Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Del Rosa Villa during CMS and state inspections, most recent first.
A resident with quadriplegia, schizoaffective disorder, and cannabis dependence was sent to acute care for behavioral concerns and, after being cleared for discharge, was declined readmission by the facility without a documented assessment of current condition, contrary to facility policy.
A CNA verbally abused a resident with a history of stroke and paralysis during perineal care, dismissing the resident's complaints of pain and ultimately using a derogatory term. The incident was witnessed by another CNA and confirmed by the DON's investigation, violating facility policy requiring respectful and abuse-free treatment.
A CNA in an LTC facility used profanity in the presence of two residents, violating their right to dignity and respect. Both residents, with intact cognition, felt disrespected by the CNA's language, which was perceived as directed towards them. The incident occurred when one resident requested assistance, and the CNA expressed frustration using inappropriate language. The facility's policy on treating residents with respect was not followed, resulting in emotional distress for one resident.
A resident with a complex medical history experienced a change in condition, including altered consciousness and confusion. The facility notified the doctor and executed orders but failed to successfully notify the responsible party on the day of the incident. The responsible party was informed the following day, but this was not documented, violating the facility's policies on notification and documentation.
The facility did not follow the approved menu for residents on pureed and carbohydrate-controlled diets, serving incorrect portion sizes. Six residents on a pureed diet received 2/3 cup of Jambalaya instead of one cup, and 33 residents on a carbohydrate-controlled diet were given a whole slice of garlic bread instead of half. The cook was unaware of the correct portions, and the Registered Dietician Nutritionist confirmed the need to adhere to the menu.
A facility failed to send a notice of transfer or discharge to the Ombudsman for a resident hospitalized twice. The resident, with hemiplegia and dysphagia, was sent to the hospital without the required notification. Interviews confirmed the facility's policy was not followed, risking inappropriate transfer or discharge.
A resident's medications were found unattended in a medication cup on their bedside table, contrary to the facility's policy. The resident had not taken their morning medications, and the LVN responsible was unsure if the medications were administered correctly. The DON confirmed the policy was not followed, highlighting the importance of proper medication administration.
A facility failed to maintain cleanliness in a residents' refrigerator, as a dark brownish-reddish frozen spill was found in the freezer. The RN and DS were unaware of the spill, and the DON acknowledged that the facility's policy on refrigerator maintenance was not followed. The FDA Federal Food Code highlights the need to keep surfaces free of debris to prevent microorganism accumulation.
A facility failed to ensure Enhanced Barrier Precautions (EBP) were followed for a resident with a wound on the right leg. A CNA was observed providing incontinence care without wearing a gown, despite the requirement for EBP. The CNA admitted to forgetting due to being in a rush. The facility's policy mandates gowns and gloves for high-contact tasks, which was not adhered to, posing a risk to resident safety.
A resident with cognitive impairments and mental health disorders eloped from a facility due to inadequate monitoring and a malfunctioning wander guard system. Despite being assessed as an elopement risk and wearing a wander guard bracelet, the resident left through a parking lot gate without triggering an alarm. The resident was last seen in an area accessible to the parking lot, and staff did not hear any alarm during the time the resident went missing.
A resident with a history of stroke and paralysis experienced verbal abuse when a Physical Therapy Assistant (PTA) yelled an expletive during a transfer. The incident was witnessed by multiple staff members, and the Director of Nursing confirmed the use of profanity. This violated the facility's policy on Residents' Rights, which requires treating residents with respect and dignity.
A resident with dementia and unsteadiness on feet fell in their room, and although neurological checks were initiated, the LVN failed to notify the physician about the resident's deteriorating level of consciousness. The resident's condition worsened, leading to their transfer to a hospital. The ADON confirmed that the physician should have been notified, as per the facility's policy on falls.
