Harbor Villa Care Center: Expired Meds, Infection Lapses - CA
Federal inspectors found seven packages of skin integrity hydrogel gauze that expired in September 2023, alongside other medical supplies that had been opened despite being labeled for single use only. The violations stretched across multiple medication carts and storage areas throughout the 92-bed facility on South Harbor Boulevard.
LVN 5 confirmed to inspectors that individual medical packages are "single use only and needs to be discarded after single use" but acknowledged finding opened packages of wound closure strips and foam dressings that should have been thrown away.
In one medication cart, inspectors documented 11 packages of oil emulsion dressing that expired September 8, 2024, and a calcium alginate wound dressing that had been expired since August 28, 2023. Another cart contained Active liquid protein supplements that expired December 1, 2024.
The medication storage problems extended into resident rooms. Inspectors found two medication cups containing white cream with wooden spatulas sitting unattended on Resident 58's nightstand. No licensed staff was present in the room. Resident 58 told inspectors the cream was for her back and that staff applied it there.
A similar scene played out in Resident 494's room, where inspectors found medication cups with white cream left on the nightstand. Resident 494 said she didn't know about the medication left there. RN 1 confirmed the substance appeared to be zinc oxide and acknowledged that "nursing staff should not have left the medication at the bed side of Resident 58 and 494 unattended."
The facility's own policy requires medications to be stored in locked compartments and states that "trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others."
Resident 81's case highlighted additional medication labeling failures. CNA 1 found white cream in a cup with a tongue depressor on the resident's bedside stand, saying the treatment nurse used it on the resident. But when LVN 5 reviewed the resident's physician orders and treatment records, no order existed for the zinc oxide cream being used.
The medication management problems were compounded by widespread infection control failures that left the facility unable to track disease outbreaks. The infection preventionist could not produce monthly surveillance logs for July, September, and December 2024.
When pressed about the missing September report, the infection preventionist initially blamed staff turnover, saying "the previous IP left the facility." A day later, she claimed to have found the July log "in the system" but still could not produce December's surveillance data.
The infection tracking that did exist contained significant errors. Reports for October and November 2024 showed conflicting infection counts between different documents. The October quality assurance report claimed 62 total infections, while the monthly surveillance report for the same month showed only 44 total infections.
The infection preventionist acknowledged preparing both sets of contradictory reports but told inspectors "she did not know" how to explain the discrepancies. The Director of Nursing said he had never seen either type of infection report before.
More troubling, the infection preventionist admitted she only included residents prescribed antibiotics in surveillance reports, ignoring those with signs and symptoms of infection who weren't given medication. This approach contradicts standard infection control practices that require monitoring all suspected infections regardless of treatment.
Staff training gaps became apparent when the infection preventionist could not answer basic questions about Enhanced Barrier Precautions, a key infection control measure. She told inspectors she had received only four days of training for her role and had been "asking the facility for more training."
The training deficits showed up in daily care practices. LVN 1 was observed removing gloves and putting on new ones during medication administration without washing her hands between glove changes. During wound care for Resident 19, LVN 5 changed gloves twice without performing hand hygiene, later admitting she "was nervous and forgot."
Resident 14's indwelling urinary catheter bag was found lying directly on the floor, violating basic infection control principles. The facility's own policy requires keeping collection bags "off the floor at all times to prevent contamination."
The infection control breakdown extended to isolation protocols. Resident 82 had physician orders for Enhanced Barrier Precautions due to wound care needs, but no warning signs were posted outside the room and no personal protective equipment cart was available. Staff members acknowledged they couldn't identify which residents required special precautions.
Food safety violations added another layer of concern. Two coffee pots were stored while still wet, creating conditions where microorganisms could grow. The kitchen's ice machine had peeling interior lining with "sticky brown discoloration," while four bowls with dried food crumbs sat in the clean dish storage area.
A food preparation sink lacked proper backflow prevention, potentially allowing sewage to contaminate areas where food and utensils are cleaned. The maintenance director confirmed he couldn't verify whether the sink had adequate protection against backflow from the sewage system.
Even the food itself suffered from quality problems. Broccoli served to residents was "mushy and overcooked," according to staff observations. Resident 5 told inspectors that "the food in the facility did not taste good."
Medical record keeping showed similar lapses in attention to detail. Resident 24's Physician Orders for Life-Sustaining Treatment form lacked a required signature from the legal decision-maker, raising questions about its validity. LVN 1 acknowledged the form "should have been signed so the staff would know if it was valid."
In a particularly egregious documentation error, staff recorded vital signs for Resident 92 one day after the resident had died. The Director of Nursing called it "carelessness" and said staff should have deactivated the resident's account to prevent such mistakes.
The hospice care coordination for Resident 52 revealed additional organizational problems. The facility lacked a January 2025 calendar showing when hospice staff were scheduled to visit, and existing documentation failed to clearly show whether scheduled visits actually occurred.
LVN 6 told inspectors she wasn't sure about the hospice aide schedule and couldn't verify if staff visited as planned or followed the care plan. The hospice provider's plan called for weekly skilled nursing visits, twice-weekly aide visits, and monthly social worker visits, but the facility's tracking system couldn't confirm compliance.
Harbor Villa Care Center's administrator and Director of Nursing acknowledged the findings when presented by inspectors. The violations occurred across multiple departments and shifts, suggesting systemic problems rather than isolated incidents.
The facility received citations for medication storage and labeling failures, infection prevention and control deficiencies, food safety violations, medical record inaccuracies, and equipment maintenance problems. Each violation carries the potential for federal fines and increased oversight.
The inspection findings paint a picture of an operation struggling with basic safety protocols across multiple areas of resident care, from medication management to infection control to food service.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harbor Villa Care Center from 2025-01-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
HARBOR VILLA CARE CENTER in ANAHEIM, CA was cited for violations during a health inspection on January 10, 2025.
The violations stretched across multiple medication carts and storage areas throughout the 92-bed facility on South Harbor Boulevard.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.