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 Villa Gardens Health Care Unit during CMS and state inspections, most recent first.
A facility failed to follow its policy on advance directives by not informing a resident with chronic kidney disease and thrombocytopenia about their right to formulate an advance directive. The absence of an acknowledgment form in the resident's chart was confirmed by both an LVN and the Social Services Director, despite the facility's policy requiring this documentation upon admission.
A resident with Parkinson's, dementia, and incontinence experienced multiple falls due to the facility's failure to identify causative factors and update the care plan with specific interventions. Despite a history of falls and confusion, the care plan lacked measures to address nighttime incontinence and confusion, leading to repeated falls and injuries.
The facility failed to follow its oxygen therapy policy for two residents. One resident received oxygen with an empty humidifier bottle, risking nasal membrane drying. Another resident received more oxygen than prescribed, and empty oxygen tanks were improperly stored in the room. Staff interviews confirmed these deficiencies.
The facility failed to follow proper food handling practices, as observed in the kitchen and resident's refrigerator. Food items were found without labels indicating the date they were opened, and expired bread was present in the dry storage area. Staff acknowledged the risk of bacterial growth and potential foodborne illness due to these deficiencies, which violated the facility's policies on food labeling and storage.
The facility failed to properly dispose of garbage, resulting in two dumpsters being uncovered and overflowing with trash. This was confirmed by the Director of Dining Services, who acknowledged the dumpsters should have been covered to prevent attracting animals. The facility's policy requires garbage containers to be maintained with lids to prevent pest attraction and ensure sanitation.
The facility failed to adhere to infection control practices for several residents. A visitor entered a COVID-19 isolation room without proper PPE, and staff did not ensure nasal cannula tubing was stored correctly for a resident. Another resident on Enhanced Barrier Precautions was not properly protected by staff during care, and a nebulizer was not stored in a clean bag, increasing infection risk.
A resident with an indwelling catheter did not receive proper catheter care as a nurse failed to cap the drainage tube with a sterile sheath during irrigation, contrary to the facility's policy. The resident, who required substantial assistance and had a history of chronic conditions, was at risk due to this oversight. The facility's policy emphasized maintaining a closed system to prevent contamination, which was not adhered to during the procedure.
A resident with type 2 diabetes was administered an incorrect insulin dose due to a transcription error, and the nurse failed to document the administration properly. Additionally, there was no documented evidence of monitoring for signs of hypoglycemia and hyperglycemia, despite recommendations. This lack of documentation and adherence to policies placed the resident at risk of inappropriate diabetes management.
A resident with functional quadriplegia and severe cognitive impairments was found to have their call light on the floor, out of reach, contrary to the facility's policy requiring call systems to be accessible. This deficiency was observed during staff interviews and record reviews.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to adhere to its Advance Directive policy by not informing and providing written information to a resident regarding their right to formulate an advance directive. This deficiency was identified for one of the two sampled residents, who was admitted with chronic kidney disease and thrombocytopenia. The resident's medical records, including the Face Sheet and Minimum Data Set, indicated fluctuating capacity for decision-making, yet the facility did not ensure the presence of an advance directives acknowledgment form in the resident's chart. During interviews, both a Licensed Vocational Nurse and the Social Services Director confirmed the absence of the required acknowledgment form, which should have been completed and placed in the resident's medical record. The facility's policy, revised in March 2024, mandates that social services staff inform residents about their rights concerning advance directives upon admission and document this in the medical record. The lack of this documentation could lead to conflicts in executing the resident's healthcare decisions during emergencies.
Failure to Prevent Falls and Update Care Plan
Penalty
Summary
The facility failed to prevent falls for a resident by not identifying the causative factors of the resident's falls and not revising the care plan with new, resident-specific interventions. The resident, who had a history of falls, Parkinson's Disease, dementia, and incontinence, experienced multiple falls over a period of time. Despite these incidents, the care plans from July to September did not include interventions to address the resident's nighttime incontinence and confusion. The resident was found on several occasions sitting on the floor, confused, and wet with urine, indicating a lack of adequate supervision and intervention. The resident's falls were often unwitnessed, and the circumstances surrounding the falls, such as attempting to reach for something or being confused about their surroundings, were not adequately addressed in the care plan. The facility's policy required immediate interventions and care plan updates, which were not consistently implemented. Interviews with facility staff, including the DON, revealed that the resident had a history of falls and unsteady gait, and was incontinent at night. However, there was no documented evidence of interventions to address these issues. The facility's policies on post-fall assessment and falls prevention emphasized the need for immediate interventions and care plan updates, which were not followed, leading to repeated falls and injuries for the resident.