Failure to Assess Resident for Return Following Hospitalization
Penalty
Summary
The facility failed to conduct an assessment to evaluate a resident's status and needs at the time of a proposed return from the hospital. The resident, who had a history of quadriplegia, schizoaffective disorder, and cannabis dependence, was sent to the hospital for behavioral evaluation due to being a danger to others. After being cleared for discharge by a psychiatrist, attempts were made by the hospital to return the resident to the facility. However, the facility declined to accept the resident back, citing her history of attempting to harm others, without performing a documented assessment of her current condition as required by facility policy. Record reviews and staff interviews confirmed that there was no documentation of an evaluation to determine if the resident was appropriate for transfer back to the facility. The facility's own policies require that residents returning from hospitalization be evaluated based on their current condition at the time of return, not their condition at the time of transfer. Despite this, the Director of Community Relations and the DON acknowledged that no such assessment was completed, and the facility's policies and procedures were not followed in this instance.
Verbal Abuse of Resident During Perineal Care
Penalty
Summary
A Certified Nursing Assistant (CNA 1) verbally abused a resident with a history of stroke and left-sided paralysis during perineal care. The resident expressed pain and concern about rough handling, which CNA 1 did not acknowledge. Another CNA (CNA 2) present during the care asked CNA 1 to be more careful, but CNA 1 responded dismissively. After care was completed, the resident told CNA 1 she did not want her to provide care anymore, at which point CNA 1 called the resident a derogatory name. CNA 2, who was leaving the room, overheard the verbal abuse. The incident was confirmed through statements from the resident, CNA 2, and CNA 1, as well as an investigation by the Director of Nursing (DON). The facility's policy requires all employees to treat residents with kindness, respect, and dignity, and prohibits abuse of any kind. The failure to adhere to these standards resulted in the resident experiencing pain, fear, and anxiety.
CNA's Use of Profanity Violates Resident Dignity
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect when a Certified Nursing Assistant (CNA) used profanity in their presence. This incident involved two residents, both of whom had intact cognition as indicated by their Brief Interview for Mental Status (BIMS) scores of 15. Resident 1, who had diagnoses including major depressive disorder, bipolar disorder, chronic pain, and alcoholic polyneuropathy, felt disrespected when the CNA used derogatory language while addressing her need for assistance. Resident 2, who had diagnoses including morbid obesity, muscle weakness, major depressive disorder, bipolar disorder, anxiety disorder, and kidney failure, witnessed the incident and corroborated the use of profanity by the CNA. The incident occurred when Resident 1 had activated her call light for assistance with changing her diaper. The CNA, identified as CNA 1, entered the room and expressed frustration using profanity, which both residents perceived as directed towards them. The Director of Nursing (DON) confirmed that CNA 1 admitted to using inappropriate language due to feeling overwhelmed by the workload. The facility's policy on resident rights, which mandates treating residents with kindness, respect, and dignity, was not adhered to in this instance, leading to emotional distress for Resident 1 as documented in her medical record.
Failure to Notify and Document Change of Condition
Penalty
Summary
The facility failed to adhere to its Change of Condition (COC) and Documentation Policies for a resident who experienced a significant change in condition. The resident, who had a medical history including rhabdomyolysis, cirrhosis, hepatic encephalopathy, type 2 diabetes mellitus, and Hepatitis C, exhibited altered levels of consciousness and confusion. Although the medical doctor was notified and orders were received and executed, the responsible party was not successfully contacted on the day of the incident. The facility attempted to reach the responsible party but marked them as unreachable, and there was no documentation of any follow-up notification. The deficiency was further compounded by the lack of documentation regarding the notification of the responsible party about the resident's change in condition. An LVN later communicated with the responsible party the following day, informing them of the previous day's events, but failed to document this conversation. Both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged the lapse in documentation, which was contrary to the facility's policy that mandates prompt notification and documentation of any significant changes in a resident's condition.
