Health inspection·February 11, 2026

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 three residents (Resident 2), was provided with an appropriate call light (an equipment used when calling for staff when assistance is needed) to use. This deficient practice resulted in the resident's feeling of being ignored and neglected, and the potential for the resident not being able to call for help when assistance is needed, and needs will not be met.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included muscle weakness and hypertension (high blood pressure). During a review of Resident 2's Care Plan titled, Needs assistance with Activities of Daily Living (ADL) and mobility, dated 3/7/2025, one of the interventions indicated to have call light within reach and answer promptly. During a review of Resident 2's History and Physical (H&P) dated 5/23/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 2/3/2026, the MDS indicated Resident 2 usually was able to understand and be understood by others. The MDS indicated Resident 2 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, shower/bathing self, upper/lower dressing, putting on/taking off footwear and personal hygiene. Resident 2 required maximal assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with rolling from left to right, and dependent for sitting to lying, lying to sitting on side of bed, sit to stand and chair/bed to chair transfer. During an interview on 2/11/2026 at 12:50 p.m., with Resident 2, Resident 2 stated he did not know where his call light was. Resident 2 stated he could not press the call light because he could not move his arms and hands. Resident 2 stated sometimes he felt powerless. Resident 2 stated he was being ignored. Resident 2 stated he would yell or wait until someone comes into the room. Resident 2 stated he was not sure how often the staff comes to check on him. Resident 2 stated when he calls, he would be dirty and wanted to be cleaned. During a concurrent observation and interview on 2/11/2026 at 1:04 p.m., with Certified Nurse Assistant (CNA 1) and Resident 2, CNA 1 stated Resident 2's call light was not within the reach. CNA 1 then placed the call light within the reach of Resident 2. Resident 2 stated he could not use the call light because he cannot move his arms and hands. CNA 1 stated she have not asked Resident 2 if she could use the call light. CNA 1 stated it was important for Resident 2 to be able to use the call light to call for assistance. CNA 1 stated not being able to use and access the call light could lead to feelings of neglect, delay in care and assisting the resident's needs. During an interview on 2/11/2026 at 1:44 p.m., with the Minimum Data Set Nurse (MDS), the MDS Nurse stated he was not aware Resident 2 could not use the call light, but he was going to re-assess Resident 2 to assist him with a new call light. During a review of Residents Affected - Few Page 1 of 5 555781 555781 02/11/2026 Villa Del Rio 7002 Gage Avenue Bell Gardens, CA 90201

F 0558 Level of Harm - Minimal harm or potential for actual harm the facility's its policy and procedures (P&P) titled, Call Lights: Accessibility and Timely Response, dated 1/2026, the P&P indicated each resident should be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system. The P&P indicated the facility policy's purpose was to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Residents Affected - Few 555781 Page 2 of 5 555781 02/11/2026 Villa Del Rio 7002 Gage Avenue Bell Gardens, CA 90201

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician and obtain an order to implement, when one of three sampled residents (Resident 1), was readmitted to the facility with a rash on bilateral (both) lower extremities (BLE, arms or legs). This deficient practice resulted in delayed treatment and could have led to worsening of rash. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included muscle wasting and atrophy (loss of muscle tissue, causing muscles to shrink and weaken), and lack of coordination. During a review of Resident 1's History and Physical (H&P) dated 10/9/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/16/2025, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for eating, oral hygiene and upper/lower dressing. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) toileting hygiene, shower/bathe self, lower body dressing, and putting on /taking off footwear. The MDS indicated Resident 1 required supervision with rolling from left to right, for sitting to lying, lying to sitting on side of the bed, sit to stand, and required moderate assistance for chair/bed to chair transfer, toilet transfer, and tub/shower transfer. During a review of Resident 1's progress notes dated 10/9/2025 at 4:04 p.m., Resident 1 was readmitted with BLE rash. During a concurrent record review and interview on 2/11/2026 at 9:50 a.m., with Licensed Vocational Nurse (LVN) 1, the Progress Notes dated 10/9/2025 at 4:04 p.m. was reviewed. LVN 1 stated she admitted Resident 1 on 10/9/2026 and noted BLE rash but did not call the doctor to notify him. LVN 1 stated she did not create a Change of Condition (COC, reassessment done for a patient when there is a change in condition, in which triggers for interventions and notifying physician) and a care plan was not created. LVN 1 stated the rash was not properly assessed and was not treated, placing the rash to worsen or infected. During a review of the facility's Policy and Procedures (P&P) titled, Change in a Resident's Condition or Status, dated 1/2026, the P&P indicated the facility should promptly notify the resident's Attending Physician of changes in the resident's medical condition and/or status. 555781 Page 3 of 5 555781 02/11/2026 Villa Del Rio 7002 Gage Avenue Bell Gardens, CA 90201

