | E · potential | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Routine |
| Jan 29, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Jan 2, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Sep 6, 2024 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Complaint |
| May 16, 2024 | D · potential | 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. | Complaint |
| May 2, 2024 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Apr 23, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Nov 29, 2023 | D · potential | 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. | Complaint |
| Apr 20, 2023 | E · potential | 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. | Routine |
| Apr 20, 2023 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| Apr 20, 2023 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Apr 20, 2023 | D · potential | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Routine |
| Apr 20, 2023 | E · potential | PASARR screening for Mental disorders or Intellectual Disabilities | Routine |
| Apr 20, 2023 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Apr 20, 2023 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Apr 20, 2023 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Apr 20, 2023 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Apr 20, 2023 | D · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Routine |
| Apr 20, 2023 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Apr 20, 2023 | E · potential | 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. | Routine |
| Apr 20, 2023 | D · potential | 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. | Routine |
| Apr 20, 2023 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Apr 20, 2023 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Oct 24, 2019 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| Oct 24, 2019 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Oct 24, 2019 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Oct 24, 2019 | D · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Oct 24, 2019 | D · potential | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Routine |
| Oct 24, 2019 | D · potential | Provide and implement an infection prevention and control program. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Westgate Gardens Care Center
4525 W. Tulare Ave., Visalia, CA 93277 · (559) 733-0901
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555208
- Certified beds
- 140
- Legal owner
- Thyme Holdings, LLC
- Part of
- Pacs Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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