Villa Del Rio
VILLA DEL RIO in BELL GARDENS, CA — inspection on May 27, 2026.
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
Discharge, dated 2026, was reviewed.
The P&P indicated when a resident expresses their wishes to
leaving.
The P&P indicated the physician should be notified of the intended AMA discharge and the
indicated social services should document any discussions held with the resident in the social services progress notes.
The ADM stated the required AMA discharge process was not completed for Resident 1.
The ADM stated the facility should have followed its AMA discharge policy but did not.
The ADM stated the facility failed to follow its AMA discharge policy when Resident 1 left the faciity on 5/22/2026.
The ADM stated the facility failed to complete the required AMA discharge process as required per facility policy.
555781 05/27/2026
Villa Del Rio 7002 Gage Avenue Bell Gardens, CA 90201
During a review of Resident 1's record titled Social Services History and Initial Assessment, dated 5/19/2026, the record indicated Resident 1 had the ability to understand and be understood by others.
The clinical record indicated Resident 1's cognition (the ability to think and process information) was intact.
During a review of Resident 1's progress note, authored by Licensed Vocational Nurse (LVN) 1, dated 5/26/2026, the progress note indicated on 5/22/2025 at 4:32 p.m., Resident 1 was observed pacing back and forth in the television room.
When approached resident became verbally aggressive towards staff.
Attempted to redirect resident to room but resident continued to show agitation.
During a concurrent observation and interview on 5/27/2026 at 12:55 p.m., with the Administrator (ADM), the facility's video surveillance footage, dated 5/22/2026, from 3:30 p.m. to 3:50 p.m., was reviewed.
The video surveillance footage revealed Resident 1 was observed standing in the television room. Resident 1 was not exhibiting aggressive behavior.
The footage did not show Resident 1 yelling, striking, threatening, or attempting to physically harm any resident or staff.
The footage also indicated there was no staff present in the television room.
The ADM stated the video surveillance footage did not show Resident 1 displaying aggressive behaviors and did show staff present in the television room on 5/22/2026 between 3:30 p.m. and 3:50 p.m.
The ADM stated the video footage did not support LVN 1's documentation that Resident 1 exhibited aggressive behaviors on 5/22/2026.
During a concurrent interview and record review on 5/27/2026 at 3:30 p.m., with LVN 1, Resident 1's progress note, dated 5/26/2026 timed 6:23 p.m., was reviewed.
The progress note indicated Resident 1 exhibited aggressive behaviors on 5/22/2026 at 4:32 p.m LVN 1 stated the progress note was not documented at the time of the alleged event and was documented four days later, on 5/26/2026. LVN 1 stated the event should have been documented timely and accurately in Resident 1's medical record to ensure the record reflected the resident's current condition, behaviors, and interventions provided. LVN 1 stated delayed documentation could affect the accuracy and completeness of Resident 1's clinical record.
During an interview on 5/27/2026 at 4:35 p.m., with the Director of Nursing (DON), the DON stated staff were expected to document resident behaviors, incidents, assessments, and interventions timely and accurately in the resident's medical record.
The DON stated documentation should be completed at or near the time the event occurred to ensure the medical record reflected the resident's current condition and the care provided.
The DON stated late documentation may affect the accuracy and completeness of the resident's clinical record.
The DON stated Resident 1's progress note, dated 5/26/2026 and timed 6:23 p.m., regarding Resident 1's alleged aggressive behavior on 5/22/2026, was not documented timely.
The DON stated Resident 1's medical record should contain accurate information supported by the resident's condition, staff observations, and interventions provided.
During a review of the facility's P&P titled Charting and Documentation, reviewed 2026, the P&P indicated all incidents, accidents, or changes in resident's condition must be timely recorded in their medical record.
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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.