Failure to Follow Menu Portion Sizes for Special Diets
Penalty
Summary
The facility failed to adhere to the approved menu for residents on specific diets, which could potentially compromise their nutritional status. During a tray line observation, it was noted that six residents on a pureed diet were served 2/3 cup of pureed Jambalaya instead of the one cup specified in the menu. The cook admitted to being unaware of the correct portion size and acknowledged the discrepancy. The facility's winter menu clearly indicated that one cup of pureed Chicken Jambalaya should be served to residents on a pureed diet. Additionally, 33 residents on a regular carbohydrate-controlled diet were served a whole slice of garlic bread instead of the half slice specified in the menu. The cook again admitted to not following the portion sizes listed on the menu. The Registered Dietician Nutritionist confirmed that the recipes and menu should be strictly followed. The facility's policy on menu planning, dated 2023, states that menus are designed to meet the nutritional needs of residents according to established national guidelines.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that a copy of the notice of transfer or discharge was sent to the Ombudsman for a resident who was hospitalized on two separate occasions. The resident, who was admitted with diagnoses of hemiplegia and hemiparesis following a cerebral infarction, as well as dysphagia, was sent to the hospital on two occasions. On both February 16, 2024, and July 6, 2024, there was no record of the notice of transfer or discharge being sent to the Ombudsman, as required by the facility's policy. Interviews with the Social Worker and the Director of Nursing confirmed that the notices were not sent, and the facility's policy and procedure for transfer or discharge notices were not followed. The policy stated that for facility-initiated discharges, a copy of the notice should be sent to the Office of the State Long-Term Care Ombudsman at the same time it is provided to the resident and their representative. This oversight had the potential for the resident to be inappropriately transferred or discharged.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered according to its policy and procedure for one resident. During an observation and interview, five medication tablets were found unattended in a medication cup on the bedside table of a resident. The resident indicated that these were their morning medications, which they had not yet taken. The resident then proceeded to take the medications. This incident occurred despite the facility's policy requiring medications to be administered safely, timely, and as prescribed. Further investigation revealed that the Licensed Vocational Nurse (LVN) responsible for administering the morning medications to the resident was unsure if the tablets found were indeed the resident's morning medications. The LVN admitted to not remembering if the resident took their medication at the prescribed time. The Director of Nursing confirmed that the facility's policy was not followed, emphasizing the importance of ensuring medications are not left unattended and are administered as prescribed by the physician.
Failure to Maintain Cleanliness in Residents' Refrigerator
Penalty
Summary
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. This observation was made on January 21, 2025, at 10:55 AM. During an interview with a Registered Nurse (RN 1) shortly after the observation, it was revealed that the responsibility for cleaning the residents' refrigerator typically falls to the Licensed Vocational Nurse on duty or the housekeeping staff. However, RN 1 was unaware of why the freezer was dirty. Further interviews with the Dietary Supervisor (DS) and the Director of Nursing (DON) revealed a lack of awareness and adherence to the facility's policy and procedures (P&P) regarding refrigerator maintenance. The DS expressed an expectation for the refrigerator to be clean and admitted to not being aware of the spill. The DON, during a review of the facility's P&P, acknowledged that the policy was not followed, as housekeeping was not informed about the spill. The FDA Federal Food Code was also reviewed, which emphasizes the importance of keeping non-food-contact surfaces free of debris to prevent the accumulation of pathogenic microorganisms.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure compliance with Enhanced Barrier Precautions (EBP) for one of the sampled residents, Resident 97, who was on EBP due to a wound on the right leg. During an observation, a Certified Nurse Assistant (CNA 1) was seen providing incontinence care to Resident 97 without wearing a gown, despite a sign outside the room indicating the need for EBP. CNA 1 admitted to forgetting to wear a gown, citing being in a rush as the reason for the oversight. Resident 97 was admitted with diagnoses including Leukocytoclastic Vasculitis, Cellulitis of the lower limbs, and a non-pressure chronic ulcer on the left lower leg. The facility's policy, reviewed with the Director of Nursing, clearly stated the requirement for gowns and gloves during high-contact tasks such as changing incontinence briefs. The Director of Nursing acknowledged that CNA 1 did not comply with the policy, which posed a risk to resident safety throughout the facility.