Oxygen Therapy Policy Violations
Penalty
Summary
The facility failed to adhere to its oxygen therapy policy for two residents, leading to potential adverse effects. For Resident 8, the facility did not ensure that the humidifier bottle attached to the oxygen concentrator was dated and filled with water. During an observation, it was noted that Resident 8 was receiving 4 liters of oxygen per minute via nasal cannula with an empty and undated humidifier bottle. This oversight could result in nasal membrane drying, as the humidifier is intended to add moisture to the oxygen flow, preventing such issues. In the case of Resident 37, the facility did not follow the physician's order for oxygen therapy. The resident was observed receiving 4 liters per minute of oxygen via nasal cannula, despite the physician's order specifying 2 liters per minute. Additionally, empty portable oxygen cylinder tanks were stored in the resident's room alongside full tanks, contrary to the facility's policy, which requires empty tanks to be stored separately. This practice poses a risk of oxygen toxicity and potential safety hazards. Interviews with facility staff, including LVNs and the Director of Nursing, confirmed these deficiencies. Staff acknowledged the importance of following physician orders and the facility's policies to prevent harm to residents. The facility's policy on oxygen therapy, revised in July 2022, outlines the proper procedures for administering oxygen and managing equipment, which were not followed in these instances.
Improper Food Handling and Labeling Practices
Penalty
Summary
The facility failed to adhere to proper food handling practices as per its policy and procedure, which was observed during a survey. In the kitchen, multiple food items inside walk-in refrigerators were found without labels indicating the date they were opened. This included a large container of cranberries, a grocery bag with various food items, and a large pan of breaded meat. The cook was unaware of the origin of the grocery bag and acknowledged that it should not have been in the refrigerator. Additionally, expired bread items were found in the dry storage area, which the Director of Dining Services and the Registered Dietician confirmed should have been discarded to prevent potential health risks. In the resident's refrigerator near the nurse's station, several food items lacked labels indicating the opened date, resident's name, room number, or the date the food was prepared. This included a small container of red sauce and multiple containers of ice cream. Licensed Vocational Nurses expressed concerns about the lack of labeling, emphasizing the risk of bacterial growth and potential foodborne illness. The facility's policies required all prepared foods and foods not in original containers to be covered, labeled, and dated, and foods brought in by family members to be labeled with the resident's name, room number, and date of preparation or opening.
Improper Garbage Disposal and Overflowing Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse as per their policy, which resulted in two out of three dumpsters being uncovered and overflowing with trash. This was observed during a visit to the facility's garbage area, where the Director of Dining Services confirmed the issue, noting that the dumpsters should have been covered to prevent attracting animals. Additionally, empty boxes were found between the dumpsters, and one dumpster's lid was only partially covering it due to the overflow. The facility's policy, reviewed during the investigation, mandates that garbage containers be maintained in good condition with lids to prevent pest attraction and maintain sanitation.
Infection Control Deficiencies in PPE Usage and Equipment Storage
Penalty
Summary
The facility failed to implement appropriate infection control practices for several residents, as outlined in their policy and procedure. For Resident 199, a visitor entered the resident's room, which was under novel respiratory isolation due to COVID-19, without wearing the required personal protective equipment (PPE) such as a gown, N-95 mask, gloves, and face shield or goggles. The visitor was not educated on the necessity of these precautions, despite the presence of a sign indicating the required PPE. The Infection Preventionist Nurse confirmed the oversight and emphasized the importance of following isolation precautions to prevent the spread of infection. Resident 37's infection control measures were compromised when the nasal cannula tubing was not stored in a bag after use and was observed touching the floor. The facility's policy requires that oxygen tubing be changed if it becomes dirty or contaminated, which includes contact with the floor. Staff interviews revealed a lack of adherence to these protocols, as the nasal cannula was left exposed, increasing the risk of infection. For Resident 24, who was on Enhanced Barrier Precautions due to a gastrostomy tube and colonization with a multidrug-resistant organism, a staff member failed to don a gown before checking the gastrostomy tube placement. This oversight was acknowledged by the staff member, who later corrected the error. Additionally, Resident 19's handheld nebulizer was not stored in a clean bag when not in use, contrary to the facility's policy, which could lead to contamination and respiratory infection. Interviews with staff confirmed the importance of storing such equipment properly to prevent infection.
