Del Rosa Villa: Pest Control Program Failures - CA
Inspectors watched him do it.
During a visit on February 8, 2026, the resident, identified in inspection records as Resident 107, told inspectors that staff were not coming in to empty the bag. He then demonstrated what he had been doing on his own, removing the drainage port, draining the urine, and replacing the port with bare hands. He did not wash his hands before or after. Inspectors observed the entire process.
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. He knew what he was doing. What he didn't know was how to do it without putting himself at risk of infection, because nobody at Del Rosa Villa had ever taught him.
The certified nursing assistant inspectors spoke to the following morning said Resident 107 wasn't his regularly assigned resident. He wasn't aware of the urinary bag at all.
The licensed vocational nurse on the unit told inspectors that emptying urinary bags was a CNA responsibility. When asked whether Resident 107 had ever been screened to determine if self-emptying was appropriate for him, the nurse could not answer. There was no documentation of any such screening.
The facility's infection preventionist, interviewed on February 11, could not confirm whether any assessment had been completed to determine if Resident 107 was capable of managing his own catheter care. There was no documentation of resident education. No documentation of supervision. No documentation of a competency evaluation.
What the records showed, instead, was a resident who had filled a gap the facility left open, doing a clinical task with his bare hands because the alternative was sitting with a full drainage bag and waiting for help that wasn't coming.
Urinary catheters are among the most common sources of healthcare-associated infection. When a drainage bag is emptied without gloves or hand hygiene, bacteria from the hands can enter the drainage system and travel up the catheter into the bladder. For a resident already managing fluid overload and compromised oxygen levels, an infection of that kind is not a minor complication.
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 prevent the development and transmission of infection. The policy existed on paper. What inspectors found on the unit was a resident demonstrating his improvised technique to a surveyor, still waiting for someone to show him how to do it right.
Del Rosa Villa is a nursing facility at 2018 N Del Rosa Ave in San Bernardino. The inspection was conducted February 12, 2026. The deficiency was cited at a level of minimal harm or potential for actual harm, affecting few residents. The facility was directed to contact the state survey agency for information on its plan of correction.
The infection preventionist had no documentation to show. The nurse couldn't say whether a screening had happened. The aide didn't know the resident existed.
Resident 107, meanwhile, had already figured out his own system.
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.
He then demonstrated what he had been doing on his own, removing the drainage port, draining the urine, and replacing the port with bare hands.
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.