Del Rosa Villa

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective training program for One of three sampled Certified Nursing Assistants (CNA 3), when the facility was unable to provide documented evidence to show CNA 3 completed the required Continued Education Units (CEUs -mandatory ongoing training hours required to maintain and renew an active certification). This failure limited the facility's ability to ensure staff met the mandatory training requirements and had the potential to result in staff not receiving essential education needed to provide safe and competent resident care. During an interview on May 15, 2026, at 10:14 AM, with CNA 3, CNA 3 stated she had completed the 48 hours of CEU required for renewal license but the Director of Staff Development (DSD) can't [cannot] find the in-services [training provided to employees while on the job]. [...]

Inspectors wroteBased on observation, interview and record the facility failed to ensure resident's needs and preferences were met when: An appropriate bed mattress was not accommodated upon request for 1 of 20 sampled residents (Resident 107) after returning from the hospital to maintain comfort. An evaluation for a power wheelchair was not coordinated upon request for 1 of 20 sampled residents (Resident 116) to accommodate her inability to self propel a manual wheelchair. These failures resulted in Resident 107 experiencing discomfort and the inability to sleep in his bed and the potential for loss of independence for Resident 116 when their needs were not met.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement individualized care plan interventions related to actual needs for two of 20 sampled residents (Resident 6 and 73) when: Multiple observation over several days showed Resident 6 had long, visibly dirty fingernails. For two consecutive days, Resident 73 remained in bed without participation in activities. These failures resulted in staff not being provided with interventions to deliver individualized care and placed residents at risk of unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary assistance for one of 20 sampled residents (Resident 6) with personal hygiene specifically nail care. This failure resulted in Resident 6 not being provided and receiving necessary activities of daily living (ADL) assistance to maintain personal hygiene.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep the environment safe and free from hazards for 1 of 20 sampled residents (Resident 28) when safety interventions to prevent falls were not implemented. These failures placed Resident 28 at risk for potential falls and injuries. During a review of Resident 28's Face Sheet (Demographics), the Face Sheet indicated Resident 28 was readmitted to the facility on [DATE] with diagnoses which included Encephalopathy (brain dysfunction that often results in altered mental state), Multiple Sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord). During an observation on 2/8/26 at 10:30 AM, in Resident 28's room, Resident 28 was resting in bed, with the bed elevated in a high position from the ground. Resident 28 was wearing a wristband that indicated Fall Risk. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide necessary respiratory care and services for two of 20 sampled residents (Resident 5 and Resident 107) when: Resident 5's oxygen cannula tubing (medical device to deliver oxygen) was not changed for twelve days (12 days) past the required time frame. Resident 107 did not receive the prescribed respiratory treatments following his return to the facility. These failures placed Resident 5 and Resident 107 at risk for compromised respiratory health status and avoidable decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hot food was served at an acceptable temperature (above 135 degrees Fahrenheit [F- measurement of temperature]) to be appetizing for two of 20 sampled residents (Resident 67 and Resident 116). This failure had the potential to affect meal and food intake which could impair the nutrition status of the residents. During an interview on 2/8/26 at 11 a.m. with Resident 67 in the resident's room, Resident 67 stated the food was not good and she did not like to eat the food served. Resident 67 stated the food would also be delivered cold, which did not make it appetizing to eat and she would often not finish her meal because of it. During an interview on 2/8/26 at 3:30 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe, sanitary, and comfortable environment for one of 20 sampled residents (Resident107) when Resident 107 did not receive education/training in infection control practices when emptying his urinary bag. These failures had the potential to place Resident 107 at risk for infection, and contamination that could affect his overall health condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program, when staff failed to report the presence of flying insects in room [ROOM NUMBER] shared bathroom. This failure had the potential to pose significant health risks to residents, visitors and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct an assessment for one of four sampled residents (Resident 1) to evaluate her status and needs at the time of the proposed return from the hospital. This failure had the potential for the facility to miss important changes in Resident 1's current behavior or condition that could have informed an appropriate and individualized discharge decision. [...]

Inspectors wroteBased on interview, and record review, the facility failed to protect against verbal abuse for one of three sampled residents (Resident 1) when a Certified Nursing Assistant 1 (CNA 1) called Resident 1 a B**ch! when Resident 1 was voicing criticism of CNA 1's perineal care (the cleaning and maintenance of the perineum, the area between the anus and the genitals) indicating rough handling with pain. This failure caused Resident 1 to suffer pain, fear, and anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Residents 1 and 2) were treated with dignity and respect when a Certified Nursing Assistant (CNA 1) used profanity in the immediate presence of the residents, while in the resident's room. This failure resulted in both Residents 1 and 2 to feel disrespected as both residents believed the staff member was directing the profanity toward them in a demeaning manner.

