Inspection visit
Health inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on observation, interview and record review, the facility failed to ensure the residents were treated
with respect and dignity for four to five residents sitting at the same table during meals, by being served at
the same time.
The failure to provide the necessary care left the residents hungry for extended periods of time while
looking at others eat, picking at other residents foods, making them anxious, and frustrated.
Findings:
a. On 7/26/18 at 7:40 am, five residents at four different tables waited more than 30 minutes to receive their
meals while the other three to four other resident's at the same table were already eating and/or finished
with their food. One resident loudly yelled out three times, Where's my food, however, he continued to wait
twenty five more minutes before he was served. Another resident asked the certified nursing assistant on
two different occasions where his food was and continued to wait twenty to twenty five more minutes before
his food was served. A third resident was observed taking food and eating it from the plate of the resident
directly across from him, he continued to wait approximately twenty five more minutes for his food.
On 7/27/18 11:35 am Resident 117 stated he eats off of other peoples (residents) plates because he's
hungry and it takes a long time to get his food.
On 8/1/18 at 7:50 am the licensed vocational nurse (LVN 15) stated she was fairly new and was not sure of
the system in place for running the dining room. LVN 15 stated had noticed some of the residents had to
wait a while to be served while other residents at their table were already eating. LVN 15 stated she had
heard some of the residents complain about being hungry and having to wait so long for their food. LVN 15
stated she had noticed some of the residents became anxious and frustrated after waiting so long for their
food. LVN 15 stated nursing and the dietary department have been communicating to come up with a better
way to serve the residents in a timely manner.
b. On 7/27/18 at 10 am, during the group meeting, three of eight residents stated the facility needs to
improve on the timeliness of when the food was served. They agreed it takes a long time for them to get
their food in the dining room. One resident stated he has to wait thirty minutes or more to get his tray.
Another resident stated when he ask the staff for his tray they say It's coming. The resident stated he did
not like that because he was hungry when he went to the dining room. The resident stated it happens
almost everyday.
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
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 11
Event ID:
555780
Printed: 05/15/2026
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
555780
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Del Rio Gardens
7004 East 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 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure the Physician Orders for
Life-Sustaining Treatment ([POLST] approach to improving end-of-life care in the United States,
encouraging providers to speak with patients and create specific medical orders to be honored by health
care workers during a medical crisis) form was completely filled out for one of 17 sampled residents (47).
The failure to provide the necessary services did not show communication between individuals and their
healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time
when individuals are not able to make their own healthcare decisions.
Findings:
On 7/27/18 at 8 am Resident 47 was observed while conducting general rounds. During attempts to
converse Resident 47 could not respond or express himself verbally.
A review of the medical records indicated Resident 47 was admitted to the facility on [DATE] with diagnoses
including schizophrenia (sever mental disorder with an abnormal interpretation of reality) and psychosis
(loss of contact with reality).
A review of the POLST form dated 2/6/18 revealed that it had not been signed by the resident or a
recognized decision-maker. A signature from the aforementioned would have acknowledged the resident's
known desires regarding resuscitative measures.
A review of a History & Physical form dated 3/8/18 indicated Resident 47 did not have the capacity to
understand and make decisions.
On 7/31/18 at 3:50 pm upon reviewing the POLST the social service designee (SSD) stated, I think that's
my handwriting, I think I wrote that Resident 47 could not sign the POLST due to his altered condition. The
SSD stated when she wrote on the POLST she meant the resident could not physically sign the form. She
stated Resident 47 could understand simple things but she did not think he could understand the entirety of
the POLST. The SSD stated she could have/should have reached out to Resident 47's family member or
considered a conservator to act as the recognized decision-maker.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555780
If continuation sheet
Page 2 of 11
Printed: 05/15/2026
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
555780
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Del Rio Gardens
7004 East 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 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure one of 17 sampled residents (59) was
covered and not exposed during incontinence (accidental or involuntary loss of urine from the bladder or
bowels) care, skin care and a wound treatment.
Residents Affected - Some
The failure to provide the necessary care created the potential to make the resident feel embarrassed,
uncomfortable and disrespected.
Findings:
a 1. On 7/26/18 at 9:15 am Resident 59 was observed during incontinence care with two certified nursing
assistants (CNAs 7 and 8), and one restorative nursing assistant (RNA 1) at the bedside. After the bed
covers and Resident 59's clothing was removed, her peri-area and buttocks were left uncovered/exposed
during the entire procedure. During a concurrent interview, Resident 59 was not exactly sure what care was
provided by the nurses earlier that day. The resident could not recall if she was covered or uncovered
during incontinence care.
