BELLFLOWER, CA - Villa Del Sol Post Acute faced significant infection control violations during an April 4, 2025 federal inspection that revealed the facility had canceled mandatory water safety testing and failed to properly monitor antibiotic use among vulnerable residents.
Critical Water Safety Testing Abandoned
The most serious violation involved the facility's failure to conduct annual Legionella bacteria testing, a critical safety measure designed to prevent potentially deadly waterborne infections. Federal inspectors discovered that Villa Del Sol had no Legionella testing results for 2024 or 2025, despite facility policies requiring annual testing.
The Infection Preventionist Nurse told inspectors she "was not sure if the testing should be done annually" and was "not very familiar with the policy." More concerning, she revealed that the previous administrator had canceled scheduled testing in April 2024.
A contracted testing company president confirmed that he had sent a letter on March 15, 2024, scheduling testing for April 23, 2024, but the previous administrator canceled the appointment. The testing company representative noted that most facilities conduct testing every three to six months, with annual testing being the minimum standard for infection control surveillance.
Legionella bacteria naturally occurs in water environments and can cause severe pneumonia-like illness, particularly dangerous for elderly residents with compromised immune systems. The bacteria multiplies in warm water systems and can be transmitted through inhalation of contaminated water droplets from showers, faucets, or cooling systems.
The Maintenance Supervisor confirmed that annual testing should have been conducted but stated the previous administrator told him "it was not necessary" and asked for risk assessments instead. However, he acknowledged that risk assessments "could not replace actual Legionella water testing."
Facility Policy Violations
Villa Del Sol's own Water Management Program policy, revised December 19, 2022, clearly states that "CDC elite Legionella testing will be performed annually" and that "the effectiveness of the water management program shall be evaluated no less than annually."
The facility's separate Legionella Water Management Program policy, dated January 2, 2024, specifically required "CDC Elite Legionella testing" annually, calling it "required by CMS" - the federal Centers for Medicare and Medicaid Services.
The Director of Nursing acknowledged that "Legionella testing should have been done annually as water management program indicated" and emphasized that "water quality would be affecting everybody, and it was important to ensure to maintain it for safety."
Antibiotic Monitoring Failures
Inspectors also found serious deficiencies in the facility's antibiotic stewardship program, which is designed to ensure antibiotics are used appropriately and prevent the development of drug-resistant infections. Two residents experienced improper antibiotic management.
For Resident 60, who was admitted in March 2025 with acute cystitis, peritoneal abscess, and bacteremia, the facility failed to identify the reason for prescribing Bactrim and did not conduct required antibiotic timeout assessments. The Infection Preventionist admitted she "was not sure what the indication was for Bactrim use" and was "guessing it was ordered for the resident's intra-abdominal infection."
Antibiotic timeout protocols require healthcare providers to reassess antibiotic prescriptions 48-72 hours after starting treatment to ensure continued necessity and appropriateness. This critical safety measure helps prevent antibiotic resistance and reduces unnecessary exposure to potential side effects.
The facility's Registered Nurse Supervisor noted that "all antibiotics should have a start date and an end date" and emphasized that documentation regarding indication and duration is essential for proper antibiotic therapy.
Prophylactic Antibiotic Mismanagement
For Resident 69, a cancer patient receiving preventive Bactrim therapy three times weekly, the facility failed to monitor for adverse reactions and side effects. The antibiotic timeout documentation showed the medication "did not meet criteria for Loeb's or McGeer's Criteria" - established standards for appropriate antibiotic use.
Prophylactic antibiotics are used to prevent infections in high-risk patients, but they require careful monitoring to avoid unnecessary antibiotic resistance and potential harmful side effects. Cancer patients like Resident 69 are particularly vulnerable to both infections and medication complications due to compromised immune systems.
The Infection Preventionist acknowledged there was "no follow up laboratory testing or evaluation done" and she "could not find any documentation indicating the resident was being monitored for adverse reactions."
Visitor Safety Protocol Breakdown
Additional infection control failures included improper enforcement of Enhanced Barrier Precautions (EBP) for a resident requiring special infection control measures. Inspectors observed four visitors touching, hugging, and sitting on the bed of Resident 57, who required gown and glove precautions due to medical devices, without using any protective equipment.
Enhanced Barrier Precautions are implemented to prevent transmission of multidrug-resistant organisms, particularly important for residents with medical devices like feeding tubes and urinary catheters that increase infection risk. Proper enforcement protects both the individual resident and prevents spread throughout the facility.
The Licensed Vocational Nurse on duty observed the violation but did not intervene, despite acknowledging that "enforcing EBP was important to minimize potential for transmission of bacteria."
Industry Standards and Best Practices
Federal regulations require nursing homes to maintain comprehensive infection prevention and control programs. Water management protocols are particularly critical because elderly residents often have weakened immune systems that make them more susceptible to waterborne illnesses.
Legionella infections can cause severe pneumonia with mortality rates ranging from 10-15% in healthcare settings, making prevention through proper water testing essential. The bacteria can colonize building water systems, including hot water tanks, cooling towers, and plumbing fixtures commonly found in healthcare facilities.
Antibiotic stewardship programs are federally mandated to combat the growing threat of antibiotic-resistant infections. Inappropriate antibiotic use contributes to the development of "superbugs" that don't respond to standard treatments, making subsequent infections potentially life-threatening.
Facility Response and Regulatory Impact
The violations affected many residents facility-wide for the water testing failure and several residents for the antibiotic monitoring deficiencies. The inspection classified both violations as causing "minimal harm or potential for actual harm," but the systemic nature of the failures indicates significant gaps in infection control oversight.
Federal regulations require the facility to submit a plan of correction addressing how these violations will be remedied and prevented in the future. The facility must demonstrate implementation of proper water testing schedules, staff education on antibiotic monitoring requirements, and enforcement of visitor safety protocols.
These infection control failures highlight the critical importance of consistent policy implementation and staff education in protecting nursing home residents from preventable infections and medication-related complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Villa Del Sol Post Acute from 2025-04-04 including all violations, facility responses, and corrective action plans.
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