Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Asistencia Villa Healthcare Center during CMS and state inspections, most recent first.
A resident with mobility and gait issues left the facility without staff knowledge and was missing for five hours before being found at a nearby building. The resident did not have authorization to leave, and staff interviews confirmed that required supervision was not maintained, resulting in the resident's unsupervised exit.
A resident with a history of cardiac arrest received a double dose of Metoprolol Tartrate when two LVNs each administered the medication, due to a lack of immediate documentation and failure to verify assignments. The medication was present in both nurses' carts, and only one administration was recorded in the MAR, contrary to facility policy requiring immediate documentation.
Two residents with significant medical needs, including respiratory failure and paralysis, experienced delays in receiving assistance with ADLs such as changing and personal hygiene. Both residents reported waiting extended periods for help, particularly during night shifts, and staff interviews confirmed that care was sometimes delayed due to insufficient staffing. Facility policy requires timely ADL support, but this was not consistently provided.
A resident with acute respiratory failure did not receive a scheduled dose of Pirfenidone due to a medication error at the facility. An LVN mistakenly disposed of the medication, believing it was discontinued, leading to its unavailability for administration. The DON confirmed the error, acknowledging that staff did not follow the facility's policy on medication error reporting.
The facility failed to maintain a sanitary kitchen, with observations of sticky residues, food crumbs, and trash in various areas, including a juice dispenser cabinet and under the steam table. An industrial mixer had food residue, and the ice machine had brown buildup. Staff acknowledged these areas should be clean, aligning with facility policies and FDA codes.
The facility failed to track and document staff COVID-19 vaccination status, as required by its policy. The ICP nurse was unaware of the responsibility to maintain such documentation until reviewing the facility's policy. The DON confirmed the lack of tracking, which could increase the risk of COVID-19 exposure to the 95 residents.
A leaking countertop water dispenser in the facility was not repaired, leading to standing water accumulation. Staff acknowledged the issue, and dietitians expected prompt repair. The facility's maintenance policy and FDA guidelines emphasize the need for equipment to be in good repair to prevent health risks.
A resident experienced a significant change in condition, transitioning from gastric tube feeding to an oral diet, but the facility failed to complete a Significant Change of Status Assessment (SCSA) within the required 14-day period. The MDS nurse did not update the assessment, resulting in a 68-day delay, leaving the resident's care plan outdated and not reflective of their current needs.
A facility failed to accurately complete the MDS assessment for a resident using mittens and an abdominal binder as restraints. Despite physician orders and observations confirming the use of these restraints, the Quarterly MDS assessment did not reflect this, violating the facility's policy on assessment accuracy. The DON and MDS Nurse acknowledged the oversight.
A medication cart in the 200's hall was found unsanitary with a yellow moist buildup in the bottom drawer containing over-the-counter medications. Both an LVN and the ICP nurse confirmed the unsanitary condition, which violated the facility's policy requiring clean and safe medication storage. The DON acknowledged the policy was not followed.
A facility failed to implement its antibiotic stewardship policy for a resident, as the ICP nurse did not accurately assess and collect necessary data to ensure appropriate antibiotic use. The resident, admitted with metabolic encephalopathy and ventilator-associated pneumonia, was prescribed Merrem and Zyvox for sepsis. However, the Surveillance Data Collection Form was incomplete, and the Loeb's criteria were not filled out, leaving it unclear if the antibiotics were used for a true infection. Interviews revealed the facility did not follow its policy, resulting in a deficiency.
A resident with polyneuropathy was mistakenly given Methocarbamol after it was discontinued, due to the facility's failure to remove the medication from the cart as per policy. The error was identified by an LVN and the resident's grandson. The facility's policy requires immediate removal of discontinued medications to prevent such errors.
Two residents with chronic conditions reported significant delays in call light response times, ranging from 10 minutes to two hours, affecting their daily living activities. Despite care plans indicating the need for prompt assistance, the facility failed to adhere to its policy, leading to residents waiting in soiled diapers and experiencing false documentation of care refusals.
A resident with a history of falls, seizures, and dementia fell and sustained a subdural hematoma due to inadequate supervision. The resident was found unsupervised at the nurse's station and fell from his wheelchair, hitting his head. The facility's policies on accident prevention and resident safety were not followed, as confirmed by the ADON.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for one of four sampled residents when the resident left the facility without staff knowledge and was missing for five hours. The resident, who had diagnoses including spinal stenosis of the cervical region and abnormalities of gait and mobility, was last seen by an LVN in the hallway around 5:00 AM. Shortly after, staff noticed the resident was not in his room during rounds, prompting a search and notification of the supervisor. The resident was eventually found at an adjacent facility and taken to the hospital. Record review and interviews revealed that the resident did not have authorization or a physician's order to leave the facility. The facility's policy requires constant supervision for residents not authorized to leave, and elopement assessments are conducted for those at risk. The administrator acknowledged that insufficient supervision contributed to the incident, as the resident was able to exit the building without staff awareness.