Resident Elopement Due to Inadequate Monitoring and System Failure
Penalty
Summary
The facility failed to prevent the elopement of a resident who was at risk due to cognitive impairments and mental health disorders. The resident, who had been assessed as an elopement risk with a high score of 18 on the Elopement and Wandering Risk Observation/Assessment, was wearing a wander guard bracelet. Despite this, the resident managed to leave the facility through a parking lot gate that automatically opened for vehicles, without triggering an alarm or being noticed by staff. Interviews and record reviews revealed that the resident was last seen in the facility's smoking area, which was accessible to the parking lot, and was not closely monitored. The Assistant Director of Nursing (ADON) confirmed that the wander guard system was supposed to alarm when a resident with a bracelet approached an exit, but no alarm was heard during the time the resident went missing. A test of the system showed that a facility exit door did not alarm, indicating a malfunction. The Certified Nursing Assistant (CNA) who last saw the resident reported that the resident was known to walk quickly around the parking lot area, which was near the automatic gate. The resident later stated that he left because he believed he was going to be sent to a mental health facility. The facility's policy on wandering and elopements was not effectively implemented, as the resident's care plan included strategies to prevent elopement, but these were not adequately followed, leading to the resident's unsupervised departure.
Removal Plan
- The administrator assigned a staff member to monitor the entrance gate of the facility by the parking lot to ensure no other residents could exit from parking lot main gate. The area will be monitored every shift. The assigned staff member will redirect residents to safety. The staff member will contact another staff member to assist as needed, so the area is not left unmonitored.
- There are 7 residents identified as high risk for elopement risks and these residents are still using a wander guard alarm system.
- Assigned Staff checks for the presence of the wander guard as well as the functionality of the wander guard daily.
- IPN, Case Manager and MDS staff conducted reassessment on the 7 residents for elopement risks and clarified the orders to reflect Licensed Nurses monitoring of the presence of the wander guard device every shift and notified the responsible party and attending physicians accordingly.
- Assigned Staff to monitor and log the expiration date of the wander guard device weekly.
- The Administrator initially in-serviced staff regarding Monitoring of Residents on wander guard. In-servicing of staff will continue.
- The facility created elopement binders for each nursing station and one by the receptionist with the resident's photo, face sheet and redirect residents who are wandering in the unit.
- Maintenance Staff removed the air curtain on door 3 so it doesn't interfere with the functionality of the wander guard system.
Verbal Abuse Incident by Physical Therapy Assistant
Penalty
Summary
The facility failed to protect a resident from verbal abuse when a Physical Therapy Assistant (PTA) yelled an expletive at the resident during a transfer. The incident occurred when the resident, who had a history of stroke and left-sided paralysis, was found on the floor by a Certified Nursing Assistant (CNA). The CNA sought assistance from the PTA, who became frustrated when the resident did not respond to instructions to get on her knees. The PTA then yelled, "Get the f**k up!" at the resident, causing fear, confusion, and anxiety. Multiple staff members, including two CNAs and a Licensed Vocational Nurse (LVN), witnessed the incident. The Director of Nursing (DON) confirmed through interviews with the witnesses that the PTA used profanity directed at the resident. The facility's policy on Residents' Rights, which mandates treating residents with kindness, respect, and dignity, was violated. The incident highlights a failure to protect the resident from verbal abuse, as required by federal and state laws.
Failure to Notify Physician of Resident's Deteriorating Condition After Fall
Penalty
Summary
The facility failed to implement its policy regarding falls when a resident experienced a change in cognition or level of consciousness following an unwitnessed fall. The resident, who had a diagnosis of unsteadiness on feet and unspecified dementia, fell in their room. Although neurological checks were initiated and an X-ray was ordered, the Licensed Vocational Nurse (LVN) did not notify the physician about the resident's deteriorating level of consciousness. The resident's condition worsened from being very drowsy but responsive to touch stimuli to only responding to painful stimuli, yet the physician was not informed. The resident was later found unresponsive during routine checks and was transferred to an acute general hospital. The Assistant Director of Nursing (ADON) confirmed that the physician should have been notified of the changes in the resident's condition, as per the facility's policy and procedure on falls. The policy required nurses to assess and report any change in cognition or level of consciousness, which was not adhered to in this case.
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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 San Bernardino
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Haven Post Acute | 0.8 mi | — | 1 | 0 |
| Sierra Vista | 1.1 mi | — | 18 | 0 |
| Waterman Canyon Post Acute | 1.7 mi | — | 2 | 0 |
| Valley Healthcare Center | 1.7 mi | — | 0 | 0 |
| Medical Center Convalescent Hospital | 1.8 mi | — | 13 | 0 |
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