Villa Del Rio
VILLA DEL RIO in BELL GARDENS, CA — inspection on November 18, 2025.
Found 2 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 an interview on 10/29/2025 at 1:00 p.m., with HK 2, HK 2 stated Resident 7's toilet seat was observed broken on 10/28/2025 but was not written in the maintenance book and the MS was not informed.
During an interview on 10/29/2025 at 1:54 p.m. with MS, the MS stated if there was anything in residents' rooms broken and needing repair, the staff should write the information in the maintenance repair binder at the nurses' station.
The MS stated the Maintenance Assistant (MA) would check the binder every morning.
During an interview on 10/29/2025 at 2:20 p.m., with the Director of Nursing (DON), the DON stated the facility must ensure the residents' bathrooms, doors, toilet seats and walls are kept clean and in good working condition, and residents are provided with a safe and home-like environment.
During a review of the facility's policy and procedures (P&P) titled, Safe and Homelike Environment, dated 1/2025, the P&P indicated the facility should provide residents with a safe, clean, comfortable and homelike environment.
During a review of the facility's P&P titled, Maintenance Services, dated 1/2025, the P&P indicated the maintenance department is responsible for maintaining the building is in good repair and free from hazards.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/18/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Del Rio
7002 Gage Avenue Bell Gardens, CA 90201
SUMMARY STATEMENT OF DEFICIENCIES
During a concurrent observation and interview on 10/28/2025 at 10:10 a.m., in Resident 3's room, LVN 1 had all of Resident 3's medications crushed in a plastic bag. LVN 1 administered Resident 3's medications via gastrostomy tube (a tube surgically inserted into the stomach for medications and nutrition administration). LVN 1 stated he usually put all medications in one bag and crush them. LVN 1 stated all the medications are going to the same place (unspecified). LVN 1 stated that after the medications were administered, the staff can monitor the residents. LVN 1 stated he does not know what the facility policy was on crushing the medications separate.During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 3's diagnoses included HTN, DM, and Parkinson disease (a progressive neurological disorder that affects movement, balance, and coordination).During a review of Residents 3's MDS dated [DATE], the MDS indicated Resident 3 had cognitive impairment.
The MDS indicated Resident 3 was dependent on staff with ADLs such as dressing, toilet use, personal hygiene, transfer and mobility.During a review of Resident 3's Physicians Orders for 10/2025, the physician orders indicated Resident 2's order for Amlodipine 10 mg daily at 9 a.m., Carvedilol (treat high blood pressure) tablet 6.25mg daily, Metformin (treat type 2 diabetes) 500 mg daily and Amantadine (anti-Parkinson's agent) 50 mg daily.During an interview on 10/28/2025 at 1:58 p.m., with LVN 1, LVN 1 stated the nurses should let the residents know what kind of medications they were given to take regardless if they understand or not. LVN 1 stated each medication should have been administered separately, in case residents display any adverse reaction to the medication and vomit. LVN 1 stated it would be easier to point out which medication had caused the discomfort.
During an interview on 10/29/2025 at 2:20 p.m. with the Director of Nursing (DON), the DON stated nurses must follow the 5 rights of medications pass (unspecified).
The DON stated nurses should explain to the residents the name of medications they were administrating.
The DON stated staff should crush the medication separately to identify what medications were administrated.During a review of the facility's policy and procedures (P&P) titled, Medication Administration, dated 1/2025, the P&P indicated, medications should be administrated by licensed nurses, in accordance with professional standards of practice.
The P&P indicated to explain the purpose of medication administration.
Facility ID:
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.