On 7/27/18 at 3:05 pm CNA 7, 8 and RNA 1 stated someone should have closed the privacy curtain while
providing care for Resident 59. Additionally, CNA 7, 8 and RNA 1 stated the resident should have been
covered as much as possible during incontinence care.
A review of the medical records indicated Resident 59 was admitted to the facility on [DATE] with diagnoses
including Alzheimer's disease (a disease process that destroys memory and thinking).
A resident care plan dated 1/9/18 addressed Resident 59's impaired activities of daily living (ADL) and
physical functioning. The nursing approach plan included ensuring the resident wore appropriate attire daily.
A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated
7/15/18 indicated Resident 59 was occasionally incontinent of bowel and bladder function. The MDS
indicated Resident 59 was totally dependent on the staff for toilet use.
A review of a facility's policy and procedure titled Dignity dated 10/09 indicated each resident shall be cared
for in a manner that promotes and enhances dignity and respect.
a 2. On 7/26/18 at 9:15 am Resident 59 was observed during a wound treatment and skin care. While
providing care to Resident 59 the licensed vocational nurses (LVN 16, 17) left the peri-area uncovered and
exposed. Additionally, Resident 59's privacy curtain remained opened during the entire procedure. Resident
59 was located in the A bed, closest to the door. While Resident 59's wound treatment/skin care was being
done the resident in bed C attempted to leave the room, however, the door to the room was closed. The
resident in bed C stood by the foot of the bed, facing Resident 59 waiting for the door to be opened, as
Resident 59 lay in the bed with the privacy curtain wide opened and her entire peri-area exposed.
A review of a resident care plan dated 7/24/18 addressed concerns with Resident 59's skin. The nursing
approaches included providing protective wears of clothing for the resident.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555780
If continuation sheet
Page 3 of 11
Printed: 05/15/2026
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
555780
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Del Rio Gardens
7004 East 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 0583
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
A review of the physicians orders dated 7/24/18 indicated Resident 59 had redness to the right and left
inguinal (groin) area. The order indicated to apply Nystatin (antifungal) cream with triamcinolone (steroid to
reduce redness, swelling, itching), left open to air over a 21 day period. The orders indicated the same
treatment was to be applied to the resident's right and left buttocks.
A review of a facility's policy and procedure titled Dignity dated 10/09 indicated the staff shall promote,
maintain and protect a resident's privacy including bodily privacy during personal care and treatment
procedures.
Event ID:
Facility ID:
555780
If continuation sheet
Page 4 of 11
Printed: 05/15/2026
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
555780
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Del Rio Gardens
7004 East 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 0584
Level of Harm - Potential for
minimal harm
Residents Affected - Many
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to maintain one of 17 sampled residents (31)
safety by:
The resident overhead bed light cover was not left open to prevent the residents from removing the
electrical light bulbs from the light socket.
This deficient practice had the potential of causing physical harm to the resident.
Findings:
On July 25, 2018, at 3 p.m., during the initial tour observed that Resident 31's room [ROOM NUMBER] Bed
- C light cover panel above the head of bed (HOB) that was used to protect the resident from removing the
glass light bulbs from the inlet socket had been removed.
According to the admission records Resident 31 was admitted to the facility on [DATE] with diagnoses that
included hemiplga (stroke one side of body) diabetes mellitus (high sugar level in blood) without
complications.
The annual Minimum Data Set (MDS), a standardized assessment and care screening tool, dated
December 15, 2017, indicated Resident 31 had the cognitive ability to make self understood and
understand others. The resident independence from the staff for activities of daily living.
On July 27, 2018 at 3:15 p.m., during an interview with the Maintenance Director about the the light cover
panel having been left open, Maintenance Director stated the cover panel was to protect Resident 31 from
removing the electrical light bud from the socket. The Maintenance Director stated the facility will have do
inservices for the staff that the light cover panels, or not to be left open but close for the residents' safety.
According to the facility's policy titled Maintenance Inspection, dated 2017 indicated it is the policy of this
facility to maintain compliance with maintenance services. The Director of Maintenance will perform random
and or routine inspections using the maintenance checklist. The maintenance supervisor will explain or
demonstrate the optimal function of an equipment or items inside a resident unit/room such as the over bed
light fixture's appropriate placement etc.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555780
If continuation sheet
Page 5 of 11
Printed: 05/15/2026
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
555780
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Del Rio Gardens
7004 East 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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to develop a comprehensive care plan with
concerns/problems, including measurable goals and interventions for one of 17 sampled residents (26),
receiving Tylenol #3 with codeine, without including location of the pain.