Double Dosing of Blood Pressure Medication Due to Documentation and Assignment Errors
Penalty
Summary
A deficiency occurred when a resident with a history of cardiac arrest was administered a double dose of Metoprolol Tartrate, a blood pressure medication, by two different licensed vocational nurses (LVNs). The first LVN administered the medication but was interrupted before documenting the administration. Upon returning, the LVN discovered that a second LVN had also administered the same medication, mistakenly believing the resident was assigned to him. The second LVN did not verify his assignment prior to giving the medication, and both LVNs found that the medication was present in both of their medication carts. Review of the Medication Administration Record (MAR) showed that only one administration was documented, and the facility's policy required immediate documentation after medication administration. Both the Administrator and the Director of Nursing confirmed that the policy was not followed, and the staff failed to adhere to the five rights of medication administration and proper documentation procedures.
Delayed Assistance with ADLs for Dependent Residents
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for two residents who were clinically compromised and dependent on staff for care. Resident 1, with diagnoses including chronic respiratory failure, morbid obesity, dependence on a respirator, and quadriplegia, reported having to wait a long time to be changed on multiple occasions. The care plan for this resident identified problems with ADL decline and set goals for improvement in grooming, dressing, and toileting. Resident 2, diagnosed with chronic respiratory failure, COPD, paraplegia, and respirator dependence, also reported waiting a long time for help with changes, particularly at night. The care plan for this resident noted a self-care performance deficit and total dependence on staff for personal hygiene and oral care. Interviews with staff confirmed that delays in providing care occurred, especially when staffing was insufficient. A CNA acknowledged that it sometimes took a while to attend to residents' needs due to lack of help. The DON stated that nursing staff are expected to provide timely assistance and confirmed that residents' needs should have been met promptly. Review of the facility's policy indicated that residents should receive care to prevent decline in ADLs unless clinically unavoidable, and that appropriate care should be provided in accordance with the care plan.
Medication Error Due to Miscommunication and Disposal
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding medication error and adverse drug reaction reporting, resulting in a significant medication error for one resident. The resident, who was admitted with a diagnosis including acute respiratory failure, did not receive a scheduled dose of Pirfenidone, a medication prescribed for interstitial lung disease, on December 21, 2024. This omission occurred because a Licensed Vocational Nurse (LVN) mistakenly disposed of the medication, believing it had been discontinued. The error was realized later that day, but the medication was not available for administration. The Director of Nursing (DON) confirmed that the medication was not administered due to its unavailability, as it had been accidentally discarded. Another LVN corroborated this account, stating that the medication was not available for the scheduled dose. The facility's policy defines a medication error as an omission of a vital medication due to an error in prescribing, dispensing, or administering. The DON acknowledged that the staff did not follow the established policy, leading to the medication error.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as evidenced by several observations. A cabinet storing a juice dispenser had a sticky residue on its handle, and inside the cabinet, there was a red juice spill. Additionally, the area under the steam table contained food crumbs and trash, and there was food residue around the floor sink. These conditions were noted during observations and confirmed through interviews with staff, who acknowledged that these areas should be kept clean. Further observations revealed that the industrial mixer was stored with white food residue on its exterior, which was covered by a black plastic bag. This was confirmed during an interview with the Registered Dietitian Nutritionists, who stated that the mixer should be cleaned thoroughly before being covered. The facility's policy on sanitization, as well as the FDA Federal Food Code, emphasize the importance of maintaining non-food contact surfaces in a clean state to prevent the accumulation of soil residues. Additionally, the ice machine in the kitchen had a brown buildup in the area where ice is formed. This was observed and confirmed by the facility's Maintenance Director, who stated that the area should be kept clean. The facility's policy on ice machines and the FDA Federal Food Code require regular cleaning to prevent the development of slime, mold, or soil residues. These deficiencies had the potential to attract pests and cause foodborne illness to the residents consuming meals prepared in the facility.
