Deficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
158% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 9
Date: Dec 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, environment safety, staffing, food safety, and antibiotic stewardship at Villa Gardens Health Care Unit.
Findings
The facility was found deficient in multiple areas including failure to provide timely Medicare coverage notice, unsafe and unsanitary environment conditions, lack of required RN coverage on specific dates, medication administration errors, improper food storage and handling, uncovered dumpsters, infection control breaches, cluttered medication storage, and failure to implement antibiotic stewardship protocols.
Deficiencies (9)
Failed to ensure one of three sampled residents received sufficient notice prior to last Medicare Part A coverage date.
Failed to provide a safe, clean, and homelike environment; wheelchair overflowing with personal belongings causing unsafe and unsanitary conditions.
Failed to ensure RN coverage for eight consecutive hours on specified dates.
Failed to provide pharmaceutical services meeting residents' needs; medication errors including unattended medication, improper timing, and failure to flush feeding tubes between medications.
Failed to ensure medication error rates were less than 5%; observed 3 errors out of 25 opportunities (12%).
Failed to ensure food was handled, prepared, and stored properly; expired products not removed, improper labeling and cleanliness in storage areas.
Failed to ensure dumpsters were covered or completely closed, risking pest infestation and contamination.
Failed to implement infection prevention and control practices including improper PPE use, contaminated equipment, improper storage of oxygen tubing, and cluttered medication room.
Failed to implement antibiotic stewardship program; no culture obtained before antibiotic administration for one resident.
Report Facts
Medication errors observed: 3
RN coverage missing days: 4
Residents sampled: 3
Residents affected by specific deficiencies: 1
Residents affected by environment deficiency: 1
Residents affected by infection control deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Named in medication administration errors including leaving medication unattended and improper flushing. |
| Director of Nursing | DON | Provided statements regarding Medicare notice, RN coverage, medication administration, infection control, and facility policies. |
| Infection Preventionist Nurse | IPN | Provided infection control observations and policy reviews. |
| Certified Nursing Assistant 1 | CNA | Observed and interviewed regarding environment cleanliness and linen handling. |
| Registered Nurse 1 | RN | Observed and interviewed regarding medication administration practices. |
| Director of Staff Development | DSD | Provided information on RN staffing shortages. |
| Licensed Vocational Nurse 3 | LVN | Observed medication administration and use of resident identifiers. |
| Registered Nurse Supervisor 3 | RNS | Reviewed medication administration policies and resident identification procedures. |
| Director of Dining Services | DDS | Interviewed regarding dumpster lid policy and compliance. |
| Director of Environmental Services | DES | Confirmed dumpster lid deficiencies and policy non-compliance. |
| Occupational Therapist | OT | Observed improper storage of oxygen tubing on wheelchair. |
Inspection Report
Routine
Deficiencies: 9
Date: Oct 4, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, fall prevention, catheter care, respiratory care, food safety, infection control, medication administration, and call system functionality.
Findings
The facility was found deficient in multiple areas including failure to inform residents about advance directives, inadequate fall prevention interventions, improper catheter irrigation technique, oxygen therapy noncompliance, food handling violations, failure to properly document insulin administration and monitor diabetes symptoms, inadequate infection control practices, and failure to ensure call lights were accessible to residents.
Deficiencies (9)
Failed to follow Advance Directive policy to inform and provide written information regarding the right to formulate an advance directive for one resident.
Failed to prevent falls for one resident by not identifying causative factors and revising care plan with new interventions.
Failed to follow manual catheter irrigation policy by not capping drainage tube with sterile protective sheath during irrigation for one resident.
Failed to provide safe and appropriate respiratory care by not following oxygen therapy orders and improper storage of oxygen equipment for two residents.
Failed to follow proper food handling practices including unlabeled food items, expired bread in storage, and unlabeled food in resident refrigerator.
Failed to properly dispose of garbage and maintain dumpsters covered and not overflowing.
Failed to accurately document insulin dose administered and monitor signs and symptoms of hypoglycemia and hyperglycemia for one resident.
Failed to implement infection prevention and control program including improper PPE use by visitor, improper storage of oxygen tubing and nebulizer, failure to don PPE before care for resident on enhanced barrier precautions.
Failed to ensure call light was within reach for one resident.
Report Facts
Fall incidents: 6
Insulin units administered: 15
Oxygen liters per minute: 4
Expired bread date: Sep 28, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 5 | LVN | Failed to cap drainage tube during catheter irrigation and verified advance directive acknowledgement form missing. |
| Licensed Vocational Nurse 4 | LVN | Administered incorrect insulin dose and failed to initial medication administration record. |
| Licensed Vocational Nurse 1 | LVN | Observed empty humidifier bottle during oxygen therapy and reviewed insulin administration record. |
| Director of Nursing | DON | Acknowledged transcription error in insulin administration and failure to follow catheter irrigation policy. |
| Director of Dining Services | DDS | Confirmed expired bread and unlabeled food items in kitchen. |
| Licensed Vocational Nurse 2 | LVN | Observed improper oxygen therapy and storage of oxygen tanks. |
| Licensed Vocational Nurse 3 | LVN | Stated importance of labeling food items in resident refrigerator. |
| Infection Preventionist Nurse | IPN | Stated visitor should have worn full PPE in COVID isolation room. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 31, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to provide and document wound care treatment for Resident 1 and failure to ensure a safe environment, resulting in an accident where a keyboard fell on Resident 1's feet causing injury.
Complaint Details
The complaint investigation found substantiated failures including lack of wound care treatment documentation and unsafe environment leading to injury of Resident 1.
