Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westgate Gardens Care Center during CMS and state inspections, most recent first.
A resident’s care plan specified that no male CNAs were to provide care, but a male CNA was assigned and provided care anyway, including during the night. The resident stated she did not like men around her, and the DON and DSD both confirmed the CNA should not have been assigned to her. Facility policy required residents’ rights to be honored and care plans to reflect and carry out the resident’s plan of care.
A confidentiality breach occurred when staff provided EMS with the wrong POLST containing another resident’s full name, birthdate, and treatment preferences. During a hospital transfer, an LVN requested a POLST from the medical records assistant, who mistakenly printed the form for a different resident with the same last name. The LVN did not verify the resident identifiers on the document before giving it to EMS, resulting in disclosure of the wrong resident’s confidential medical information in violation of the facility’s confidentiality policy.
A resident was found to be sleeping on a low air flow therapeutic mattress with a dark brown circular stain. An LVN reported that the stain did not look appealing and that the mattress should have been changed. The DON and DOH later reviewed a photograph of the mattress and confirmed the dark brown stain, acknowledging it should have been removed and replaced. This situation occurred despite a facility policy stating that residents are to be provided with a safe, clean, comfortable, and homelike environment.
A resident with Parkinson's Disease, panic disorder, and severe cognitive impairment (BIMS score of 3) did not have a comprehensive, person-centered care plan addressing cognition. The DON confirmed that such a care plan was required but had not been developed, contrary to facility policy.
A resident with end stage renal disease missed a scheduled dialysis session due to transportation issues, and staff did not notify the attending physician as required by facility policy. Multiple staff interviews confirmed the lack of notification, despite established procedures for reporting missed treatments.
A resident with End Stage Renal Disease missed a scheduled hemodialysis treatment because transportation was not provided, and staff did not notify the transportation company as required by facility policy. Nursing staff either did not realize the resident was not picked up or failed to follow the expected procedure to address the missed transport.
A resident who required partial assistance for transfers was moved from a wheelchair to bed by a CNA and LVN without the use of a gait belt, contrary to facility policy. The improper transfer resulted in the resident landing face down on the bed. Staff interviews and documentation confirmed that the required gait belt was not used during the transfer.
A resident with dementia and hemiplegia reported being struck on the head by a CNA, an incident witnessed by a family member during a phone call. Although the CNA was removed from care and an internal investigation was started, facility staff did not report the abuse allegation to the Ombudsman, law enforcement, or state licensing agency as required by policy.
Staff did not follow the care plan for a resident with a history of verbally abusive behavior, resulting in the resident verbally and physically abusing another resident. Despite observing aggressive behavior, staff failed to intervene, allowing the situation to escalate and leading to physical harm and distress for the affected resident.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident was discharged home without home health services being arranged in advance, despite physician orders and discharge documentation specifying the need for physical therapy, occupational therapy, nursing, and durable medical equipment. The referral to home health was not sent until several days after discharge, and there was no evidence that the required services were coordinated prior to the resident leaving the facility.
A resident was found with lidocaine at the bedside without having been evaluated for self-administration, as required by facility policy. Nursing staff confirmed the medication was left accessible and that no physician orders or lock box were in place. The facility's policy mandates an interdisciplinary assessment before allowing self-administration, which was not completed in this instance.
A resident was issued a 30-day discharge notice for non-payment, but the facility did not notify the Ombudsman as required. The administrator stated notification was not needed since the resident did not dispute the discharge, and the Ombudsman confirmed they were unaware of the notice. Facility policy requires simultaneous notification to the Ombudsman when a discharge notice is given.
The facility failed to ensure Advance Directives (ADs) were offered and completed for two residents, potentially leading to their healthcare wishes not being honored. Resident 19 had no AD on file, and there was no documentation of it being offered or discussed. Resident 103 expressed interest in an AD, but no follow-up was documented. The facility's policy requires providing information about ADs, which was not followed in these cases.
The facility's arbitration agreement failed to explicitly state that residents or their representatives had the right to rescind the agreement within 30 days of signing. This was discovered during a review with the Admissions Director, revealing that 92 out of 138 residents had signed such agreements. The Administrator confirmed the omission, despite the facility's policy indicating a 30-day rescission period.