This deficient practice had the potential of contributing to further pain leading to mismanaged, when the
location of the pain was not identified by the staff.
Findings:
On July 30, 2018 at 2:39 p.m., during clinical record review revealed Resident 26's care plan did not
indicate the location of the pain as a concern, nor included Tylenol #3 with codeine at 300 - 30 milligram
(mg) one tablet in the intervention section of the care plan. Moreover, the care plan did not reflected the
pain assessment sheet, and the physician current order.
According to the admission records Resident 26 was admitted to the facility on [DATE] with diagnoses that
included hypothyroidism (decrease function of thyroid gland), anemia (low red blood cells), and and loss of
consciousness.
The annual Minimum Data Set (MDS), a standardized assessment and care screening tool, dated
November 24, 2017, indicated Resident 26 had the cognitive ability to make self understood and
understand others. The resident required total dependence from the staff for activities of daily living. The
resident MDS was triggered for pain requiring the staff to do frequent monitoring.
A review of the physician's order dated July 27, 2018 indicated Tylenol #3 with codeine at 300 - 30 mg
tablet: give one tablet every six hours as necessary for moderate to severe pain.
A review of Resident 26's current care plan dated February 26, 2018 indicated alteration in comfort due to
motor vehicle accident but did not included where the pain was located nor the specific pain medication,
Tylenol #3 with codeine, as necessary have been administered since November 11, 2014.
A review of the physician's current order dated July 27, 2014 indicated Tylenol #3 with Codeine at 300 - 30
mg: give one tablet every six hour as necessary.
On July 30, 2018 at 2:39 p.m., during an interview with Licensed Vocational Nurse (LVN 20) was asked why
Resident 26's revised care plan did not reflected the pain locations, and the name of current pain
medication. LVN 20 stated care plan was not specifically related to the locations of the resident's pain, and
the revised care plan did not reflected the current order.
According to the facility's undated policy titled Care Plan Comprehensive, an individualized comprehensive
care plan that includes measurable objective and timetables to meet the resident's medical needs.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555780
If continuation sheet
Page 6 of 11
Printed: 05/15/2026
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
555780
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Del Rio Gardens
7004 East 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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure one of 17 sampled residents (47) splint
was applied to the right upper extremity on a daily basis as ordered by the physician and that his fingernails
were cleaned, trimmed and well groomed.
Residents Affected - Few
The failure to provide the necessary care created the potential for the resident to have increased
contractures of his fingers.
Findings:
a 1. On 7/25/18 at 3:30 pm, during an initial tour of the facility Resident 47 did not have a splint on to the
upper extremities. Resident 47 was observed again on 7/26/18 at 8:45 am, at 11:25 am and at 2:20 pm
without a splint on. Other observations conducted on 7/27/18 at 8:10 am, 10:50 am, 1:45 pm and 3:15 pm,
revealed Resident 47 did not a have any splint on.
A review of the medical records indicated Resident 47 was admitted to the facility on [DATE] with diagnoses
including contractures (loss of joint motion) of the right and left hands.
A physicians order dated 4/9/18 indicated Resident 47 was to have a hand splint for contracture
management applied daily, seven times a week, for four to six hours.
A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated
7/3/18 indicated Resident 47 was totally dependent on the staff for his activities of daily living. The MDS
indicated Resident 47 had limitation in his range of motion to his upper and lower extremities.
A resident care plan titled Activities of Daily Living/Residents with Splints dated 7/3/18 indicated Resident
47 was at risk for further contractures. The nursing approaches included applying the splint to the affected
extremity per the physicians orders.
A review of the Restorative Record notes for July 2018 indicated RNA services had been provided for
Resident 47 on 7/25/18, 7/26/18 and 7/27/18. Further review of the records indicated the initials for the
RNA applying the splint to Resident 47 had been crossed out for 7/26/18 and 7/27/18.
On 7/27/18 at 3:20 pm during an interview the restorative nursing assistant stated the splint was taken to
the laundry on Monday, 7/23/18. The splint was in the laundry room washed and ready however, the
laundry staff had not returned it to Resident 47, nor had nursing picked it up from the laundry. There were
no clear instructions on who was responsible for getting the splint back to the resident in a timely manner.
