Westgate Gardens Care Center
4525 W. Tulare Ave. · Visalia, CA · 93277 · 5597330901
140 certified beds For profit - Corporation Chain: Pacs Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
RN staffing in the bottom 10% nationally
0.29 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 4.14 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.29 | 0.55–0.75 |
| Weekend hours / resident-day | 3.79 | ≈ weekday level |
| Nursing turnover / year | 48% | median 45% |
| Fines (3-yr window) | 1 · $10,317 |
Inspection citations (54 in the current record)
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Potential for harm · D April 9, 2026 · found via complaint
Keep residents' personal and medical records private and confidential.
Corrected April 24, 2026 · Resident Rights
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Potential for harm · D February 17, 2026 · found via complaint
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.
Corrected February 24, 2026 · Environmental
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Potential for harm · D December 22, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected December 29, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 5, 2025 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected September 3, 2025 · Resident Rights
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Potential for harm · D August 5, 2025 · found via complaint
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected September 3, 2025 · Quality of Life and Care
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Potential for harm · D July 1, 2025 · found via complaint
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.
Corrected August 12, 2025 · Administration
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Potential for harm · D June 11, 2025 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected July 30, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 11, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 30, 2025 · Resident Assessment and Care Planning
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Actual harm · G June 4, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 20, 2025 · Quality of Life and Care
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Potential for harm · D May 15, 2025 · found via complaint
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected June 13, 2025 · Resident Rights
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Potential for harm · D April 7, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected April 9, 2025 · Pharmacy Service
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Potential for harm · D March 28, 2025 · found via complaint
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected March 30, 2025 · Resident Rights
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Potential for harm · D February 24, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected March 24, 2025 · Resident Rights
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Potential for harm · D February 24, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected March 24, 2025 · Resident Rights
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Potential for harm · E February 24, 2025
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.
Corrected March 24, 2025 · Resident Rights
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Potential for harm · D February 24, 2025
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.
Corrected March 24, 2025 · Resident Rights
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Potential for harm · D February 24, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 24, 2025 · Resident Assessment and Care Planning
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Potential for harm · D February 24, 2025
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.
Corrected March 24, 2025 · Pharmacy Service
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Potential for harm · D February 24, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected March 24, 2025 · Resident Assessment and Care Planning
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Potential for harm · E February 24, 2025
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected March 24, 2025 · Administration
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Potential for harm · E February 24, 2025
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected March 24, 2025 · Administration
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Potential for harm · D January 29, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected March 4, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D January 2, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected January 3, 2025 · Resident Assessment and Care Planning
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Potential for harm · D September 6, 2024 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected October 3, 2024 · Resident Rights
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Potential for harm · D May 16, 2024 · found via complaint
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.
Corrected June 28, 2024 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| May 15, 2025 | Fine | $10,317 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 555208 · certified since October 2, 1985. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.