The facility did not document attendance for ten out of twelve QAPI meetings in 2024, as required. While meetings were held monthly, attendance records were only available for November and December. The facility's policy assigns the responsibility of maintaining meeting documentation to the QAPI Administrator, but this was not followed for most of the year.
Three residents experienced significant delays in having their call light requests answered, leading to discomfort and emotional distress. One resident waited up to two hours for assistance with changing a soiled brief, while two others waited over 15 minutes for toileting help. The facility's policies on prompt response and dignity were not adhered to, as indicated by ongoing issues noted in Resident Council Minutes.
The facility failed to ensure call lights were within reach for two residents, potentially impacting their ability to call for assistance. Observations revealed that one resident's call light was tied to the bed rail, and another's was attached to the bed but not reachable. CNAs confirmed the call lights should be within reach, as per facility policy.
A facility failed to provide a functioning overhead light for a resident, compromising their right to a safe and comfortable environment. The resident, with moderate cognitive impairment, was unable to use the light due to a detached string. Despite being reported and marked as corrected in the maintenance log, the issue persisted, as confirmed by staff interviews.
A resident with mobility issues was not assisted by CNAs to attend scheduled smoking breaks, as outlined in their care plan. Despite being ready, the resident remained in bed without receiving the necessary help to reach the designated smoking area, contrary to facility policy.
A facility failed to properly label medications for a resident, leading to potential medication errors. A resident prescribed two types of insulin had mislabeled insulin pens, with one pen labeled with another resident's name. The DON confirmed that labels should match to prevent errors. The facility's policy requires correct labeling and contacting the pharmacy for mislabeled items.
The facility failed to accurately document meal consumption for two residents, leading to potential weight changes. One resident expressed dissatisfaction with the food and left most of the meal uneaten, yet it was recorded as 76-100% consumed. Another resident also left parts of the meal uneaten, but the consumption was similarly overestimated. The DSD and IPC confirmed the inaccuracies, noting only 25% was consumed in both cases.
The facility failed to report an allegation of sexual abuse between two residents to the proper authorities. A CNA observed inappropriate touching, but the required SOC 341 form was not sent to the Ombudsman. The DON admitted to not completing the form, and the Administrator could not provide evidence of notification. The facility's policy required immediate reporting, which was not followed.
A facility failed to implement a care plan intervention for a resident who had fallen in the restroom. The care plan required non-skid strips on the restroom floor, but they were not present during an observation. A CNA confirmed their absence, and the Maintenance Director, responsible for placing them, was unaware of the requirement. The ADON acknowledged the strips should have been placed. The facility's policy emphasizes ongoing assessments and revisions to care plans, which was not followed.
A resident with moderate cognitive impairment expressed discomfort with a specific CNA and requested that the CNA not return to his room. This request was reported to the LVN on duty but was not communicated to the oncoming staff, resulting in the CNA being reassigned to the resident. The facility's policy required immediate reassignment of staff in such cases, which was not followed.
A facility failed to notify a physician of a change in a resident's discharge plan, resulting in the physician being unaware of the resident's transfer to a hospital. The resident was initially planned for discharge with home health services, but the plan changed to a hospital transfer after a Medicare appeal was denied. The facility's policy required physician notification, but no documentation was found. Both the Administrator and DON acknowledged the oversight.
A resident with a history of falls and cognitive impairment experienced a fall resulting in a head injury and spinal fracture. Despite multiple falls, the facility failed to adequately revise the care plan, relying on insufficient interventions like bed positioning and call light accessibility. The only new measure added was placing mattresses beside the bed, which did not prevent further incidents.
The facility failed to implement a care plan for a resident at risk for falls by not ensuring the call light was within reach. The call light was found clipped to the wall, out of the resident's reach, contrary to the care plan and facility policies.
