Del Rosa Villa: Infection Control Program Failures - CA
The resident, identified in inspection records only as Resident 107, told the inspector on February 8 that staff were not coming to empty the bag. So he had been handling it himself. He demonstrated: removed the drainage port, drained the urine, replaced the port. No gloves. No hand hygiene before. No hand hygiene after.
He had intact cognition, according to his own assessment on file at the facility. He knew what he was doing. What he had not been given was any instruction on how to do it safely.
Resident 107 had been readmitted to Del Rosa Villa with diagnoses that included fluid overload and hypoxemia, a condition in which the blood carries insufficient oxygen. He was in a wheelchair. His urinary drainage bag hung from it with a covering attached.
When inspectors spoke to a certified nursing assistant the following morning, the CNA said Resident 107 was not his regularly assigned resident. He was not aware of the urinary bag. When inspectors asked a licensed vocational nurse about the situation, she confirmed that CNAs were responsible for emptying urinary bags. She could not say whether anyone had ever screened Resident 107 to determine if self-emptying was appropriate for him.
Nobody had.
The facility's infection preventionist, interviewed on February 11, could not point to any documentation showing Resident 107 had been assessed as capable of managing his own catheter care. There was no record of education provided to him. No record of supervision. No competency evaluation of any kind related to how he was handling the drainage bag attached to his body every day.
What inspectors found instead was a gap: a man with a catheter, a bag that needed regular emptying, and a care system that had apparently stopped showing up. In the absence of staff, he improvised. The improvisation put him at risk for infection. A urinary catheter is a direct line into the body. Bacteria introduced during improper handling can travel that line and cause serious, sometimes life-threatening infections.
Del Rosa Villa has an infection prevention and control policy. It was last revised in October 2018. It states the facility maintains a program to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of infection. Inspectors cited the facility for failing to meet that standard for Resident 107.
The violation was rated as minimal harm or potential for actual harm, the lower end of the federal harm scale. But the scenario inspectors documented was not a paperwork lapse. It was a resident sitting in his wheelchair, demonstrating to an inspector how he had learned, on his own, to manage a medical device because no one from the facility had made it their business to do it for him or teach him how to do it right.
No staff member interviewed could account for how long this had been going on. No one could say when Resident 107 had last had his catheter bag emptied by a trained employee. The CNA who spoke to inspectors had not known the bag existed.
Resident 107 told inspectors himself. He showed them. He sat there in his wheelchair and pulled out the drainage port and explained what he had figured out to do, alone, in a room where the staff were not coming.
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 5, 2026 · Our methodology
Del Rosa Villa in San Bernardino, CA was cited for violations during a health inspection on February 12, 2026.
The resident, identified in inspection records only as Resident 107, told the inspector on February 8 that staff were not coming to empty the bag.
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.