Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Health Care Center during CMS and state inspections, most recent first.
A resident with multiple healing fractures and a right arm splint and sling, who had difficulty performing daily tasks and required help with activities such as dating food, reported that call lights were answered between five and 30 minutes. During a surveyor observation, the resident activated the call light and waited about 15 minutes before a nurse responded, despite the care plan and facility policy requiring prompt response and staff interviews indicating expectations ranging from immediate to within 10 minutes.
A resident with multiple complex conditions was administered Eliquis 5 mg twice daily instead of the intended 2.5 mg twice daily after returning from a hospital stay. The medication reconciliation process failed to identify the discrepancy, resulting in four doses at double the prescribed strength before the error was recognized and clarified by the DON.
A resident with multiple fractures and non-weight bearing status was transferred using a Hoyer lift by a CNA without the required assistance of a second staff member. During the transfer, a lift strap slipped, causing the resident to fall onto the bed and feel unsafe. Staff interviews and facility policy confirmed that at least two staff are required for Hoyer lift use, but this protocol was not followed.
Several residents with various medical conditions were not provided with documented follow-up information or education regarding their right to formulate an advance directive, despite expressing uncertainty or requesting more information. The facility did not ensure that quarterly care conferences included this follow-up, as required by policy, and the Social Services Director confirmed the lack of documentation for these actions.
Surveyors found that five large plastic basins used for ice and food items were stacked and stored while still wet in the kitchen. Both the Dietary Services Supervisor and the Registered Dietitian confirmed that all kitchenware should be air-dried before storage to prevent bacteria or mold growth. This practice did not meet FDA food code standards and had the potential to impact 52 medically vulnerable residents.
A nurse left potassium chloride at the bedside of a resident without observing its administration, contrary to facility policy requiring staff to remain with residents until all medications are taken. The DON confirmed that medications should not be left at the bedside and that staff are expected to observe residents taking their medications.
A nurse did not follow the manufacturer's required two-minute contact time when disinfecting a shared blood pressure cuff and stethoscope with germicidal wipes after use with a resident. The nurse believed the required time was one minute, but both the product instructions and facility policy specified two minutes. Interviews with the IP and DON confirmed that staff are expected to follow these instructions to ensure proper disinfection.
The facility did not provide the required minimum of 80 sq ft per resident in 16 multi-resident rooms, as confirmed by facility records and staff interviews. Despite this, no negative impacts on care, comfort, or privacy were observed, and residents reported no concerns regarding room size.
A facility failed to report an alleged abuse incident involving a resident with Huntington's Disease to the CDPH within the required timeframe. The incident, where a CNA reportedly slapped a resident, was internally investigated and deemed a misunderstanding of a calming technique. Despite this, the facility's policy required immediate reporting of all allegations, which was not followed.
A resident with Huntington's Disease experienced involuntary movements, but the facility failed to update the care plan to reflect effective interventions. Staff interviews revealed a lack of awareness and documentation of a method used by a CNA to calm the resident's movements, which was not included in the care plan. The DON acknowledged the importance of including such interventions for person-centered care.
A resident with a multidrug-resistant organism (MDRO) was not placed in a single room or cohorted with others with the same infection, contrary to the facility's policy. The resident, who tested positive for ESBL, remained in a shared room with two other residents. Staff were unclear about the necessary precautions, and the facility's policy, which follows CDC guidelines, was not followed, potentially exposing roommates to the infection.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS was incorrectly coded to show antipsychotic medication use, omitting antianxiety and hypnotic medications. Another resident's MDS did not capture a documented fall. The MDS Coordinator and DON confirmed these inaccuracies.
The facility failed to ensure that pressure injury interventions ordered by the physician were implemented for a resident at risk for pressure injuries. Despite an order to float the resident's heels off the bed with pillows every shift, observations revealed that the resident's heels were lying against the mattress without the required support. Staff interviews confirmed the inconsistency in following the physician's order.
The facility had a medication error rate of 5.56%, with errors involving the administration of amlodipine and MiraLAX powder to a resident. The resident's heart rate was below the threshold for administering amlodipine, and the MiraLAX powder was not fully dissolved, resulting in incomplete dosing.
A facility failed to prevent significant medication errors when an LVN administered amlodipine to a resident with a heart rate below the physician-specified threshold. The LVN repeatedly gave the medication despite documented low heart rates, contrary to the facility's policy and physician's orders.