Failure to Follow Resident Preference for Female CNAs
Penalty
Summary
The facility failed to implement Resident 1’s care plan when the resident requested no male CNAs provide care. Resident 1’s care plan report identified the focus as “RESIDENT IS REQUESTING NO MALE CNAS” with the goal that the request would be met, and the intervention specified that female CNAs were to provide care. During observation and interview, Resident 1 was sitting in a wheelchair and stated that a male staff member had gone into her room in the middle of the night and provided care, adding, “I don’t like men around me.” Record review and staff interviews confirmed that CNA 1, a male staff member, provided care for Resident 1 on two dates. The DON stated that CNA 1 had provided care for Resident 1 and acknowledged that the resident’s care plan indicated no male CNAs were to provide care. The DSD also stated that CNA 1 should not have been assigned to Resident 1. CNA 1 confirmed working with Resident 1 on the dates reviewed and stated he had worked with her ever since she was admitted. The facility policy on Resident’s Rights stated residents are entitled to exercise their rights to the fullest extent possible and be treated with respect, kindness, and dignity, and the Care Plans policy stated the care plan must be consistent with the resident’s rights and include the services and items in the plan of care.
Confidentiality Breach When Wrong POLST Given to EMS
Penalty
Summary
The facility failed to maintain confidentiality of a resident’s personal and medical records when the wrong Physician Orders for Life-Sustaining Treatment (POLST), which contained a resident’s full name, birthdate, and treatment preferences, was printed and provided to Emergency Medical Services (EMS). During transfer of Resident 2 to an acute hospital, the Licensed Vocational Nurse (LVN) requested a copy of Resident 2’s POLST from the Medical Records Assistant (MRA). The MRA, noting that Resident 1 and Resident 2 shared the same last name, mistakenly provided Resident 1’s POLST instead of Resident 2’s and acknowledged that the wrong POLST was given. The LVN then failed to verify that the POLST received from MRA belonged to Resident 2 before handing it to EMS, and was unaware that the document actually pertained to Resident 1. Resident 2’s responsible party later reported that EMS had been given the POLST for Resident 1 rather than for Resident 2. This sequence of actions and inactions violated the facility’s policy and procedure on Confidentiality of Information and Personal Privacy, which requires safeguarding the confidentiality of all residents’ personal and medical records.
Failure to Provide a Clean Therapeutic Mattress
Penalty
Summary
Surveyors identified that the facility failed to provide a clean mattress for one of six sampled residents. On 2/8/26, a Licensed Vocational Nurse (LVN) observed that this resident’s low air flow therapeutic mattress had a dark brown circular stain and stated the stain did not look appealing and the mattress should have been changed. During a subsequent interview, the Director of Nursing (DON) and Director of Housekeeping (DOH) reviewed a photograph of the mattress taken on 2/8/26 and confirmed the presence of the dark brown stain, agreeing that the mattress should have been removed and replaced. As a result of this inaction, the resident slept on a stained mattress, with the report noting potential for skin irritation and respiratory issues. Review of the facility’s “Homelike Environment” policy dated 2001 indicated residents are to be provided with a safe, clean, comfortable, and homelike environment, which was not met in this instance. The deficiency centers on the facility’s failure to ensure the resident’s mattress was clean and appropriately maintained in accordance with its own policy and procedure for providing a safe and clean environment.
Failure to Develop Care Plan for Cognition in Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing cognition for a resident with severe cognitive impairment. The resident had diagnoses of Parkinson's Disease and panic disorder, and a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Despite this, a review of the resident's admission record and care plan revealed that no care plan had been created to address the resident's cognitive needs. During an interview and record review, the DON confirmed that a care plan should have been developed for the resident's cognitive impairment, but none was present. The facility's policy requires the interdisciplinary team to create and implement a comprehensive care plan with measurable objectives and timeframes for each resident, including those with cognitive issues. This process was not followed for the resident in question.
Failure to Notify Physician of Missed Dialysis Treatment
Penalty
Summary
The facility failed to notify the attending physician when a resident with end stage renal disease missed a scheduled dialysis treatment. The resident was scheduled for hemodialysis three times a week, and on one occasion, did not attend the treatment because transportation did not arrive. Review of the resident's clinical records confirmed the missed dialysis session, and interviews with nursing staff and the Director of Nursing revealed that the attending physician was not informed of the missed treatment, despite facility practice and policy requiring such notification. Interviews with multiple staff members, including two LVNs and an RN, confirmed that it was standard practice to notify the attending physician of any missed dialysis treatments. However, documentation and staff statements indicated that this notification did not occur. The facility's policy on changes in a resident's condition or status specifically required physician notification in the event of significant changes, such as missed treatments, but this protocol was not followed in this instance.
