Villa Del Rio
VILLA DEL RIO in BELL GARDENS, CA — inspection on April 24, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 41's Admission Record, the Admission Record indicated Resident 41 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a
potential for actual harm persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and mood disorder (conditions that primarily affect a person's emotional
41 was self-responsible and did not have an emergency contact nor next of kin listed.
During a review of Resident 41's Minimum Data Set ([MDS], a resident assessment tool), dated 2/7/2025, the MDS indicated Resident 41's cognition (process of thinking) was severely impaired.
The MDS indicated Resident 41 required maximal assistance (helper does more than half the effort) with toileting, bathing, and lower body dressing.
The MDS indicated Resident 41 received antipsychotic, antidepressant, and anticonvulsant medication.
During a review of Resident 41's History and Physical (H&P), dated 2/3/2025, the H&P indicated Resident 41 did not have the capacity to understand and make decisions.
During a review of Resident 41's Orders, dated 2/3/2025, the Orders indicated to give:
1.
Aripiprazole 10 milligrams (mg, a unit of measurement), one tablet by mouth at bedtime, for schizoaffective disorder manifested by screaming.
2.
Depakote 125mg, three tablets by mouth, twice a day, for mood disorder as manifested by attempting to strike out.
3.
Lexapro 5mg, one tablet by mouth, once a day, for depression manifested by crying.
During a review of Resident 41's Medication Administration Record ([MAR], a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 2/1/2025 through 2/28/2025, the MAR indicated:
1. Resident 41 received the first dose of aripiprazole 10 mg on 2/3/2025 at 9 p.m.
2. Resident 41 received the first dose of Lexapro 5 mg on 2/4/2025 at 9 a.m.
3. Resident 41 received the first dose of Depakote 375 mg on 2/4/2025 at 9 a.m.
During an interview on 4/23/2025 at 11:05 a.m., with the Social Services Director (SSD), the SSD stated Resident 41 was unable to understand and make decisions for himself therefore Resident 41 should not be consenting to medical treatments or medications.
The SSD stated Resident 41 should have been referred to obtain a conservator (an appointed person to act or make decisions for a person who cannot make decisions for themselves) who would advocate for Resident 41 and determine whether a prescribed treatment or medication was appropriate for Resident 41 to receive.
555781
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555781 B.
Wing 04/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Del Rio 7002 Gage Avenue Bell Gardens, CA 90201
During a review of Resident 41's Admission Record (Face Sheet), the Face Sheet indicated Resident 41 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and mood disorder (conditions that primarily affect a person's emotional state, causing significant distress or impairment in their daily life).
The Face Sheet indicated Resident 41 was self-responsible and did not have an emergency contact nor next of kin listed.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
555781
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555781 B.
Wing 04/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Del Rio 7002 Gage Avenue Bell Gardens, CA 90201
During a review of Resident 114's Admission Record, the Admission Record indicated Resident 114 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), cerebral infarction (stroke, loss of blood flow to a part of the brain), aphasia (a disorder that makes it difficult to speak), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting right dominant side and a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered).
During a review of Resident 114's Minimum Data Set ([MDS], a resident assessment tool), dated 3/28/2025, the MDS indicated Resident 114's cognitive skills (ability to think and reason) for daily decision making were severely impaired.
The MDS indicated Resident 114 was entirely dependent (helper does all the tasks) on staff for bathing, toileting, performing personal hygiene, sitting to standing, and transferring from the bed to a chair.
The MDS indicated Resident 114 had an active diagnosis of a stroke.
During a review of Resident 114's Order Summary Report, dated 4/23/2025, Resident 114 was ordered to have a physical therapy (PT) and occupational therapy (OT) evaluation (PT evaluations assesses a person's movement, strength, and range of motion. OT evaluation focuses on how those physical and cognitive skills impact daily activities) performed on 1/1/2023.
The Order Summary Report did not indicate Resident 114 was ordered PT, OT and, or RNA services after the evaluations were ordered.
555781
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555781 B.
Wing 04/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Del Rio 7002 Gage Avenue Bell Gardens, CA 90201
During a review of Resident 114's Admission Record, the Admission Record indicated Resident 114 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), cerebral infarction (stroke, loss of blood flow to a part of the brain), aphasia (a disorder that makes it difficult to speak), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting right dominant side and a gastrostomy (a surgical opening fitted with a device to allow feedings to be administered).
During a review of Resident 114's Activities of Daily Living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) Care Plan, dated 12/10/2024, the ADL Care Plan indicated Resident 114 required extensive assistance with bed mobility, eating, toileting, and transfers.
During a review of Resident 114's Minimum Data Set ([MDS], a resident assessment tool), dated 3/28/2025, the MDS indicated Resident 114's cognitive skills (ability to think and reason) for daily decision making was severely impaired.
The MDS indicated Resident 114 was entirely dependent (helper does all the task) on staff for bathing, toileting, performing personal hygiene, sitting to standing, and transferring from the bed to a chair.
The MDS indicated Resident 114 had an active diagnosis of a stroke (loss of blood flow to a part of the brain).
During a review of Resident 114's Order Summary Report, dated 4/23/2025, Resident 114 was ordered to have a PT and OT evaluation performed on 1/1/2023.
The Order Summary Report did not indicate Resident 114 was ordered PT, OT, or RNA services after the evaluations were ordered on 1/1/2023.
During observations made on 4/21/2025 at 9:30 a.m. and on 4/24/2025 at 10:38 a.m., Resident 114 was non-verbal, and was positioned on her back in bed while her g-tube feeding (liquid nutrition delivered directly to the stomach) was administered. Resident 114's arms and legs were bent.
555781
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555781 B.
Wing 04/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Del Rio 7002 Gage Avenue Bell Gardens, CA 90201