The facility failed to ensure that all multiple-resident bedrooms provided at least 80 square feet per resident for 16 out of 22 rooms observed. Despite having a room size waiver, the facility did not meet the regulatory requirements for resident living space, although no adverse effects on care provision or resident comfort were observed.
The facility failed to provide a written Notice of Discharge to two residents and their representatives prior to the date of discharge. Both residents signed the discharge instructions and Notice of Discharge on the day of discharge, and the Ombudsman was notified only on the day of discharge, not prior as required.
Delayed Call Light Response for Resident Requiring Assistance With Daily Tasks
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure timely response to a resident’s call light. During an unannounced complaint investigation for quality-of-care issues, a resident with decision-making capacity and recent fractures of the right ulna, right radius, and multiple right-sided ribs was observed and interviewed. The resident, who was right-handed and wearing a long arm splint and sling on the right arm, reported difficulty performing normal daily tasks and stated that call lights were typically answered between five and 30 minutes. The resident also stated she required assistance with dating her food and was waiting for staff to come and help. During the interview, the resident activated her call light at 12:17 p.m., and the Treatment Nurse did not respond until approximately 15 minutes later, at 12:32 p.m. Staff interviews revealed inconsistent expectations for call light response times: the Treatment Nurse stated all staff are responsible for answering call lights and that residents should not wait 15 minutes; the CNA stated call lights should be answered within five to 10 minutes; and the LVN stated call lights should be answered immediately and that delays of up to 15 minutes could result in the resident’s needs not being met and increase the risk of falls. The resident’s care plan indicated the resident was at low risk for falls and required that the call light be within reach, with encouragement to use it for assistance, and that the resident needed a prompt response to all requests for assistance. The facility’s policy on answering call lights directed staff to respond timely and, when possible, complete the resident’s request within five minutes.
Failure to Reconcile and Administer Correct Eliquis Dosage
Penalty
Summary
The facility failed to ensure proper medication reconciliation for a resident who was admitted with multiple complex medical conditions, including infected amputated stump, renal dialysis, diabetes mellitus type 2, peripheral vascular disease, and bilateral below-knee amputations. Upon return from a general acute care hospital, the resident's discharge medication list specified Eliquis 2.5 mg to be taken orally twice daily. However, the facility's order summary and medication administration record indicated that Eliquis 5 mg was administered twice daily for four doses, which was double the intended strength. Interviews and record reviews revealed that the medication list from the hospital was reviewed and sent to the physician for reconciliation, but the discrepancy in Eliquis dosage was not identified before administration. The DON confirmed that the resident received the higher dose before a telephone order was obtained to confirm the medication. The facility's policy required careful comparison of pre- and post-discharge medications, including dose, route, and frequency, to prevent unintended changes, but this process was not effectively followed, resulting in the administration of an incorrect medication dose.
Failure to Follow Safe Hoyer Lift Procedures During Resident Transfer
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's policy and procedure for the safe use of a Hoyer lift during a resident transfer. The resident involved had multiple significant injuries, including fractures to the ankle, fibula, breastbone, cervical and thoracic vertebrae, ribs, and a bed sore, and was non-weight bearing at the time. On the day of the incident, a Certified Nursing Assistant (CNA) attempted to use the Hoyer lift to transfer the resident without the required assistance of a second staff member. During the transfer, one of the lift straps slipped out of place, causing the resident to fall onto the bed. The resident was assessed for injuries and none were found, but the incident left the resident feeling unsafe. Interviews with staff confirmed that facility policy required at least two staff members to operate the Hoyer lift. The CNA involved acknowledged being aware of this requirement but proceeded to use the lift alone. Another CNA witnessed the incident and reported that the resident requested not to be lifted again, but observed the same CNA attempt another lift with the resident. The facility's policy, as well as staff interviews, confirmed that the use of the Hoyer lift by a single staff member was not permitted and constituted a failure to provide adequate supervision and accident prevention.