Findings
The facility failed to provide and document wound care treatments as ordered for Resident 1, resulting in untreated wounds. Additionally, the facility failed to secure a keyboard on a music equipment cart, which fell and injured Resident 1's feet, causing blood blisters requiring surgical intervention and hospitalization.
Deficiencies (2)
Failure to document and perform wound care treatment for Resident 1 as ordered, including multiple wounds requiring Medihoney ointment.
Failure to ensure a safe environment by not securing a keyboard on a music equipment cart, resulting in injury to Resident 1.
Report Facts
Date of wound care treatment failure: Jan 22, 2024
Date of accident: Dec 31, 2023
Blood blister size left dorsal foot: 2.5
Blood blister size right medial malleolus: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse 1 | Treatment Nurse | Stated he provided wound care to upper arms but not areas requiring Medihoney on 1/22/24 and forgot to sign TAR |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding wound care failures and facility policy; acknowledged lack of policy and treatment documentation |
| Activities Specialist | Activities Specialist (AS) | Reported keyboard fell on Resident 1's feet during entertainer setup on 12/31/23 |
Inspection Report
Routine
Deficiencies: 9
Date: Oct 8, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory standards related to resident care, medication administration, infection control, food safety, hospice care coordination, and other professional standards.
Findings
The facility was found deficient in multiple areas including failure to develop individualized baseline care plans within 48 hours of admission, improper medication administration practices, failure to clean dryer lint traps, medication errors, storage of expired medications and food, inadequate hospice care coordination, improper infection control practices for C. diff, and incomplete antibiotic stewardship documentation.
Deficiencies (9)
Failed to develop an individualized baseline care plan within 48 hours of admission to address hearing needs for Resident 189.
Failed to flush in between each medication administered through gastrostomy tube for Resident 23.
Failed to clean dryer lint trap for three dryers, posing fire hazard.
Medication errors with Resident 4: Eliquis and Carvedilol administered without food as ordered.
Expired medications found in medication room not disposed of properly.
Failed to store food under sanitary conditions including mixing pasteurized and regular eggs, unlabeled and expired food items in kitchen.
Failed to ensure coordination of hospice care for Resident 24 including missing physician orders, certifications, hospice care plan, and documentation of hospice visits.
Failed to implement appropriate infection control practices for Resident 26 with C. diff by not providing EPA approved disinfectant solution in contact isolation room.
Failed to complete Infection Surveillance Log Form prior to antibiotic administration for Residents 22, 26, and 90.
Report Facts
Medication errors: 2
Medication administration: 6
Dryer lint removal logs: 3
Expired food items: 3
Antibiotic administration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Named in medication error finding and observation of Resident 4 medication administration. |
| Licensed Vocational Nurse 2 | LVN | Named in medication administration observation for Resident 23 failing to flush between medications. |
| Director of Nursing | DON | Provided statements regarding medication administration policies and errors. |
| Social Services Director | SSD | Interviewed regarding Resident 189's hearing care plan deficiency. |
| Environmental Service Director | ESD | Interviewed regarding dryer lint trap cleaning deficiency. |
| Certified Dietary Manager | CDM | Interviewed regarding food storage and labeling deficiencies. |
| Director of Dining Services | DDS | Interviewed regarding food storage and labeling deficiencies. |
| Licensed Vocational Nurse 3 | LVN | Interviewed regarding hospice care coordination for Resident 24. |
| Licensed Vocational Nurse 4 | LVN | Interviewed regarding hospice care coordination for Resident 24. |
| Infection Preventionist Nurse | IPN | Interviewed regarding infection control practices and antibiotic stewardship. |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 24, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with nutritional menu requirements and the maintenance of the facility's physical environment, including roof and ceiling conditions.
Findings
The facility failed to follow its menu portioning policies for 31 residents receiving unportioned Haricot Verts and 7 residents receiving unportioned steak fajitas, risking unplanned weight changes. Additionally, the facility failed to maintain the roof and ceilings in good repair, resulting in water leaks, ceiling damage, and potential safety hazards.
Deficiencies (2)
Failure to follow the facility's menu portioning policy resulting in unportioned Haricot Verts served to 31 residents and unportioned steak fajitas served to 7 residents.
Failure to maintain the facility's roof and ceilings in good repair, causing water leaks, ceiling damage, and exposing pipes, ducts, and electricals.
Report Facts
Residents affected: 31
Residents affected: 7
Hole size: 70
Hole size: 72
Hole size: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Worker 1 | Food Service Worker | Interviewed regarding use of tongs instead of scoops for food portioning |
| Executive Chef | Executive Chef | Interviewed about proper portion sizes and utensil use for food service |
| Director of Dining Services | Director of Dining Services | Interviewed about risks of inaccurate food portions to residents |
| Registered Dietitian | Registered Dietitian | Interviewed about correct scoop sizes and risks of inaccurate portioning |
| Administrator | Administrator | Interviewed about facility maintenance and safety concerns |
| Maintenance Coordinator | Maintenance Coordinator | Interviewed regarding ceiling damage and roof leaks |
| Maintenance 1 | Maintenance Staff | Measured ceiling hole and discussed damage |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed about rainwater leaks, ceiling damage, and roof cracks |
| Dietary Aide 1 | Dietary Aide | Reported prior observations of water leaking from ceiling |
Report
November 25, 2025
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May 27, 2025
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May 9, 2025
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June 18, 2024
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June 13, 2024
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January 18, 2024
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August 29, 2023
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June 10, 2023
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June 8, 2023
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June 17, 2022
Report
November 2, 2021
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November 2, 2021
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October 22, 2021
Report
September 29, 2021
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