Failure to Ensure Transportation for Dialysis Appointment
Penalty
Summary
A resident with a diagnosis of End Stage Renal Disease, requiring hemodialysis three times weekly, missed a scheduled dialysis treatment due to a failure in transportation arrangements. The resident's clinical records and progress notes confirmed that the resident did not attend the scheduled dialysis session because the transportation service did not arrive to pick up the resident. Interviews with nursing staff revealed that the transportation company was not notified when the resident was not picked up, and staff were either unaware of the missed pickup or did not follow the facility's practice of contacting the transportation provider to determine the cause. The Director of Nursing confirmed that the expectation was for nurses to notify the transportation company in such situations, but this was not done. Review of the facility's policy indicated that the facility is responsible for helping arrange transportation for residents as needed. The failure to ensure transportation resulted in the resident missing a critical dialysis treatment.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the use of a gait belt during resident transfers for one of three sampled residents. According to the resident's Minimum Data Set, the individual required partial/moderate assistance for chair/bed-to-chair transfers. During a transfer from wheelchair to bed, the resident reported that the CNA and LVN did not transfer her correctly, resulting in her landing face down on the bed. Multiple interviews with facility staff, including the Social Services Director, Director of Staff Development, and Director of Nursing, confirmed that a gait belt was not used during the transfer, and the transfer was performed inappropriately. A review of the facility's policies indicated that a gait belt must always be used for any resident who is not completely independent, with no exceptions. The staff involved did not adhere to this policy, as confirmed by their own statements and the investigation findings. The incident was documented in the Facility Reported Event and progress notes, and the resident expressed that the staff were rough and did not transfer her correctly, leading to the incident.
Failure to Report Abuse Allegation to Required Agencies
Penalty
Summary
The facility failed to implement its own policy regarding the reporting of an abuse allegation involving a resident with multiple medical conditions, including metabolic encephalopathy, dementia, hemiplegia, and hemiparesis. The resident, who had moderate cognitive impairment, reported an incident where a CNA struck her on the head, causing her head to hit the bed's side rail. This incident was witnessed indirectly by a family member during a phone call and subsequently reported to facility staff. Upon learning of the allegation, facility staff, including the Director of Staff Development (DSD), Infection Preventionist (IP), Director of Nursing (DON), and the Administrator, were informed. The CNA involved was immediately removed from resident care, and an internal investigation was initiated. However, the staff did not report the allegation to any external agencies, such as the Ombudsman, law enforcement, or the state licensing agency, as required by the facility's policy and regulatory guidelines. The facility's policy clearly states that all allegations of abuse must be reported to the appropriate external agencies immediately, defined as within two hours for abuse allegations or those resulting in serious bodily injury. Despite this, the staff acknowledged during interviews that the required external reporting did not occur. The failure to follow the established reporting procedures constituted a deficiency in the facility's abuse prevention and response protocols.
Failure to Implement Care Plan for Resident with Behavioral Issues
Penalty
Summary
Staff failed to implement the care plan for a resident with a history of verbally abusive behaviors related to poor impulse control. The care plan included interventions such as gentle redirection when applicable. On the day of the incident, staff observed the resident invading another resident's personal space, appearing angry and aggressive, but did not intervene. This inaction allowed the resident to escalate, resulting in cussing at and physically hitting the other resident on the leg, as well as throwing the resident's belongings on the floor. Documentation and interviews confirmed that the resident had a moderately impaired cognitive status and had previously exhibited similar behaviors, including yelling and becoming upset with the roommate. Staff members present at the time either did not intervene or delayed intervention, despite being aware of the resident's behavioral history and the care plan interventions. The facility's policy required individualized behavioral interventions to address such behaviors, but these were not implemented during the incident.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Arrange Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure that home health services were arranged prior to the discharge of a resident. Physician orders indicated that the resident was to be discharged home with home health services, including physical therapy, occupational therapy, nursing, and durable medical equipment. The discharge summary also documented that these services and equipment were to be provided upon discharge. However, a review of the resident's progress notes revealed that the referral to home health was not sent until six days after the resident had already been discharged. During an interview and record review with the Social Service Director, it was confirmed that there was no evidence of home health being notified of the resident's discharge orders before the resident left the facility. The facility's policy required that discharge planning ensure the resident's health and safety needs were met and that arrangements for community care and support services were made prior to discharge. This process was not followed, resulting in the resident being discharged without the necessary home health services in place.