Failure to Provide and Document Follow-Up on Advance Directives
Penalty
Summary
The facility failed to ensure that residents' rights regarding advance directives (ADs) were fully honored and documented for five of seven residents reviewed. Multiple residents, including those with intact or moderate cognitive function, expressed uncertainty about whether they had an AD or requested more information about formulating one. Despite this, there was no documented evidence that these residents or their resident representatives (RPs) were provided with follow-up information or education about their right to formulate an AD after admission. Record reviews for each resident showed that, upon admission, residents were provided with an acknowledgment form regarding ADs, and if they did not have an AD, they were to be given a handout and education on how to create one. The facility's policy also required quarterly follow-up during care conferences for residents without an AD. However, for all five residents cited, there was no documentation that such follow-up or education occurred during the relevant care conferences, even when residents indicated a desire for more information or were unsure about their AD status. Interviews with the Social Services Director (SSD) confirmed that the expected process was not consistently documented or followed. The SSD acknowledged that if there was no AD on file, there was a potential for the facility to be unable to honor residents' wishes for care. The lack of documentation and follow-up regarding ADs was observed across multiple residents with varying medical conditions, including stroke, chronic obstructive pulmonary disease, diabetes, hypertensive heart disease, major depressive disorder, chronic kidney disease, and malnutrition.
Wet-Stored Food Basins Violate Food Safety Standards
Penalty
Summary
Surveyors observed five large plastic basins used for ice and food items that were stacked while still wet and stored on a metal storage shelf in the facility's kitchen. During interviews, both the Dietary Services Supervisor and the Registered Dietitian confirmed that all dishes, pots, pans, and utensils should be air-dried and completely dried before being stored, as moisture can promote bacteria or mold growth. The facility's practice of stacking and storing wet basins did not comply with professional standards for food service safety, specifically the FDA Federal Food Code requirement that equipment and utensils be air-dried after cleaning and sanitizing before coming into contact with food. This deficiency had the potential to affect 52 medically vulnerable residents who consumed food prepared and served in the facility.
Medication Administration Not Observed by Nurse
Penalty
Summary
A licensed vocational nurse failed to follow proper medication administration practices by leaving a cup containing potassium chloride, an orange liquid medication, at the bedside of a resident instead of observing the resident take the medication as required. The nurse confirmed that the medication was scheduled for administration at 9 a.m. and acknowledged that it should not have been left unattended. The resident identified the liquid as her medication during the observation. The Director of Nursing confirmed that facility policy requires nursing staff to remain with residents until all medications have been taken and that medications should not be left at the bedside. A review of the facility's policy on administering oral medications reiterated this expectation.
Failure to Follow Manufacturer's Disinfection Instructions for Shared Equipment
Penalty
Summary
Nursing staff failed to implement proper infection control practices during medication administration for one of four residents reviewed. Specifically, a licensed vocational nurse (LVN) was observed cleaning a shared manual blood pressure cuff and stethoscope with a germicidal disposable wipe but did not allow the equipment to remain visibly wet for the required two minutes as specified by the manufacturer's instructions. The LVN incorrectly believed the required contact time was one minute, despite the instructions on the wipe container indicating a two-minute wet time was necessary to effectively disinfect the equipment. Interviews with the LVN, the Infection Preventionist (IP), and the Director of Nursing (DON) confirmed that staff are expected to disinfect shared equipment according to the manufacturer's instructions, which include maintaining the specified contact time. The facility's policy also requires reusable resident care equipment to be decontaminated between residents per manufacturer guidelines. The failure to follow these procedures was observed during a medication pass and was corroborated by staff interviews and a review of the facility's policy and the manufacturer's instructions.
Failure to Meet Minimum Square Footage Requirements in Multi-Resident Rooms
Penalty
Summary
The facility failed to ensure that multi-resident bedrooms provided the required minimum of 80 square feet per resident in 16 out of 22 rooms, as identified through observation, interview, and record review. A facility document listing room measurements showed that several three-bed and two-bed rooms had less than the required square footage per resident, with some rooms offering as little as 71.7 to 73.7 square feet per resident. During the survey, care was observed in these rooms, and the room sizes did not appear to limit the provision of care. No negative impacts on residents' health, safety, or comfort were observed, and residents interviewed reported being comfortable and having no concerns about space or privacy. Interviews with the DON and Administrator confirmed awareness of the room size deficiency, with both stating there had been no complaints or concerns from staff or residents regarding space or privacy. The facility maintained a policy to ensure resident comfort with living space and to assess for any adverse effects on health and safety related to room size. The Administrator noted that the facility was requesting a continued room waiver for the affected rooms.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an alleged physical abuse incident to the California Department of Public Health (CDPH) and other officials within the required two-hour timeframe. The incident involved a resident with Huntington's Disease, who was reportedly slapped on the leg by a Certified Nurse Assistant (CNA) during a transfer to a shower chair. The Director of Nursing (DON) was informed of the incident by student nurses and initiated an internal investigation, which included suspending the CNA involved and interviewing other staff members. However, the facility did not report the incident to the CDPH as it was deemed unsubstantiated after the internal investigation. The investigation revealed that the alleged abuse was a misunderstanding of a calming technique used by the CNA to manage the resident's involuntary movements. The resident, who was cognitively severely impaired, denied being hit, and other staff members, including the Social Services Director (SSD), confirmed that the CNA was using a rhythmic tapping method to calm the resident. Despite these findings, the facility's policy required that even unsubstantiated allegations of abuse be reported immediately to the appropriate authorities. The facility's failure to report the incident was acknowledged by the DON, who admitted that the incident should have been reported to the CDPH regardless of the investigation's outcome. The facility's policy on abuse reporting clearly states that all allegations must be reported within two hours, highlighting a lapse in adherence to regulatory requirements. This oversight had the potential to delay the investigation and expose residents to further risk.