On 7/31/18 at 1:45 pm, during an interview RNA 1 stated Resident 47's splint went to the laundry on
Wednesday (7/25/18), not Monday (7/23/18). RNA 1 stated after the splint was washed it took at least two
days for it to dry. RNA 1 stated either the laundry staff brought the splint to the resident's room or the
nursing staff picked it up from the laundry. RNA 1 stated she was aware Resident 47 was supposed to wear
the splint daily. The nursing staff was aware Resident 47 was at risk for worsening of his contractures
without use of the splint.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555780
If continuation sheet
Page 7 of 11
Printed: 05/15/2026
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
555780
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Del Rio Gardens
7004 East 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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
A review an undated facility's policy and procedure titled Restorative Nursing Program indicated residents
are to be assisted with use of any assistive device. Services will be provided by the RNA's including splint
or brace application per the physicians orders.
a 2. On 7/27/18 at 2 pm Resident 47 was observed during incontinence care. Resident 47 had contractures
to both hands and his fingernails were long, dirty and unkempt. The resident's fingernails were
approximately 1/8 of an inch or more over the nail bed with food particles, dirt and debris underneath them.
A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated
7/3/18 indicated Resident 47 was totally dependent on the staff for his activities of daily living (ADL),
including personal hygiene.
A resident care plan titled Activities of Daily Living dated 7/3/18 indicated Resident 47 was unable to do his
own care. The nursing approaches included cleaning the resident's fingernails daily during morning care
and as needed.
On 7/27/18 at 3:15 pm the director of staff development (DSD) and CNA 9 observed Resident 47's
fingernails and agreed that they were long, dirty and unkempt. The DSD stated nail care should be included
in the resident's daily grooming.
A review of a facility's policy and procedure titled Care of Fingernails dated 10/10 indicated the purpose is
to clean the nail bed, keep the nails trimmed and to prevent infections. Nail care was to include daily
cleaning and regular trimming.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555780
If continuation sheet
Page 8 of 11
Printed: 05/15/2026
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
555780
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Del Rio Gardens
7004 East 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 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to identify drug irregularities (rationale) during the monthly
Medication Regimen Review (MRR), when two anticonvulsant ([seizure] a sudden surge of electrical
activity in the brain, a seizure usually affects how a person feels or acts) medications Carbanazepine and
Levetiracetam without a documented clinical rationale for one of 17 sampled residents (18).
Residents Affected - Few
Findings:
According to the admission records Resident 18 was admitted to the facility on [DATE], with diagnoses that
included altered mental status, and toxic encephalopathy (a diseased of one's brain).
The admission Minimum Data Set (MDS), a standardized assessment and care screening tool, dated May
15, 2018 indicated Resident 18's cognition was intact and total dependent on staff for activities of daily
livings (ADLs) such as transferring, eating, and dressing.
A review of the physician's order for Resident 18 dated July 20, 2018, indicated to administer Levetiracetam
1500 mg by mouth twice a day, and Carbamazepine 200 milligram (mg) 1.5 tablet (300 mg) by mouth three
times a day for seizure disorder. A review of the physician's order dated December 15, 2014, indicated to
administer both Carbamazepine 200 mg 1.5 tablets (300 mg) by mouth three times daily as ordered, and
Levetiracetam 1500 mg by mouth twice a day.
A review of the Medication Administration Records (MARs) for the month of July 2017, indicated Resident
18 received both Carbamazepine 200 mg 1.5 tablets (300 mg) by mouth three times daily as ordered, and
Levetiracetam 1500 mg by mouth twice a day.
A review of the monthly Medication Regimen Review (MRR) dated the for the months of June and July
2018 did not indicate the identification of drug irregularities when two anticonvulsant medication from the
same category Carbamazepine also known as Tegretol, and Levetiracetam also known as Keppra was
used for Resident 18's treatment of seizure.
On August 1, 2018 at 12:30 p.m., during an interview the Director of Nursing (DON) was unable to provide
information if there was recommendation made during by the pharmacist consultant for Resident 18's drug
irregularities during the monthly Medication Regimen Review (MRR) in June and July 2018. The DON also
agreed the irregularity should have been addressed by the pharmacist to the physician because two
anticonvulsant was used to treat the seizure.
On August 1, 2018 at 12:40 p.m., an attempted to reach the pharmacist by telephone for an interview was
unsuccessful.