Medication Left at Bedside Without Self-Administration Evaluation
Penalty
Summary
A deficiency occurred when a resident was found with lidocaine, a medication used to relieve pain, left at the bedside without having been evaluated for self-administration. During observation, the resident was seen holding a washcloth to her mouth in apparent pain, with a medication cup containing a clear gel substance on her over-bed table. The resident reported that the nurse provided the lidocaine so she could use it when in pain. Licensed nursing staff confirmed that the medication was left at the bedside and acknowledged that an evaluation is required before a resident is permitted to self-administer medication. However, the resident had not been evaluated for this, nor were there physician orders or a lock box present as required by facility policy. Further interviews with nursing staff and the Director of Nursing confirmed that the resident did not have physician orders to self-administer medications and that the lidocaine should not have been left at the bedside. Review of the facility's policy indicated that an interdisciplinary team assessment is necessary to determine if self-administration is safe and appropriate, considering the resident's cognitive and physical abilities. In this case, the required assessment and procedures were not followed, resulting in the medication being accessible to the resident without proper authorization or safeguards.
Failure to Notify Ombudsman of Resident Discharge for Non-Payment
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman when a resident was issued a 30-day notice of discharge for non-payment. The Notice of Proposed Transfer/Discharge (NPTD) was provided to the resident, citing non-payment of the share of cost assigned by Medi-Cal as the reason for discharge. The notice was signed by both the facility representative and the resident. However, the Ombudsman was not informed of the impending discharge, as required by facility policy and federal regulations. During interviews, the facility administrator stated that the Ombudsman was not notified because the resident did not dispute the discharge. The Ombudsman confirmed that their office was unaware of the discharge notice. Review of the facility's policy indicated that a copy of the discharge notice should be sent to the Ombudsman at the same time it is provided to the resident and their representative. This omission resulted in a failure to follow required notification procedures for resident discharge.
Failure to Ensure Advance Directives Offered and Completed
Penalty
Summary
The facility failed to ensure that Advance Directives (ADs) were offered and completed for two residents, which could potentially lead to their healthcare wishes not being honored. During an interview and record review, it was found that there was no documentation of an AD being offered or discussed with Resident 19 or their responsible party. The Nursing Consultant confirmed the absence of an AD on file for Resident 19. For Resident 103, the AD indicated interest in executing an AD, but there was no follow-up documentation. The Social Services staff acknowledged that Resident 103 had expressed interest in an AD, but no further action was documented. The facility's policy requires that residents or their representatives be provided with information about their rights to accept or refuse treatment and to formulate an AD, but this was not adhered to in these cases.
Arbitration Agreement Rescission Rights Not Explicitly Stated
Penalty
Summary
The facility failed to ensure its arbitration agreement explicitly stated that residents or their representatives had the right to rescind the agreement within 30 calendar days of signing. This oversight was identified during an interview and record review with the Admissions Director, where it was found that 92 out of 138 residents had signed arbitration agreements. The facility's Arbitration Agreement mentioned the possibility of rescission within 30 days but did not explicitly state the right to do so. The Administrator acknowledged that the agreement should have clearly indicated this right. Additionally, the facility's policy on Binding Arbitration Agreements, dated November 2023, stated that residents or their representatives are provided 30 days to review and rescind any agreement not understood at the time of admission.