Failure to Update Care Plan for Resident with Huntington's Disease
Penalty
Summary
The facility failed to review and revise the care plan for a resident with Huntington's Disease, who exhibited involuntary twitching and jerking movements. The care plan, initially created in October 2022, was not updated to reflect the resident's changing needs or to assess the effectiveness of interventions aimed at controlling these movements. This oversight was identified during an unannounced visit to investigate an abuse allegation, where it was found that the care plan had not been periodically reviewed or updated. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's care plan. A registered nurse was unaware of any recent revisions to the care plan, and the Social Services Director noted that a method used by a CNA to calm the resident's movements was not documented in the care plan. The Director of Nursing acknowledged that the effective intervention of rhythmic tapping, which helped reduce the resident's involuntary movements, was not included in the care plan, highlighting a gap in ensuring person-centered care through documented and shared interventions.
Failure to Isolate Resident with MDRO
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy by not placing a resident with a multidrug-resistant organism (MDRO) in a single room or cohorting them with other residents with the same infection. Resident A, who tested positive for extended spectrum beta-lactamase (ESBL) in her urine, was placed on contact isolation but remained in a shared room with two other residents. The Certified Nursing Assistants (CNAs) caring for the residents were observed wearing gloves, but there was confusion about the necessity of additional personal protective equipment (PPE) and the reason for the contact isolation sign. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) both acknowledged that Resident A was not moved to a private room despite the positive ESBL test. The LVN was unaware of when Resident A tested positive and whether it was an active infection. The facility's policy, which follows CDC recommendations, states that residents with known or suspected MDRO colonization or infection should be prioritized for single-resident rooms or cohorted with others with the same MDRO. This oversight had the potential to expose Resident A's roommates to the infection.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. Resident #37's quarterly MDS was inaccurately coded to indicate the resident had taken an antipsychotic medication during the seven-day assessment period, while it did not include the resident's use of antianxiety or hypnotic medication. The resident's care plan and Medication Administration Record (MAR) confirmed the use of lorazepam and Ambien, but no antipsychotic medication was documented. The MDS Coordinator confirmed the incorrect coding during an interview, and the Director of Nursing (DON) stated that the antipsychotic medication had been discontinued upon admission. Resident #17's quarterly MDS inaccurately indicated that the resident had no falls since admission, despite an incident review documenting a fall in November 2023. The resident, who had severe cognitive impairment and other significant diagnoses, was found on the floor next to their bed, which was in the lowest position. The MDS Coordinator acknowledged that the fall should have been captured in the MDS assessment but was not. These inaccuracies in MDS assessments highlight the facility's failure to ensure accurate resident assessments.