Failure to Follow Catheter Irrigation Policy
Penalty
Summary
The facility staff failed to adhere to its manual catheter irrigation policy when a Licensed Vocational Nurse (LVN) did not cap the drainage tube of an indwelling catheter with a sterile protective sheath during the irrigation process for a resident. This oversight was observed during a procedure where the LVN cleansed the connection site, disconnected the catheter from the drainage tubing, and placed the tubing on a clean disposable absorbent pad without capping it. The LVN then proceeded to flush the catheter with normal saline and reconnected the tubing without using a sterile sheath, contrary to the facility's policy. The resident involved had a history of benign prostatic hyperplasia, chronic systolic congestive heart failure, and chronic obstructive pulmonary disease, and required substantial assistance with daily activities. The resident's physician had ordered regular flushing of the indwelling catheter due to sediment buildup. The facility's policy, which was not followed, emphasized maintaining a closed urinary drainage system to prevent contamination. Both the Director of Nursing and the Administrator acknowledged that the LVN did not follow the established policy, which could potentially lead to an infection if bacteria entered the drainage tubing.
Insulin Administration and Monitoring Deficiencies
Penalty
Summary
The facility staff failed to accurately and completely document the insulin dose administered to a resident on a specific date. The resident, who had a history of type 2 diabetes and other medical conditions, was given an incorrect dose of insulin according to the sliding scale prescribed by the physician. The Sliding Scale Insulin Administration Record indicated that the resident's blood sugar level was 197, which required 8 units of insulin, but the record showed that 15 units were administered. Additionally, the licensed nurse who administered the insulin did not initial the record, which is against the facility's policy for charting medications. The Director of Nursing (DON) confirmed that a transcription error occurred, and the wrong amount of insulin was recorded. The DON stated that the nurse should have documented 8 units instead of 15 units and should have initialed the record after administering the insulin. This failure to follow the facility's charting guidelines and medication administration policies placed the resident at risk of receiving inappropriate diabetes management and care. Furthermore, the facility staff did not have documented evidence for monitoring the resident for signs and symptoms of hypoglycemia and hyperglycemia, as recommended by the pharmacist and indicated in the resident's care plan. The Medical Doctor (MD) stated that monitoring for these symptoms is a standard nursing practice and does not require a written order. However, the lack of documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) suggests that the monitoring was not consistently performed or recorded, which could lead to unmonitored and untreated adverse reactions from insulin therapy.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 24, who was completely immobile due to functional quadriplegia and had severe cognitive impairments. The resident was dependent on staff for all activities of daily living, including eating, personal hygiene, and toileting. During observations, the call light was found on the floor, out of the resident's reach, which was confirmed by both a Certified Nursing Assistant and a Licensed Vocational Nurse. The facility's policy required that call lights be within reach at all times to enable residents to request assistance. The deficiency was identified during a review of the resident's records and through direct observation and interviews with staff. The facility's policy, dated February 2009, clearly stated the necessity of having call systems accessible to residents to ensure they can request help, especially in emergencies. Despite this policy, the call light for Resident 24 was not accessible, which could prevent the resident from calling for assistance when needed.
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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 Pasadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pasadena Grove Health Center | 1.6 mi | — | 22 | 0 |
| Foothill Heights Care Center | 1.7 mi | — | 2 | 0 |
| Pasadena Nursing Center | 1.7 mi | — | 26 | 0 |
| Cedar Pine Post Acute | 1.8 mi | — | 8 | 0 |
| Pasadena Palace Tcu | 1.8 mi | — | 25 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.