Villa Del Rio

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

still needed.During a review of Resident 5's Psychiatric Note, dated 6/16/2025, the Note indicated, Staff report intermittent episodes of verbal abuse, aggressive behavior, and occasional refusal of oral medications, necessitating administration of [PRN] Haldol. Current treatment plan to be maintained.During

an interview on 8/26/2025 at 11:54 a.m., with Pharmacist 1, Pharmacist 1 stated orders for PRN antipsychotic medication were limited to 14 days without any exceptions. Pharmacist 1 stated if the resident's physician wanted to continue the PRN antipsychotic medication, the physician had to examine

the resident directly to determine if the medication was still required. During an interview on 8/26/2025 at 12:34 p.m., with the Medical Director (MD), the MD stated PRN antipsychotic medication was limited to 14 days and after 14 days, the order should be discontinued until the resident was evaluated by the psychiatrist. The MD stated if the psychiatrist orders a PRN antipsychotic medication for longer than 14 days, the facility was responsible for calling the psychiatrist to ensure the order was changed. The MD stated the evaluation by the psychiatrist was important to determine whether the current medication regimen was effective or if the regimen had to be adjusted. During an interview on 8/26/2025 at 1:17 p.m., with the Director of Nursing (DON), the DON stated Resident 5 received PRN Haldol when Resident 5 refused the oral Haldol. The DON stated Resident 5's PRN Haldol order exceeded the 14 days instead of being discontinued. The DON stated after 14 days, Resident 5's psychiatrist should have reevaluated Resident 5's need for PRN Haldol. The DON stated if Resident 5 was reevaluated every 14 days, Resident 5's psychiatric healthcare team would have evaluated her about twice a month, however Resident 5 was only seen once a month. The DON stated if Resident 5's medications were reevaluated; a different medication regimen could have been attempted where Resident 5 would be less likely refuse medications.

The DON stated due to the lack of evaluation, Resident 5 continued to refuse medications which exacerbated her behavior. During a review of the facility's Policy and Procedure (P&P) titled, Use of Psychotropic Medication(s), reviewed 1/2025, the P&P indicated, PRN orders for psychotropic medications only, shall be limited to 14 days with no exceptions. If the attending physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate.

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Del Rio

7002 Gage Avenue Bell Gardens, CA 90201

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

residents. The DON stated retaining the records was necessary to refer to, if needed, and to provide proof that the staff member was cleared of any criminal history prior to working on the floor. The DON stated if a staff member had a criminal record of abuse or neglect and were to abuse a resident, that situation could have been prevented.During a review of the facility's Policy and Procedure (P&P) titled, Employee Screening, revised 2025, the P&P indicated, Background checks and verification of employment eligibility status will be conducted in accordance with our facility's established policies and procedures governing

these issues.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Del Rio

7002 Gage Avenue Bell Gardens, CA 90201

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to implement their policy and procedure titled Enteral Feedings-Safety Precautions to ensure one of four sampled residents, Resident 2 was in an upright 30-degree position during gastrostomy tube (G-tube- is a tube inserted through the belly that brings nutrition directly to the stomach) feeding. This failure had the potential to result in aspiration (occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed), difficulty breathing, infections and impede progress to wellness.Findings: During a concurrent interview and observation on 08/20/2025 at 11:00 a.m. with the assigned Licensed Vocational Nurse (LVN 1), Resident 2 was observed lying in bed with the head of bed (HOB) at a 20-degree angle, while receiving gastrostomy tube (G-tube- is

a tube inserted through the belly that brings nutrition directly to the stomach) feeding of Glucerna 1.2 calorie infusing at 60 cc (cubic centimeters) an hour. LVN 1 stated the head of the bed is lower than a 25-degree angle and it should be at a 30-35-degree angle to decrease the risk of aspirating from the feeding. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE REDACTED] with diagnoses of chronic obstructive pulmonary disease (COPDa common lung disease that makes it difficult to breathe), hemiplegia and hemiparesis following a cerebral infraction (hemiplegia is complete paralysis of one side of the body, while hemiparesis is partial weakness

on one side, and both can be caused by a stroke), and aphasia (a neurological disorder that impairs the ability to communicate effectively) following stroke. During a review of Resident 2's Minimum Data Set (MDS- an assessment and care planning tool) dated 6/28/2025, indicated Resident 2 had unclear speech, sometimes understood, and sometimes understands. The MDS indicated Resident 2 was dependent (helper does all the effort) on staff for toileting hygiene, personal hygiene and showering/bathing. During a

review of Resident 2's Order Summary Report, dated 8/20/2025, the order summary report indicated Enteral Feed Order every shift for Glucerna 1.2 at 60 cc an hour to deliver 1200 cc/1440 kilocalorie (kcal, unit of energy measurement commonly used in nutrition and food science) daily via g-tube or 20 hours or until completed. Keep head of bed elevated greater than 30-45 degrees at all times while feeding and at least 1 hour after feeding. During a review of Resident 2's care plan related to g-tube feeding, dated 07/12/2025, the care plan indicated Resident 2 was at risk for gastrointestinal (the stomach and intestines, along with the organs and processes involved in digestion, absorption of nutrients, and elimination of waste) complications related to tube feeding such as aspiration, dehydration and nausea, vomiting and diarrhea. The care plan goal indicated Resident 2 will tolerate tube feeding free from complications daily for 90 days. The care plan nursing interventions included elevating the head of the bed at least 30-45 degrees at all times during feeding and at least 1 hour after feeding, check tube placement/patency, and cleanse g-tube site daily and as needed for soilage/leakage or staining. During a review of the facility's policy and procedure titled Enteral Feedings-Safety Precautions revised 2025, indicated to ensure the safe administration of enteral nutrition all personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. The facility will remain current in and follow accepted best practices in enteral nutrition. Always elevate the head of the bed (HOB) at least 30 -45 during tube feeding and at least 1 hour after. Monitor the tube-fed resident for signs and symptoms of respiratory distress during feedings and medication administration.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Villa Del Rio

7002 Gage Avenue Bell Gardens, CA 90201

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Nursing (DON), the DON stated the licensed nurses were responsible for explaining to each of their residents the medications they administered. The DON stated the residents had the right to be informed and given the chance to refuse their medications. The DON stated informing the residents of their medications would allow the residents to ask questions if they did not understand why they were taking a specific medication.During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration, revised 1/2025, the P&P indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. The P&P stated to explain the purpose of the nurse's visit to the resident.

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Facility ID:

If continuation sheet