Del Rosa Villa: Safety Hazard Violations Found - CA
The resident, identified in inspection records only as Resident 107, was readmitted to the facility with fluid overload and hypoxemia, a condition in which the blood carries insufficient oxygen. Inspectors noted he had intact cognition. He was not confused about what was happening. He knew the staff had stopped coming to empty the bag attached to his wheelchair, so he started doing it himself.
On the morning of February 8, 2026, an inspector observed Resident 107 remove the drainage port from his urinary bag, demonstrate how he emptied it, and replace the port. He wore no gloves. He did not perform hand hygiene before or after. He told the inspector directly: staff were not coming in, so he had taken over the task himself.
Nobody had trained him to do it safely.
The next morning, a certified nursing assistant identified in the report as CNA 4 told inspectors that Resident 107 was not his regularly assigned resident. He said he was not aware of the urinary bag at all. A licensed vocational nurse, LVN 1, confirmed that CNAs were responsible for emptying urinary bags but could not say whether Resident 107 had ever been evaluated to determine if self-emptying was appropriate for him.
By February 11, the facility's own infection preventionist could not confirm that any documentation existed, not an assessment of whether the resident was capable of managing his own catheter care, not a record of any education provided to him, not a record of supervision, and not a competency evaluation of any kind.
There was nothing.
A urinary catheter creates a direct pathway into the bladder. Improper handling, contaminated hands touching the drainage port, failure to maintain a closed system, introduces bacteria that can travel that pathway and cause a urinary tract infection. In a resident already admitted with fluid overload and low blood oxygen, an additional infection 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 communicable diseases and infection. Inspectors cited the facility for failing to meet that standard for Resident 107.
The violation was classified as minimal harm or potential for actual harm, the lower tier of federal deficiency findings. One resident was identified as affected.
What the inspection captured, though, was not a single bad moment. It was a system that had no grip on this resident's situation at all. The nurse didn't know if he'd been evaluated. The aide didn't know about the bag. The infection preventionist had no paperwork to show anyone had ever considered what Resident 107 needed to do this safely, or whether he should be doing it himself at all.
Resident 107 knew his bag needed emptying. He figured it out on his own. He showed the inspector exactly how he'd been doing it, port removed, urine drained, port replaced, bare hands throughout.
The inspection was completed February 12, 2026.
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 noted he had intact cognition.
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.