Del Rosa Villa: Respiratory Care Deficiency - CA
Resident 107, described in inspection records as having intact cognition, told the inspector on the morning of February 8 that staff had stopped coming in to empty the bag. So he had taken over the task himself. As the inspector watched, he removed the drainage port, drained the urine, and replaced the port. No gloves. No hand hygiene before. No hand hygiene after. Nobody had taught him the correct way to do it. Nobody had assessed whether he was capable of doing it safely. Nobody had documented any of it.
The catheter bag was attached to his wheelchair.
When inspectors spoke with Certified Nursing Assistant 4 the following morning, the CNA said Resident 107 was not his regularly assigned resident. He was not aware the man had a urinary bag at all.
Licensed Vocational Nurse 1, interviewed the same morning, said CNAs were responsible for emptying urinary bags. When asked whether Resident 107 had been screened to perform the task himself, LVN 1 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 as capable of managing his own catheter care. There was no record of education provided to him. No record of supervision. No record of a competency evaluation.
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. His body was already under strain. An improperly managed urinary catheter, one of the most common sources of healthcare-associated infection, carried the potential to add to that burden.
Urinary tract infections tied to catheters can progress quickly in elderly residents, particularly those with underlying health conditions. The inspection report classified the harm level as minimal, or potential for actual harm, meaning inspectors determined no infection had been confirmed at the time of the survey. What they confirmed was the setup for one.
The gap between what the facility's own infection control policy promised and what Resident 107 actually received was not subtle. The policy, last revised in October 2018, described a program designed to provide a safe, sanitary, and comfortable environment and to prevent the transmission of infection. The man emptying his catheter bag ungloved in his wheelchair was one of 20 residents sampled during the inspection.
Nobody on the nursing staff could say how long the situation had been going on. Nobody could say who, if anyone, had last emptied the bag before Resident 107 started doing it himself. The CNA responsible for his care that day hadn't known the bag existed.
Del Rosa Villa sits on North Del Rosa Avenue in San Bernardino. The inspection was completed February 12, 2026. The deficiency was cited under federal standards requiring facilities to maintain an infection prevention and control program.
What the records show is a man with a serious medical history, a catheter attached to his wheelchair, and no one coming to help him. So he helped himself, the wrong way, because no one had shown him the right way, and no one had thought to check.
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.
So he had taken over the task himself.
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.