Villa Del Rio

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

moderate// cognitive impairment. The MDS indicated Resident 7 required supervision or touching assistance with ADLs such as dressing, toilet use, personal hygiene, transfer and mobility.During an

interview on 10/29/2025 at 11:53 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated if Resident 7's toilet was broken, it placed Resident 7 at risk for skin injuries and fall. 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.

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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

11/18/2025

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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

10/28/2025 at 11:45 a.m., Resident 2 stated nurses never explain what medications he was given to drink.

Resident 2 stated it was his right to know what medications he would take or whether he would take it or not. c). 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 REDACTED] and re-admitted on [DATE REDACTED].

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 REDACTED], 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.

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