Failure to Document QAPI Meeting Attendance
Penalty
Summary
The facility failed to document the attendance of required members at the Quality Assurance and Performance Improvement (QAPI) committee meetings for ten out of twelve meetings in 2024. During an interview and record review with the Administrator, it was revealed that while the facility held monthly QAPI meetings throughout 2024, attendance records were only available for the meetings in November and December. There was no documentation of attendance for meetings from January to October 2024. The facility's policy indicated that the QAPI Administrator is responsible for maintaining documentation of meeting minutes, but this was not adhered to for the majority of the year.
Delayed Response to Call Lights Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity, as they experienced significant delays in having their call light requests answered. Resident 97 reported waiting up to two hours for assistance with changing her soiled brief, which required the help of two staff members. This delay caused her discomfort and emotional distress. Resident 97 had a diagnosis of long-term complications from a stroke and required substantial assistance with hygiene. Similarly, Resident 34, who had Parkinson's Disease, reported waiting more than 15 minutes for assistance with toileting, which left him feeling upset. Resident 13, diagnosed with spinal stenosis, also experienced a delay of more than 15 minutes for help with changing her brief, resulting in discomfort and anger. The facility's Resident Council Minutes from the past few months indicated ongoing issues with CNAs not responding promptly to call lights, with residents expressing concerns about staff availability and willingness to assist. The facility's policy on answering call lights emphasized the importance of responding to residents' needs as soon as possible, and the dignity policy highlighted the prohibition of practices that compromise residents' dignity, including delays in toileting assistance. Despite these policies, the facility's failure to adhere to them resulted in residents experiencing discomfort and emotional distress.
Call Lights Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, which could potentially result in their needs not being met. During an observation and interview, it was noted that Resident 42's call light was tied to the right side rail near the top of the bed, making it unreachable for the resident. Both Resident 42 and a Certified Nursing Assistant (CNA) confirmed that the call light was out of reach. Similarly, in Resident 101's room, the call light was attached to the bed but not within reach of the resident. CNA 2 also acknowledged that the call light should be within reach. The facility's policy, dated 2010, states that call lights should be within easy reach when residents are in bed or confined to a chair.
Failure to Provide Functioning Overhead Light for Resident
Penalty
Summary
The facility failed to ensure a functioning overhead light was available for a resident, identified as Resident 37, which compromised the resident's right to a safe and comfortable environment. During an observation and interview, it was noted that the string to turn on the light above the resident's bed was detached, rendering the light unusable for personal use. The resident reported that the string had been broken for a couple of weeks, indicating a prolonged period without access to adequate lighting. The resident's Minimum Data Set (MDS) assessment indicated a moderate cognitive impairment with a BIMS score of 11. Interviews with a Licensed Vocational Nurse and a Maintenance Assistant confirmed that the string should have been longer to allow the resident to operate the light. A review of the facility's Maintenance Log showed that the issue was reported by another LVN and was marked as corrected the day before the observation, suggesting a discrepancy between reported maintenance actions and the actual condition of the light.
Failure to Assist Resident with Scheduled Smoking Breaks
Penalty
Summary
The facility failed to adhere to the care plan for a resident, identified as Resident 103, regarding smoking breaks. The care plan specified that Resident 103, who has muscle weakness and mobility issues, required assistance to and from the designated smoking area. However, on the day of observation, Resident 103 was not offered assistance to attend the scheduled smoking breaks. Despite being dressed and ready, the resident remained in bed and expressed that no staff had come to help him prepare for the smoke break. The facility's policy outlined specific smoking times and locations, and it was the responsibility of the CNAs to assist residents to these areas. During interviews, it was confirmed that the CNAs did not offer the smoking break to residents in the relevant hallway, including Resident 103. The facility's policy mandates that smoking is only permitted in designated areas outside the building, and the care plan emphasized the need for assistance, which was not provided, leading to a failure in meeting the resident's psychosocial needs.
Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure proper labeling of medications for one of its residents, identified as Resident 83, which led to a potential risk of medication errors. During a review of Resident 83's records, it was found that the resident was prescribed two types of insulin: Insulin Lispro, a fast-acting insulin to be administered before meals, and Insulin NPH, an intermediate-acting insulin to be administered at bedtime. However, during an observation, a Licensed Vocational Nurse (LVN) discovered that the insulin pen intended for Resident 83 was mislabeled. The plastic bag containing the insulin pen was labeled with Resident 83's name but indicated Insulin NPH, while the pen inside was labeled as Insulin Lispro. Furthermore, a replacement insulin pen obtained from the medication room was also mislabeled, with the pen inside labeled with another resident's name. The Director of Nursing (DON) confirmed that the labels on insulin bags and pens should match to prevent residents from receiving the wrong type of insulin or another resident's medication. The facility's policy on medication labeling and storage requires that medications dispensed by the pharmacy be labeled in accordance with federal and state requirements and accepted pharmaceutical practices. The policy also states that if medication containers have incorrect labels, the dispensing pharmacy should be contacted for instructions on returning or destroying these items. This incident highlights a failure in the facility's medication management system, specifically in ensuring that medications are correctly labeled to prevent potential medication errors.
Inaccurate Meal Consumption Documentation for Two Residents
Penalty
Summary
The facility failed to accurately document meal consumption percentages for two residents, Resident 93 and Resident 103, which could potentially lead to unplanned weight changes. During an observation and interview, Resident 93 expressed dissatisfaction with the food, stating she never ate 80% of her meals. Observations showed that Resident 93 left most of her meal uneaten, yet her meal consumption was inaccurately recorded as 76-100% consumed. The Director of Staff Development (DSD) and Infection Preventionist Consultant (IPC) reviewed the meal and agreed that only 25% was consumed. Similarly, Resident 103's meal consumption was inaccurately documented. Observations revealed that Resident 103 ate only a portion of the meal, leaving the salad and apple juice untouched. However, the meal consumption was recorded as 76-100% consumed. The DSD and IPC, upon reviewing the meal, concurred that only 25% was consumed. The facility's Dietary Intake Guide and policy on charting and documenting emphasize the need for accurate and complete documentation, which was not adhered to in these instances.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to provide a written report of an allegation of sexual abuse to the proper authorities for two residents. During an interview, the Ombudsman stated they did not receive the required SOC 341 form from the facility regarding the allegation of sexual abuse between the two residents. The incident was documented in Resident 2's Progress Notes, indicating that a CNA observed Resident 2 inappropriately touching Resident 1. The Licensed Vocational Nurse confirmed the observation, stating that the CNA saw Resident 2 with his hands on Resident 1's peri area. The Director of Nurses admitted to not filling out or sending the SOC 341 form to the Ombudsman. The Administrator, upon reviewing the mandated reporter pathway, acknowledged that law enforcement and the Ombudsman should have been notified immediately or as soon as practically possible by phone and with a written report within 24 hours of the alleged abuse. However, the Administrator could not provide documented evidence that the written SOC 341 was sent to the Ombudsman. The facility's policy and procedure required verbal and written notices to be submitted via special carrier, fax, email, or telephone, which was not adhered to in this case.
Failure to Implement Care Plan Intervention for Fall Prevention
Penalty
Summary
The facility failed to implement a care plan intervention for a resident who had experienced a fall in the restroom. The care plan, dated January 11, 2024, specified that non-skid strips should be placed on the restroom floor to prevent further falls, with the intervention initiated on December 23, 2024. However, during an observation and interview on January 2, 2025, it was found that the non-skid strips were not present on the restroom floor. A Certified Nursing Assistant confirmed the absence of the strips, and the Maintenance Director, who was responsible for placing them, stated he was unaware of the requirement. The Assistant Director of Nursing acknowledged that the strips should have been placed following the care plan update. The facility's policy on comprehensive, person-centered care plans emphasizes the need for ongoing assessments and revisions to ensure residents' well-being, which was not adhered to in this instance.
