Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 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 Mesa Care Center during CMS and state inspections, most recent first.
A facility failed to maintain accurate records of Norco administration for a resident when an LVN did not document the medication in the eMAR, despite recording it in the controlled drug book. The resident had a history of hemiparesis, dysphagia, and hypertensive heart disease, and Norco was prescribed for moderate pain. The LVN acknowledged the oversight, which was confirmed by the DON, highlighting a discrepancy between the controlled drug log and the eMAR.
A resident identified as high risk for falls experienced two fall incidents within 48 hours, resulting in a pelvic fracture. The resident's room was located far from the nurse's station, hindering effective supervision. The facility's policy required supervision based on assessed needs, but the resident was not placed in a location that allowed for adequate monitoring.
The facility failed to complete PASARR screenings for three residents with mental health diagnoses. One resident's PASARR was not transferred from a previous facility, another required but did not receive a Level II screening, and a third did not have a Level I screening resubmitted as required. The MDS Coordinator was unaware of the requirements, and the DON and Administrator were not involved in the PASARR process.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to maintain an accurate record of Norco, a controlled medication, for a resident when a Licensed Vocational Nurse (LVN1) administered the medication but did not document it in the electronic Medication Administration Record (eMAR). This discrepancy was identified during a review of the controlled drug log and the eMAR for the resident. The Director of Nursing (DON) confirmed that on several occasions, the medication was documented as administered in the controlled drug book but was not recorded in the eMAR. LVN1 acknowledged the failure to sign the eMAR for the administration of Norco, despite having signed for other medications, and admitted that both the eMAR and the Narcotic Control Book must be signed for narcotics. The resident involved had a medical history that included hemiparesis, dysphagia, and hypertensive heart disease. The Norco was ordered to be given as needed for moderate pain. The facility's policy requires that all medications administered be documented immediately after administration in the resident's medication administration record. The failure to document the administration of Norco in the eMAR had the potential to delay the recognition of possible diversion of a controlled medication.
Inadequate Supervision Leads to Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was identified as high risk for falls, resulting in two fall incidents within a 48-hour period. The first fall was witnessed and occurred in the hallway, while the second fall was unwitnessed and also took place in the hallway. These incidents led to the resident sustaining a pelvic fracture during the latest fall. The resident's room was located far from the nurse's station, making it difficult for staff to monitor the resident effectively. The facility's policy on safety and supervision of residents, dated July 2017, emphasizes that resident supervision should be based on individual assessed needs and environmental hazards. Despite this policy, the resident, who required closer monitoring due to their high fall risk, was not placed in a location that allowed for adequate supervision. The Assistant Administrator acknowledged that the resident should have been positioned closer to the nurse's station to ensure better monitoring, highlighting a lapse in adhering to the facility's safety and supervision policy.
Failure to Complete PASARR Screenings
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) was completed prior to admission for three residents. Resident #22 was admitted with a history of schizoaffective disorder, PTSD, and anxiety disorder, but the facility did not have a documented Level I PASARR screening prior to admission. The MDS Coordinator confirmed that the PASARR was not transferred from the previous facility and was not received for this resident. Resident #86, admitted with schizophrenia and anxiety disorder, had a Level I PASARR screening indicating a need for a Level II screening due to a serious mental illness, but there was no evidence of a Level II screening being conducted. The MDS Coordinator admitted to not ensuring a new PASARR was submitted. Resident #42, admitted with paranoid schizophrenia and severe major depressive disorder, was initially exempt from a Level II evaluation due to an Exempted Hospital Discharge, but the facility failed to resubmit a Level I screening on the 31st day as required. The MDS Coordinator was unaware of the need to resubmit, and the Director of Nursing and Administrator were not involved in the PASARR process but expected it to be completed accurately and timely.
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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 Upland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Upland Rehabilitation And Care Center | 0.2 mi | — | 1 | 0 |
| Heritage Park Nursing Center | 0.7 mi | — | 0 | 0 |
| Ontario Grove Healthcare & Wellness Centre, Lp | 1.2 mi | — | 1 | 0 |
| Las Colinas Post Acute | 1.5 mi | — | 3 | 0 |
| Rancho Mesa Care Center | 2.7 mi | — | 15 | 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.