Del Rosa Villa: Daily Living Care Failures - CA
Nobody had taught him to do this. Nobody had checked whether he was capable of doing it safely. Nobody, as far as inspectors could determine, had noticed he was doing it at all.
Inspectors from the Centers for Medicare and Medicaid Services visited the facility at 2018 N Del Rosa Ave on February 8, 2026, and observed the resident, identified in records as Resident 107, during a concurrent observation and interview at 10:10 a.m. He told them directly: staff were not coming in to empty the urinary bag, so he had been handling it himself. Then he showed them how, removing the drainage port and replacing it without gloves or hand hygiene before or after.
Resident 107 had been readmitted to the facility with diagnoses including fluid overload and low oxygen levels in the blood. His cognition was recorded as intact. That detail matters, because it explains why he could manage the task at all. It does not explain why he was left to manage it alone, without instruction, without equipment, and without anyone at the facility apparently knowing it was happening.
The next morning, inspectors spoke with the certified nursing assistant who should have known. CNA 4 said Resident 107 was not his regularly assigned resident and that he was unaware of the urinary bag.
The licensed vocational nurse interviewed that same day said CNAs were responsible for emptying urinary bags. When asked whether Resident 107 had been screened to perform self-emptying, she could not say.
Two days later, inspectors sat down with the facility's infection preventionist. The infection preventionist could not confirm whether any documentation existed showing Resident 107 had been assessed as capable of managing his own catheter care. There was no documentation of resident education. No supervision records. No competency evaluation related to catheter bag emptying.
The gap the inspection exposed is specific and serious. Urinary catheters are a direct pathway for bacteria to travel into the bladder. Emptying a catheter bag without gloves or hand hygiene introduces contamination at the drainage port, the precise point where the risk is highest. Urinary tract infections in catheterized patients can escalate to kidney infections and, in residents with compromised health, to bloodstream infections.
Resident 107 had been managing this task on his own, using no protective equipment, for an undetermined period of time before a federal inspector happened to be in the room when he did it.
The facility's own infection prevention and control policy, last revised in October 2018, states the program exists to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. Inspectors cited the facility for failing to meet that standard for Resident 107, classifying the harm level as minimal harm or potential for actual harm, and noting the failure affected few residents.
The classification reflects the inspection's scope, not a judgment that the situation carried no risk. A resident with fluid overload and low oxygen levels, draining his own catheter bag without gloves in a nursing facility where no one on staff could account for his care, occupied exactly the kind of gap that infection control programs exist to close.
Whether anyone at Del Rosa Villa spoke with Resident 107 about what he had been doing, or assessed his catheter care in the days after inspectors left, is not recorded in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Del Rosa Villa from 2026-02-12 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: August 4, 2026 · Our methodology
Del Rosa Villa in San Bernardino, CA was cited for violations during a health inspection on February 12, 2026.
Nobody had taught him to do this.
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.