Del Rosa Villa: Resident Rights Violations - CA
Inspectors visited the facility on February 8, 2026, and found Resident 107 sitting in his wheelchair with a urinary drainage bag attached. He told them staff had not been coming in to empty it, so he had been handling it himself. Then he showed them exactly what that looked like: he removed the drainage port, emptied the bag, and replaced the port, all without gloves, and without washing his hands before or after.
The resident had intact cognition, according to his assessment records. He knew what he was doing. He just hadn't been shown how to do it without putting himself at risk.
A catheter that drains into a collection bag creates a direct pathway for bacteria to travel into the bladder. Improper handling, including touching the drainage port with unwashed hands, is one of the primary ways catheter-associated urinary tract infections begin. The resident had been readmitted to Del Rosa Villa with diagnoses that included fluid overload and hypoxemia, low oxygen levels in the blood. An infection on top of those conditions would not be a minor complication.
The next morning, inspectors spoke with a certified nursing assistant identified in the report as CNA 4. He said Resident 107 was not his regularly assigned resident and that he was not aware the man had a urinary bag. A licensed vocational nurse told inspectors that CNAs were responsible for emptying urinary bags. When asked whether Resident 107 had been screened to determine if he could safely manage the task himself, the nurse could not say.
Nobody could say.
On February 11, inspectors spoke with the facility's infection preventionist, the staff member whose specific job is to track and prevent exactly this kind of risk. The infection preventionist could not confirm whether Resident 107 had ever been assessed as capable of managing his own catheter care. There was no documentation of education provided to him, no record of supervision, no competency evaluation. Nothing on paper to show the facility had made a deliberate decision to let him handle this himself, or had prepared him to do it without causing himself harm.
What the record showed instead was a resident who had figured out, on his own, that nobody was coming. So he handled it.
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 help prevent the development and transmission of communicable diseases and infection. Inspectors cited the facility for falling short of that standard for Resident 107.
The violation was classified as minimal harm or potential for actual harm, meaning inspectors found no documented evidence the resident had already developed an infection. That classification reflects what could be confirmed on paper, not necessarily what the resident experienced during the weeks or months he had been emptying the bag himself.
He showed the inspectors the technique unprompted. He had clearly done it many times.
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.
Inspectors visited the facility on February 8, 2026, and found Resident 107 sitting in his wheelchair with a urinary drainage bag attached.
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.