Inspectors wroteBased on interview and record review the facility failed to follow its Change of Condition (COC) and Documentation Policies for 1 of 3 sampled residents (Resident 1) when: 1. Resident 1 had a (COC), and responsible party was not notified, left as unreachable. 2. No documentation of when responsible party was notified of COC. This failure placed a clinically compromised Resident (Resident 1) health and safety at risk by causing a delay in notification and family involvement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu when: 1. six (6) of six (6) Residents on pureed diet (a diet of smooth, blended foods that require no chewing) was served 2/3 cup of pureed Jambalaya instead of one cup that the menu called for during lunch on January 21, 2025. 2. 33 of 33 Residents on regular carbohydrate controlled (CCHO-consistent, constant, or controlled carbohydrate [sugars, starches and fiber]) diet, were served one whole slice of garlic bread instead of half a slice the menu called for during lunch on January 21, 2025. This failure had the potential to compromise residents' nutritional status when menus were not followed for 39 of 39 Residents on a Pureed and CCHO diet.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a copy of the notice of transfer or discharge were sent to the Ombudsman for one (1) of three (3) sampled residents (Resident 63) reviewed for hospitalizations when: 1. Resident 63 was sent to the hospital on February 16, 2024, and there was no copy of notice of transfer or discharge sent to the Ombudsman. 2. Resident 63 was sent to the hospital on July 6, 2024, and there was no copy of notice of transfer or discharge sent to the Ombudsman. This failure had the potential for Resident 63 to be inappropriately transferred or discharged .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to the facility's policy and procedure (P&P) for one (1) of 92 residents (Resident 75) when five tablets were found in a medication cup, on the bedside table, unattended by staff. This failure had the potential to cause ineffective drug therapy, significant side effects, and adversely affect the health and safety of Resident 75.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store residents' food according to professional standards for food service safety when a dark brownish-reddish frozen spill was found on the bottom part of the freezer of the residents' refrigerator on January 21, 2025. This failure had the potential for bacteria to growth and to cause foodborne illness in residents who store food in the the residents' refrigerator.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP-are a set of infection control practices that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs- germs that resist treatment with more than one antibiotic]) were maintained for one (1) of five (5) sampled residents (Resident 97) when one Certified Nurse Assistant (CNA 1) did not wear a gown when providing incontinence care. This failure had the potential to result in an increased risk of cross-contamination (the transfer of harmful bacteria) to 92 highly vulnerable residents whose health conditions are already compromised.

Inspectors wroteBased on interview and record review, the facility failed to prevent elopement (an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment) by one of eight residents (Resident 1) with a wander guard system (a wander guard system relies on three components: bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alerts with an audible sound) when Resident 1, who was at risk for elopement, did not have close monitoring of his whereabouts and eloped from the facility through a parking lot gate which automatically opened to vehicles entering and exiting from the facility's parking lot. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect against verbal abuse for one of three sampled residents (Resident 1) when a Physical Therapy Assistant (PTA 1) yelled Get the f**k up! at Resident 1 when Resident 1 was uncooperative during a transfer. This failure caused Resident 1 to suffer fear, confusion and anxiety.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that the facility ' s policy regarding falls was implemented, when one of the four sampled residents (Resident 1) experienced a change of cognition or level of consciousness was not promptly reported to the physician following an unwitnessed fall. This failure potentially led to a deterioration in Resident ' s 1 condition necessitating his transfer to a general acute hospital for evaluation and treatment.

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, the facility failed to ensure the facility medication error rate was e less than 5%. There were two medication errors out of 34 opportunities, which yielded a medication error rate of 5.88%, for 2 (Resident #10 and Resident #60) of 5 residents observed for medication administration.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to have evidence to indicate 1 (Resident #79) of 20 sampled residents were invited to their care plan meeting.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to ensure privacy was provided during personal care for 1 (Resident #57) of 1 sampled resident reviewed for privacy.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement abuse policy when they failed to investigate a potential allegation of misappropriation of resident property reported by 1 (Resident #15) of 20 sampled residents.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to report an allegation to the state agency within the required time frame that involved 2 (Resident #38 and Resident #42) of 20 sampled residents.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure an admission Minimum Data Set (MDS) assessment was completed in a timely manner for 1 (Resident #187) of 20 sampled residents.

Inspectors wroteBased on interviews, record review, document review, and facility policy review, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed timely for 1 (Resident #2) of 1 sampled resident reviewed for resident assessment.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 1 (Resident #83) of 20 sampled residents.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to have a level II preadmission screening and resident review (PASARR) completed after the addition of a new mental health diagnosis for 1 (Resident #42) of 20 sampled residents.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure the risk, benefits, and informed consent for the use of bed rails was completed for 1 (Resident #191) of 3 sampled residents reviewed for accident hazards.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure the ordered four times a day fingerstick blood sugar checks were necessary for 1 (Resident #48) of 6 sampled residents reviewed for unnecessary medications, psychotropic medications, and medication regimen review.

Inspectors wroteBased on observation, interviews, document review, facility policy review, the facility failed to ensure staff properly cleaned and disinfected a glucometer used to obtain a blood glucose level for 1 (Resident #289) of 4 residents observed for fingerstick blood sugar checks.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to have evidence residents received influenza and pneumococcal vaccines and education for 2 (Resident #3 and Resident 12) of 6 sampled residents reviewed for immunizations.