Del Rosa Villa: Care Planning Deficiencies - CA
No gloves. No hand hygiene before. No hand hygiene after.
The man, identified in inspection records only as Resident 107, was sitting in his wheelchair when an inspector observed him on the morning of February 8. He removed the drainage port himself, demonstrated how he emptied the bag, and replaced the port. He told the inspector directly: staff were not coming in to do it, so he had been handling it himself.
Resident 107 is cognitively intact. He was readmitted to Del Rosa Villa with diagnoses that included fluid overload and hypoxemia, a condition in which the blood carries insufficient oxygen. He was also managing a urinary catheter, a device that, when handled without proper technique, creates a direct pathway for bacteria to enter the body and cause infection.
Nobody at the facility had assessed whether he was capable of managing his own catheter care. Nobody had trained him how to do it safely. Nobody had documented supervising him or checked whether he understood the risks.
When inspectors interviewed a certified nursing assistant the following morning, the aide said Resident 107 was not his regularly assigned resident. He was not aware the man had a urinary bag at all.
A licensed vocational nurse interviewed the same day said the CNAs were responsible for emptying urinary bags. When asked whether Resident 107 had ever been screened to perform the task himself, the nurse could not answer.
The facility's infection preventionist, interviewed on February 11, could not confirm whether any documentation existed showing Resident 107 had been assessed, educated, or evaluated on catheter-bag emptying. There was nothing to point to.
What inspectors found was a gap that had apparently gone unnoticed across multiple shifts and multiple staff members. A resident with a catheter, sitting in his wheelchair, doing a clinical task with bare hands because the alternative was waiting for help that was not coming.
Urinary catheters carry well-established infection risks under any circumstances. Catheter-associated urinary tract infections are among the most common healthcare-acquired infections in long-term care settings, and improper handling of drainage equipment is a recognized contributor. For a resident already admitted with compromised respiratory function and fluid imbalance, an added infection is not a minor complication.
Del Rosa Villa'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 communicable diseases and infection. The policy did not prevent what inspectors watched happen on a Tuesday morning in February.
The deficiency was cited at a level of minimal harm or potential for actual harm, the lower tier of the federal harm scale. CMS inspectors completed the survey on February 12, 2026.
What the rating does not capture is the picture inspectors recorded: a man showing a federal inspector, step by step, exactly how he had been doing something he was never taught to do safely, in a facility that had no record he was doing it at all.
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.
The man, identified in inspection records only as Resident 107, was sitting in his wheelchair when an inspector observed him on the morning of February 8.
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.