According to the facility's policy and procedures titled MMRR and Reporting dated 2017 indicated that the
consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly
to appropriately monitor the medication regimen and ensure that the medication each resident received are
clinically indicated. Identification of irregularities may occur by the consultant pharmacist utilizing a variety
of sources including medication administration records (MAR) and prescribed orders.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555780
If continuation sheet
Page 9 of 11
Printed: 05/15/2026
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
555780
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Del Rio Gardens
7004 East 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 0772
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't
provided.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to monitor one of 17 sampled residents (18) baseline tegretol
levels (medication to treat seizure disorder [ sudden surge of electrical activity in the brain, a seizure
usually affects how a person feels or acts]).
This deficient practice had the potential for adverse consequences that includes dizziness, fatigue,
depression including suicide and worsening of seizures.
Findings:
According to the admission records Resident 18 was admitted to the facility on [DATE], with diagnoses that
included altered mental status, and toxic encephalopathy (a diseased of one's brain).
The admission Minimum Data Set (MDS), a standardized assessment and care screening tool, dated May
15, 2018 indicated Resident 18's cognition was intact and total dependent on staff for activities of daily
livings (ADLs) such as transferring, eating, and dressing.
A review of the physician's order for Resident 18 dated June 12, 2015, indicated Carbamazepine 200
milligram (mg) 1.5 tablet (300 mg) by mouth three times a day for seizure disorder, and Levetiracetam 1500
mg by mouth twice a day.
A review of the Medication Administration Records (MARs) for the month of July 2017, indicated Resident
18 had received both Carbamazepine 200 mg 1.5 tablets (300 mg) by mouth three times daily as ordered.
On July 30, 2018 at 12:30 p.m., during an interview the director of nursing (DON) was asked did the facility
obtain a baseline level before starting Resident 18 on another anti-seizure mediation (Carbamazepine 200
mg 1.5 tablet (300 mg) by mouth three times a day). The DON stated no and agreed a baseline should
have been done before starting the Carbamazepine. The DON stated the facility received noticed for the
labs to be drawn on August 1, 2018.
According to the facility's drug reference book Nursing Drug Book, page 272 dated 2018 indicated to obtain
baseline determinations of urinalysis, iron level, liver function and complete blood count blood uremia
nitrogen BUN (to determine kidney function), and monitor these values periodically thereafter.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555780
If continuation sheet
Page 10 of 11
Printed: 05/15/2026
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
555780
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/01/2018
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Del Rio Gardens
7004 East 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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to wash hands while providing incontinence care
for one of 17 sampled residents (59), that had a bowel movement.
Residents Affected - Few
The failure to provide care in a sanitary manner created the potential for the spread of harmful bacteria and
the development of disease and/or infection.
Findings:
On 7/26/18 9:15 am Resident 59 was observed during incontinence care after urinating and having a bowel
movement. Two certified nursing assistants (CNA 7, 8) and one restorative nursing assistant (RNA 1) were
at the resident's bedside. RNA 1 wore gloves to clean the resident, and did not change her gloves after
cleaning the stool. RNA 1 did not change her gloves until the entire procedure was complete. However,
during the procedure RNA 1 picked up approximately four clean wash cloths and handled a bottle of
peri-wash on four to five different occasions.
On 7/27/18 at 3:05 pm, during an interview RNA 1 stated she should have changed her gloves and washed
her hands during incontinence care. RNA 1 stated it was an infection control issue by touching other items
with the soiled gloves.
A review of the medical records indicated Resident 59 was admitted to the facility on [DATE] with diagnoses
including Alzheimer's disease (a disease process that destroys memory and thinking).
A resident care plan dated 1/9/18 addressed Resident 59's impaired activities of daily living (ADL) and
physical functioning. The care plan goals included meeting the resident's ADL needs by being clean, dry
and free of odor.
A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated
7/15/18 indicated Resident 59 was occasionally incontinent of bowel and bladder function. The MDS
indicated Resident 59 was totally dependent on the staff for toilet use.
A review of a facility's policy and procedure titled Handwashing/Hand Hygiene dated 4/12 indicated hand
hygiene is the primary means to prevent the spread of infection. Employees must wash their hands after
handling soiled linens or coming into contact with a resident's excretions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555780
If continuation sheet
Page 11 of 11
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Back to topCitations
9 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F772 - The facility must provide or obtain laboratory services to meet the
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the August 1, 2018 survey of VILLA DEL RIO GARDENS?
This was a inspection survey of VILLA DEL RIO GARDENS on August 1, 2018. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at VILLA DEL RIO GARDENS on August 1, 2018?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.