BELL GARDENS, CA - Federal inspectors cited Villa Del Rio Convalescent Center for a pattern of administering powerful psychotropic medications to residents who lacked the cognitive capacity to consent to their own treatment, according to an April 2025 inspection report. The facility, located at 7002 Gage Avenue, received deficiency findings across multiple categories including informed consent violations, care planning failures, inadequate shift communication, and a resident found covered in feces while lying exposed in bed.
Psychiatric Medications Given Without Valid Consent
The inspection uncovered that at least five residents received psychotropic drugs — including antipsychotics, anticonvulsants, and antidepressants — without proper informed consent from an authorized decision-maker.
One resident with dementia and schizoaffective disorder, identified in the report as Resident 41, had been assessed as having severely impaired cognition and documented as lacking the capacity to understand and make decisions. Despite this, the facility obtained consent for three psychotropic medications — aripiprazole, Lexapro, and Depakote — directly from the resident himself.
The facility's Director of Nursing acknowledged the error during the inspection, stating that consent "should not have been obtained from Resident 41 because he did not have the capacity to understand and make decisions." The DON further confirmed the facility should have initiated proceedings to obtain a conservator — a court-appointed individual authorized to make medical decisions on behalf of someone who cannot do so themselves.
Informed consent is a foundational principle in medical care. For psychotropic medications in particular, the consent process must include a clear explanation of the medication's purpose, its probable side effects, and the risks and benefits of treatment. When a patient cannot comprehend this information, consent must come from a legally authorized representative. Administering these medications without valid consent means a vulnerable individual is receiving drugs that alter brain chemistry without anyone independently evaluating whether the treatment is appropriate.
The problem extended to other residents as well. Resident 122, who had an appointed Public Guardian, received quetiapine, Depakote, and trazodone — but the informed consent forms were incomplete. They lacked any indication of who had provided consent or the date it was obtained. A registered nurse at the facility acknowledged her signature appeared on the forms but could not explain why they were never completed, noting it was possible she had been unable to reach the resident's Public Guardian.
For Resident 114, a stroke patient with severe cognitive impairment and total physical dependence on staff, a psychotropic consent form for Haloperidol dated back to December 2022 — more than two years prior. California regulations require these consent forms to be renewed every six months. When a new order for the same medication was placed in April 2025, no updated consent was obtained. Making matters worse, the resident's admission record listed three emergency contacts, but all phone numbers were no longer in service.
Resident 45, diagnosed with dementia and schizoaffective disorder, received a monthly intramuscular injection of Invega Sustenna — a long-acting antipsychotic — with no consent forms on file at all. A fifth resident's consent form was missing the patient's printed name, date, and any verification that a physician had obtained informed consent prior to starting the medication.
Psychotropic medications carry significant risks including metabolic changes, movement disorders, excessive sedation, cardiovascular effects, and falls. Antipsychotics in particular carry an FDA black-box warning regarding increased mortality risk in elderly patients with dementia. The consent process exists specifically to ensure these risks are weighed against potential benefits by someone capable of making that judgment.
Resident Found Covered in Feces, Exposed to Hallway
During the inspection on April 21, 2025, inspectors directly observed a resident lying in bed undressed and completely visible from the hallway. Resident 8, who had severe cognitive impairment and diagnoses including dementia and Parkinson's disease, was covered in feces on her shoulder, hand, and thigh. Feces were also observed on the floor beside the bed. The resident was calling out in Spanish.
A certified nurse assistant assigned to the resident stated he was a new employee on his first day after orientation. He told inspectors he had not received any report from the charge nurse indicating that Resident 8 had a known pattern of removing her diaper and undressing. The CNA said he had attempted to change the resident before lunch, but she became agitated and refused care. He reported that the charge nurse told him to "leave the resident alone and change her after his lunch."