Failure to Track and Document Staff COVID-19 Vaccination Status
Penalty
Summary
The facility failed to implement its infection control program to prevent the spread of COVID-19 by not maintaining any tracking and documentation of staff COVID-19 vaccination status. During an interview and record review, the Infection Control Preventionist (ICP) nurse was unable to provide documentation indicating a tracking system for staff members' COVID-19 vaccination status. The ICP nurse admitted to being unaware of her responsibility to maintain such a system until she reviewed the facility's Policy and Procedure on COVID-19 Vaccination for Staff. The Director of Nursing (DON) confirmed that there was no tracking and documentation of staff COVID-19 vaccination status. The facility's policy, revised in January 2024, required the infection preventionist to maintain a tracking worksheet of staff members and their vaccination status, including specific details such as staff name, job title, vaccination status, and documentation of informed consent. The DON acknowledged that the facility did not follow this policy, which had the potential to cause harm to the 95 residents by increasing the risk of exposure and spread of the COVID-19 virus.
Leaking Water Dispenser Not Repaired
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, as evidenced by a leaking countertop water dispenser. During an observation, it was noted that the water dispenser was leaking and collecting standing water in the drain beneath it. This issue was confirmed during an interview with a staff member who acknowledged that the dispenser was not in use and required repair. Further interviews with two Registered Dietitian Nutritionists revealed that there was an expectation for the water dispenser to be fixed promptly. A review of the facility's maintenance policy indicated that the maintenance department is responsible for ensuring all equipment is kept in a safe and operable condition. Additionally, the FDA Federal Food Code emphasizes the importance of maintaining equipment in good repair to prevent health risks to consumers.
Failure to Complete SCSA for Resident After Significant Change
Penalty
Summary
The facility failed to complete a Significant Change of Status Assessment (SCSA) for a resident within the required 14-day period following a significant change in the resident's condition. The resident, who was initially receiving nutrition through a gastric tube, had the tube removed and transitioned to an oral diet. This change in the nutrition route and the level of eating assistance required an updated assessment to reflect the resident's current status. However, the MDS nurse did not complete the SCSA, which was due by August 10, 2024, resulting in a delay of 68 days without the assessment being completed. The deficiency was identified during a review of the resident's records and interviews with the Director of Nursing (DON) and the MDS nurse. The resident's clinical records indicated a change from dependent gastric tube feeding to oral partial/moderate assistance for eating, but the last MDS assessment was a quarterly assessment completed on July 18, 2024. The facility's policy requires a comprehensive assessment when there is a significant change in a resident's condition, but this was not adhered to, leading to the resident's care plan not being updated to reflect the current status.
Inaccurate MDS Assessment for Restraint Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were completed accurately for a resident, specifically regarding the use of restraints. Resident 68, who was admitted with diagnoses including metabolic encephalopathy and a tracheostomy, was observed wearing mittens and an abdominal binder to prevent interference with medical equipment. However, the Quarterly MDS assessment did not reflect the use of these physical restraints, as it was not coded under the relevant section for restraints and alarms. Interviews with the Director of Nursing (DON) and the MDS Nurse confirmed that the orders for the use of mittens and an abdominal binder were present, but the MDS assessment failed to capture this information. The facility's policy on certifying the accuracy of resident assessments was not followed, as the assessment did not accurately reflect the resident's status during the observation period. The MDS Nurse acknowledged that the restraints should have been coded, and the facility's failure to adhere to the policy was confirmed during the review.
Unsanitary Medication Cart Found in Facility
Penalty
Summary
The facility failed to store all drugs and biologicals in accordance with currently accepted professional principles and its own policies and procedures. During an observation on October 16, 2024, a medication cart on the 200's hall was found to be unsanitary. Specifically, the left bottom drawer of the cart, which contained as-needed over-the-counter medications, had a yellow moist buildup. This was confirmed by a Licensed Vocational Nurse (LVN 2) who acknowledged the unsanitary condition of the drawer. Further inspection by the Infection Control Preventionist (ICP) nurse confirmed the presence of the yellow buildup. The ICP nurse emphasized the importance of keeping medication carts clean to maintain medication efficacy and prevent contamination. The Director of Nurses (DON) reviewed the facility's policy on medication storage, which mandates that nursing staff maintain medication storage areas in a clean, safe, and sanitary manner. The DON acknowledged that the policy was not followed, leading to the deficiency.