Failure to Implement Pressure Injury Interventions
Penalty
Summary
The facility failed to ensure that pressure injury interventions ordered by the physician were implemented for a resident at risk for pressure injuries. The resident, who had severe cognitive impairment and was at risk for pressure ulcers due to decreased mobility, poor safety awareness, and incontinence, had an order to have their heels floated off the bed with pillows every shift. However, observations on multiple occasions revealed that the resident's heels were lying against the mattress without the required pillow support. Interviews with staff, including a Treatment Nurse, Licensed Vocational Nurse, and Certified Nurse Aide, confirmed that the pillow was not consistently in place as ordered. The Director of Nursing and the Administrator both acknowledged that the resident's heels should have been offloaded using a pillow and that staff should have ensured the pillow remained in place. Despite the facility's policy and the physician's order, the staff failed to implement the necessary intervention to prevent pressure injuries, as evidenced by the repeated observations and staff admissions. The deficiency was identified through a combination of observations, interviews, and record reviews, highlighting a lapse in adherence to prescribed care protocols for pressure injury prevention.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, resulting in a medication error rate of 5.56%. This was based on observations, interviews, record reviews, and facility policy reviews. Specifically, there were 2 medication errors out of 36 opportunities, affecting one resident. The errors involved the administration of amlodipine and MiraLAX powder to Resident #19. The resident had a physician's order to hold amlodipine if their heart rate was less than 60 beats per minute, but the medication was administered despite the resident's heart rate being 57 beats per minute. Additionally, the MiraLAX powder was not fully dissolved in the liquid before administration, resulting in the resident not receiving the full dose of the medication. During interviews, LVN #3 acknowledged the errors, stating that she thought it would be okay to administer the amlodipine despite the low heart rate and admitted to not ensuring the MiraLAX powder was completely dissolved. The Director of Nursing confirmed that medications should be held if vital signs are outside the specified parameters, and the Administrator stated that medications are expected to be given according to physician's orders and professional standards.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure no significant medication errors occurred for one resident during the medication administration task. Specifically, a Licensed Vocational Nurse (LVN) administered amlodipine to a resident despite the resident's heart rate being below the parameters specified by the physician's order. The resident's heart rate was documented as 57 beats per minute, below the threshold of 60 beats per minute, at the time of administration. The LVN admitted to administering the medication despite the low heart rate, citing that the resident's heart rate was frequently in the 50s and she thought it would be okay. This action was contrary to the physician's order, which specified holding the medication if the heart rate was less than 60 beats per minute. Further review revealed that the same LVN had administered amlodipine to the resident on multiple occasions when the resident's heart rate was below 60 beats per minute, as documented in the Medication Administration Records (MAR) for February and April 2024. Interviews with the Physician Assistant and the Director of Nursing confirmed that administering amlodipine with a heart rate below 60 could be detrimental and that the medication should have been held according to the physician's order. The facility's policy on administering medications also required verification of vital signs prior to administration, which was not adhered to in this case.
Failure to Meet Room Size Requirements
Penalty
Summary
The facility failed to ensure that all multiple-resident bedrooms provided at least 80 square feet per resident for 16 out of 22 resident rooms observed. The facility's policy, revised in July 2023, mandates that each resident in a multiple-resident bedroom should have at least 80 square feet of space. However, a review of the Client Accommodations Analysis form dated April 12, 2024, revealed that several rooms did not meet this requirement, with some rooms providing as little as 71.7 square feet per resident. Despite this, observations during the recertification survey indicated that the room sizes did not restrict the provision of care, and residents did not voice any concerns regarding their space or room size. Maintenance staff confirmed the measurements, and the Director of Nursing and the Administrator both stated that the facility had a room size waiver for these rooms. During interviews, the Director of Nursing and the Administrator emphasized that staff were expected to respect resident privacy and ensure comfort despite the smaller room sizes. The Administrator also mentioned that staff were mindful of equipment needs to ensure that the room sizes did not impact the residents' quality of life. However, the facility's failure to comply with the required room size standards constitutes a deficiency, as it did not meet the regulatory requirements for resident living space.
Failure to Provide Timely Notice of Discharge
Penalty
Summary
The facility failed to provide a written Notice of Discharge to two residents and their representatives prior to the date of discharge. Resident 1, admitted with a fracture of the right pubis, was given discharge instructions and signed the Notice of Transfer/Discharge on the same day of discharge. Similarly, Resident 2, admitted with a fracture of the left Ilium, signed the discharge instructions and Notice of Discharge on the day of discharge. Both residents were not informed of their discharge in advance, and the Ombudsman was notified only on the day of discharge, not prior as required. Interviews with the Social Services Discharge Planner, Nursing Supervisor, and Director of Nursing revealed that the facility's process involved notifying the Ombudsman on the day of discharge, contrary to the facility's policy which mandates that the Ombudsman be notified at the same time the resident is informed. The facility's policy requires a 30-day advance written notice of discharge, or as soon as practicable if the resident has not resided in the facility for 30 days. The failure to adhere to this policy resulted in the residents and the Ombudsman not being properly informed in a timely manner.
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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 Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alta Vista Healthcare & Wellness Centre | 0.2 mi | ★★★★★ | 17 | 0 |
| Mission Care Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Riverwalk Post Acute | 0.7 mi | ★★★★★ | 21 | 0 |
| Citrus Grove Post Acute | 1 mi | ★★★★★ | 20 | 0 |
| Extended Care Hospital Of Riverside | 1.3 mi | ★★★★★ | 17 | 0 |
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