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 implement infection control measures, for one of three residents (Resident 2) by failing to:1). Perform hand hygiene before putting on gloves (a personal protective equipment used when providing resident care).2). Remove used contaminated gloves prior to placing a clean diaper and clean linen and before touching Resident 2. These deficient practices had the potential to result in cross-contamination (process by which bacteria or other microorganisms are unintentionally transferred from one object or person to another, with harmful effect), severe infection and hospitalization. Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included muscle weakness and hypertension (high blood pressure). During a review of Resident 2's History and Physical (H&P) dated 5/23/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 2/3/2026, the MDS indicated Resident 2 usually was able to understand and be understood by others. The MDS indicated Resident 2 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, shower/bathing self, upper/lower dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 2 required maximal assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with rolling from left to right, and dependent for sitting to lying, lying to sitting on side of bed, sit to stand and chair/bed to chair transfer. During a concurrent observation and interview on 1/6/2026 at 2/11/2026 at 1:18 p.m., with Licensed Vocational Nurse (LVN 2), LVN 2 was observed starting to clean (providing care) Resident 2. LVN 2 put on gloves, opened the resident's dirty diaper, cleaned the pubic area (area of the body located just above the genitals) with a towel, then turned the resident, cleaned the buttocks with another towel and placed the dirty towels on top of the resident's bed. LVN 2 placed a new clean diaper on Resident 2 and put a blanket over the resident. LVN 2 then touched Resident 2's knees with the gloved hands and stated, all done. LVN 2 stated she did not wash /sanitize her hands prior to putting on a pair of gloves when providing resident care, did not remove used/ dirty gloves prior to placing a clean diaper and after cleaning Resident 2. LVN 2 stated she should have washed her hands or sanitized her hands prior to putting on the gloves or prior to cleaning the resident and touching the resident. LVN 2 stated not washing/sanitizing hands could lead to infections, such as urinary infections, wound infections that could lead to hospitalization. During a review of the facility's policy and procedure, (P&P) titled, Hand Hygiene, dated 1/2026, the P&P indicated staff involved in direct resident contact should perform proper hand hygiene (a general term that applies to either handwashing or the use of an antiseptic hand rub) procedures to prevent the spread of infection to other personnel, residents, and visitors. During a review of the facility's undated Hand Hygiene Table, indicated to perform hand hygiene before applying and after removing of personal protective equipment (PPE), including gloves, and before performing resident care procedures. Residents Affected - Few 555781 Page 4 of 5 555781 02/11/2026 Villa Del Rio 7002 Gage Avenue Bell Gardens, CA 90201

F 0914 Provide bedrooms that don't allow residents to see each other when privacy is needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure two of three sampled residents (Resident 1 and 2) rooms were equipped with functional ceiling suspended curtains.This deficient practice violated Resident 1 and Resident 2's rights to full visual privacy.During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnoses included anxiety disorder (mental health condition characterized by excessive worry, fear and nervousness that can interfere with daily life), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), muscle wasting and atrophy (loss of muscle tissue, causing muscles to shrink and weaken), and lack of coordination.During a review of Resident 1's History and Physical (H&P) dated 10/9/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/16/2025, the MDS indicated Resident 1 usually was able to understand and be understood by others. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for Activities of Daily Living (ADLs) such as toileting hygiene, showering, lower body dressing, transfers and walking. During a concurrent observation and interview on 2/10/2026 at 1:50 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1's curtain was short and did not close completely. CNA 1 stated Resident 1 did not have enough privacy, and another resident could walk in and see Resident 1 being changed. CNA 1 stated that the short curtain could not offer full privacy for Resident 1 while being changed and it was the facility's responsibility to ensure Resident 1 had full privacy. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2 diagnoses included muscle weakness and hypertension (high blood pressure).During a review of Resident 2's History and Physical (H&P) dated 5/23/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 usually was able to understand and be understood by others. The MDS indicated Resident 2 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) for ADLS such as eating, personal hygiene, toileting hygiene, showering, dressing, putting on/taking off footwear and transfers. During a concurrent observation and interview on 2/11/2026 at 1:18 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 2's curtain was shortened and did not provide enough privacy for the resident. LVN 2 stated, Resident 2's curtain strings appeared to be tangled, and she did not know how long the curtain had not been functional. LVN 2 stated not having full privacy with the curtain placed the resident at risk of being exposed to other residents. During a review of the facility's Policy and Procedures (P&P) titled, Resident Rooms, dated 1/2025, the P&P indicated the resident bedrooms must be designed and equipped for adequate nursing care, comfort and privacy of residents. The P&P indicated all resident bedrooms will be equipped to assure full visual privacy for each resident. Including ceiling suspended curtains which extend around each bed in non-private bedrooms. Residents Affected - Few 555781 Page 5 of 5