Failure to Implement Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to implement its policy and procedure on antibiotic stewardship for one of the residents, identified as Resident 47, who was reviewed for antibiotic use. The Infection Control Preventionist (ICP) nurse did not accurately assess and collect data to indicate the rationale and common clinical conditions necessary to ensure the appropriate use of antibiotic therapy for this resident. This oversight had the potential to place Resident 47 at risk for adverse events, including the development of antibiotic-resistant organisms, due to unnecessary or inappropriate antibiotic use. Resident 47 was admitted to the facility with diagnoses including metabolic encephalopathy and ventilator-associated pneumonia. A review of the resident's physician's orders revealed that antibiotics Merrem and Zyvox were prescribed for sepsis. However, during the review, it was found that the Surveillance Data Collection Form used to monitor and collect data on antibiotic use was incomplete. Key fields such as the diagnosis, culture, and type of infection were left blank, and the Loeb's minimum criteria for initiating antibiotics were not filled out, leaving it unclear whether the antibiotics were used for a true infection. Interviews with the ICP nurse and the Director of Nursing (DON) revealed that the facility's policy on antibiotic stewardship was not followed. The policy required that all clinical infections treated with antibiotics undergo review by the infection preventionist, and that antibiotic usage and outcome data be collected and documented. However, the ICP nurse admitted to not conducting the necessary analysis and review to confirm whether Resident 47 had a true infection, which was a critical step in ensuring the appropriate use of antibiotic therapy. The facility's failure to adhere to its own policy and procedure resulted in a deficiency in antibiotic stewardship practices.
Failure to Remove Discontinued Medication Leads to Administration Error
Penalty
Summary
The facility failed to adhere to its policy and procedure for the removal of discontinued medication from the medication cart, leading to a medication error involving a resident. The resident, who was admitted with a diagnosis of polyneuropathy, was administered Methocarbamol, a muscle relaxant, despite the medication having been discontinued. The error was identified when a licensed vocational nurse (LVN) administered the medication and later realized the mistake, which was also pointed out by the resident's grandson. The registered nurse supervisor and the facility administrator confirmed that the medication should have been removed from the cart immediately upon receiving the discontinuation order. However, the medication remained in the cart due to oversight, contributing to the error. The facility's policy, as outlined in their Discontinued Medications - Disposal policy and procedure manual, mandates the immediate removal of discontinued medications to prevent such errors, but this protocol was not followed in this instance.
Delayed Call Light Response for Two Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure for answering call lights in a timely manner, which affected two residents. Resident 1, who has chronic obstructive pulmonary disease and no mental impairment, reported that the average response time for assistance was 20 minutes. Additionally, Resident 1 mentioned instances of false documentation by staff regarding his refusal to shower. Resident 2, diagnosed with chronic respiratory failure with hypoxia and also without mental impairment, reported that call light response times ranged from 10 minutes to two hours, with longer delays during nighttime and shift changes. Resident 2 experienced waiting in soiled diapers for up to two hours. The care plans for both residents indicated deficits in activities of daily living, requiring prompt assistance with tasks such as personal hygiene, dressing, and toilet use. Despite these documented needs, the facility did not ensure that call lights were answered promptly, as confirmed by interviews with the residents and a Certified Nursing Assistant. The assistant director of nursing acknowledged the issue but did not provide comments on the findings. The facility's policy, revised in October 2010, emphasized the importance of responding to residents' requests and needs, which was not followed in these cases.
Failure to Provide Adequate Supervision Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision to prevent avoidable accidents, resulting in a resident falling and sustaining a subdural hematoma. Resident 4, who had a history of repeated falls, seizures, dementia, and gait abnormalities, was found unsupervised and fell from his wheelchair, hitting his head. The incident occurred while the resident was sitting at the nurse's station, and the fall was unwitnessed. Following the fall, the resident reported head pain and dizziness and was subsequently transferred to the emergency department, where a CT scan revealed bilateral subdural hematomas. Interviews with staff and review of the resident's care plan and clinical records indicated that the resident had not been adequately supervised, despite being identified as at risk for falls. The facility's policies on accident prevention and resident safety were not followed, as acknowledged by the Assistant Director of Nursing (ADON). The ADON confirmed that more supervision should have been provided to the resident to prevent the accident, highlighting a failure to adhere to established safety protocols and procedures designed to protect residents from avoidable accidents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Redlands
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Gardens Health Care Center | 1.1 mi | — | 0 | 0 |
| Loma Linda Post Acute | 1.2 mi | — | 0 | 0 |
| Brookside Healthcare Center | 1.2 mi | — | 0 | 0 |
| Totally Kids Rehabilitation Hospital - D/p Snf | 1.6 mi | — | 10 | 0 |
| Madison Grove Post Acute | 1.9 mi | — | 16 | 0 |
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