The facility's Director of Staff Development confirmed that hand-off reporting — the process of communicating critical resident information between shifts — was not part of the CNA orientation program. The Director of Nursing acknowledged that shift reporting "has been a problem in the facility for the past year."
Proper shift-to-shift communication is considered a basic patient safety requirement in any healthcare setting. Without it, incoming staff members have no awareness of individual residents' behavioral patterns, care needs, or risk factors. For a resident with severe cognitive impairment and known behaviors of undressing, this information gap directly contributed to the resident being left in an undignified and unsanitary condition.
Cardiac Monitor Removed Without Physician Notification
Inspectors also identified a failure involving Resident 104, who had diagnosed bradycardia — a dangerously slow heart rate — and a history of fainting. The resident had returned from a cardiology appointment with a cardiac monitor device prescribed for continuous wear.
A licensed vocational nurse told inspectors he recalled the resident being non-compliant with the device and that he removed it and placed it at the nurses' station — without notifying the prescribing physician. There was no documented evidence of any communication with the doctor about the device's removal or any scheduled follow-up.
Records further showed that Resident 104's heart rate was recorded below the physician-ordered threshold of 60 beats per minute on six separate occasions between January and April 2025, with one reading as low as 52 bpm and another spiking to 120 bpm. Despite standing physician orders to notify the doctor when heart rate fell outside parameters, there was no documentation that notification occurred for any of these readings.
Bradycardia at the levels documented can reduce blood flow to the brain and vital organs. At 52 beats per minute, a patient with an already-compromised cardiovascular system faces elevated risk for syncope, falls, and in serious cases, cardiac arrest. The physician ordered continuous monitoring specifically to detect and respond to these dangerous fluctuations — a purpose that was entirely defeated when the device was removed without medical authorization.
Language Barriers and Assessment Inaccuracies
The inspection found that the facility incorrectly documented the language preferences of at least two residents, creating communication barriers that affected their care.
Resident 39, a Cantonese speaker, was documented in the facility's assessment system as preferring English and not wanting or needing an interpreter. A family member confirmed the resident preferred Cantonese and could better understand it. A CNA assigned to the resident stated she "could not understand anything" the resident was saying and did not know what language the resident spoke.
Similarly, Resident 159, a Korean speaker, told inspectors that staff spoke to him in English or Spanish and "he could not understand them most of the time." The assessment nurse admitted he had assumed both residents would not need interpreters based on their ability to speak some English — without ever asking them.
Missing Care Plans Across Multiple Residents
Inspectors documented a widespread failure to develop individualized care plans. Multiple residents lacked care plans for their psychotropic medications, meaning staff had no written guidance on monitoring for side effects or evaluating whether the drugs were effective. One resident on blood thinners and insulin had no care plans addressing the bleeding risks or blood sugar management those medications require.
A resident with documented physical aggression — including an allegation that he entered another resident's room and struck her — did not have a care plan addressing his aggressive behaviors until the day inspectors were on-site.
Another resident, who was edentulous and had been provided dentures that subsequently went missing, was left eating a regular-texture diet with no teeth. The resident told inspectors: "I have to talk with my mouth closed so no one can tell I don't have teeth in my mouth." Staff were unaware the dentures were missing, and no care plan existed to address the situation.
Facility Background
Villa Del Rio Convalescent Center, also identified as Villa Del Rio in federal records, is a skilled nursing facility in Bell Gardens, California. The April 24, 2025 health inspection identified deficiencies spanning informed consent (F-552), resident dignity (F-557), call light accessibility (F-558), advance directives (F-578), change of condition notification (F-580), assessment accuracy (F-641), care planning (F-656, F-657), personal hygiene (F-677), treatment and care (F-684), and mobility services (F-688).
For the full inspection report and the facility's plan of correction, readers can visit the Centers for Medicare and Medicaid Services Care Compare website or contact the California Department of Public Health.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Del Rio Convalescent Center from 2025-04-24 including all violations, facility responses, and corrective action plans.
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