Failure to Address Resident's Grievance Regarding CNA Assignment
Penalty
Summary
The facility failed to promptly address a grievance raised by a resident who expressed discomfort with a specific Certified Nursing Assistant (CNA). On August 26, 2024, after receiving care from CNA 1, the resident reported feeling uncomfortable and requested that CNA 1 not return to his room. This request was immediately communicated by CNA 2 to the Licensed Vocational Nurse (LVN) on duty. However, the LVN did not relay this information to the oncoming staff or take any action to ensure the resident's request was honored. As a result, when CNA 1 returned to work on August 30, 2024, he was again assigned to care for the resident, leading to the resident expressing his discomfort vocally. The Director of Staff Development (DSD) confirmed that the facility's policy required immediate reassignment of staff when a resident expressed discomfort, which was not followed in this case. The resident, who had a moderate cognitive impairment as indicated by a BIMS score of 12, was entitled to have his grievances addressed promptly according to the facility's policy on resident rights.
Failure to Notify Physician of Change in Discharge Plan
Penalty
Summary
The facility failed to notify the physician when there was a change in the discharge plan for a resident, resulting in the physician being unaware of the resident's transfer to the hospital. The physician order dated two days prior to the discharge indicated that the resident was to be discharged with home health services, including physical therapy, occupational therapy, a registered nurse, a wound nurse, a home health aide, and a master of social work. However, the resident's responsible party was informed that the appeal for the Notice of Medicare Non-Coverage was denied, and the discharge plan was changed to transfer the resident to a hospital. The resident was transferred to the hospital via ambulance, and the responsible party signed the transfer discharge, discharge summary, and inventory of personal items. During interviews, both the Administrator and the Director of Nursing acknowledged that the physician should have been notified of the change in the discharge plan and that a new discharge order should have been written. The facility's policy and procedure for transfer or discharge indicated that the resident's attending physician should be notified in such cases, but there was no documentation of this notification in the resident's clinical record.
Failure to Revise Fall Care Plan for Resident
Penalty
Summary
The facility failed to revise and implement an appropriate plan of care for falls for a resident, which had the potential to cause serious harm. The resident, who had a history of falls and was generally confused, experienced a fall on 3/16/24, resulting in a head injury and a fracture of the L3 vertebra. Despite previous falls in the facility, the care plan was not adequately updated to address the resident's high risk of falling. The resident's medical records indicated a high fall risk score and cognitive impairment, as evidenced by an unassessable score on the Brief Interview for Mental Status. The resident required partial moderate assistance for various movements and had a history of attempting to get up independently, which was not effectively managed by the facility. The interventions in place, such as keeping the bed in the lowest position and ensuring the call light was within reach, were not sufficient to prevent further falls. The facility's Interdisciplinary Team (IDT) met multiple times to discuss the resident's falls but failed to implement new or effective interventions. The only new measure added to the care plan since January 2024 was placing mattresses on either side of the bed. The Director of Nursing acknowledged that the care plan should have been revised and suggested that moving the resident closer to the nurse's station could have been a more effective intervention.
Failure to Implement Care Plan for Call Light Accessibility
Penalty
Summary
The facility failed to ensure the care plan was implemented for a resident at risk for falls when the call light was not within reach. The care plan, dated 1/5/24, specified that the call light should be kept within reach of the resident. However, during an observation on 4/17/24, the call light was found clipped to the wall, out of the resident's reach. A Certified Nursing Assistant (CNA) had to unclip the call light and place it on the resident's abdomen for accessibility. The resident confirmed that the call light was used to call for help, and the CNA acknowledged that it should have been on the bed for easy access. The Director of Nursing (DON) also confirmed that the call light should have been close to the resident. A review of the facility's policy and procedure (P&P) on answering call lights, dated 10/10, indicated that the call light should be within easy reach when the resident is in bed or confined to a chair. Additionally, the facility's P&P on comprehensive, person-centered care plans, dated 3/22, emphasized that care plans should describe services to help residents attain or maintain their desired level of wellbeing. The failure to follow these policies resulted in the resident's inability to call for assistance when needed.
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What surveyors actually found near you
We read the 262 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Visalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Linwood Meadows Care Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Sequoia Vista | 0.6 mi | ★★★★★ | 12 | 0 |
| Kaweah Health Skilled Nursing Center | 2.8 mi | ★★★★★ | 11 | 0 |
| Delta Healthcare & Wellness Center, Lp | 2.9 mi | ★★★★★ | 3 | 0 |
| Visalia Post Acute | 4.2 mi | ★★★★★ | 32 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.