Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 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.
Two residents had deficient wound care and skin monitoring. One resident with a left iliac crest PI had missing TAR initials, no documented wound treatments for a period of time, no dated dressing, and no documented change in condition, IDT note, or care plan update as the wound worsened from DTI to unstageable. Another resident with a stage 4 sacral PU and high risk for skin breakdown had MASD on the left buttock that was not documented on repeated skin assessments, with no timely SBAR, treatment order, or care plan focus before the later date reviewed.
Failure to Provide Dignified Meal Assistance: An IP nurse stood while feeding a resident who had dysphagia, hemiplegia, and dementia, instead of being seated at the resident’s level. The IP nurse stated staff should be seated during feeding assistance for safety and to help prevent aspiration, and the ADON confirmed the facility policy says staff should not stand over residents while assisting with meals.
A resident's quarterly MDS was incorrectly coded to show a history of fall with injury even though the MDS Nurse stated there was no fall history in the facility. The DON confirmed the coding error, and the RAI manual was not followed when completing Section J of the MDS.
Incomplete care plans for IV therapy and hospice services: Two residents had missing or incomplete comprehensive, person-centered care plans. One resident receiving continuous IV NS via lower-extremity access had a care plan that identified poor IV access and malnutrition-related tissue perfusion risk but lacked measurable goals and defined outcomes. Another resident on hospice with dementia, malnutrition, and Alzheimer’s disease had no comprehensive hospice care plan in the record, and the DON acknowledged the expected comfort measures and hospice coordination were not documented.
Failure to monitor and address a resident’s weight loss. A resident with stroke-related hemiplegia, epilepsy, and metabolic encephalopathy required meal assistance and received a fortified pureed diet with thickened liquids, but staff did not document weekly weights for an extended period despite a physician order. The resident lost about 11 lbs, the RD was unaware of the loss during assessment, and the DON acknowledged the SBAR, 72-hour monitoring, and care plan did not reflect the weight loss.
Unlabeled IV Dressing on Resident with Peripheral IV: A resident with dysphagia and dementia had an IV infusing for dehydration, but the peripheral IV site in the right arm was observed with no label showing the date, time, or staff initials. The DON and RN confirmed the dressing should have been labeled, and the facility policy required the dressing to be marked with the date and time of the change and initials.
Medication Cart B had incomplete controlled substance count records, with 17 missing signatures on the 8-hr CDCR across multiple shifts. An LVN confirmed the omissions and stated two licensed nurses are supposed to verify the log at shift change. The DON reviewed the facility’s Controlled Medication Storage policy, which requires a physical inventory of controlled meds by two licensed nurses at each shift change, and stated the facility did not follow the policy.
Improper storage of catheter and respiratory equipment was observed for three residents. A urinary catheter bag was found resting on the floor, oxygen tubing from nebulizer equipment was hanging under a bed and touching the floor, and another resident’s nebulizer mask and tubing were left uncovered and unlabeled on a nightstand. Staff acknowledged the equipment was not stored according to policy, and the ADON confirmed the policies were not followed.
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.
Missed wound treatment and skin monitoring for pressure injuries and MASD
Penalty
Summary
Failure to provide appropriate pressure ulcer care and to prevent new ulcers from developing was identified for two residents. For one resident with Parkinson’s disease with dyskinesia, dysphagia, dementia, and heart failure, the record showed a left iliac crest pressure injury that was first documented as a deep tissue injury and later described as unstageable with slough and eschar. During observation, the wound was covered with an undated dressing, and treatment nurses stated they were not sure when the last wound treatment had been rendered. One nurse stated the wound treatment was not done on the day of observation. The resident’s record showed physician orders for wound treatment on the left iliac crest, but the treatment administration record had missing initials and there was no documented evidence of wound treatments from January 7 through January 16. The DON stated there was no treatment order during that period and could not explain the missing initials. The record review also found no documented evidence of a change in condition, IDT meeting notes, or care plan documentation addressing the worsening wound before January 20. Staff stated they only documented wound descriptions weekly on the Skin Observation Tool and did not document wound descriptions with each treatment, and they did not date the dressing. The facility policy required wound assessment data to be recorded and the dressing to be dated, initialed, and timed. For the second resident, who had a stage 4 sacral pressure ulcer, sepsis, and neuromuscular dysfunction of the bladder and was documented as lacking capacity to make and understand medical decisions, the record showed MASD on the left buttock. The resident was dependent for toileting hygiene and transfers and was at high risk for pressure sore development. During observation, the wound treatment nurse identified the left buttock area as MASD, but the Skin Observation Tool had no documentation of the MASD on multiple dates reviewed. The SBAR communication form addressing the MASD was not initiated until the later date reviewed, and the TAR showed the treatment order for the MASD also started on that same date. The care plan contained no focus, goals, or interventions for the MASD, and staff stated there was no treatment order addressing the MASD prior to that date. The facility’s policies for wound care, change in condition, and care plans were reviewed, and the ADON stated the policies were not followed.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
The facility failed to ensure that Resident 61 was provided a dignified experience during meal assistance when the Infection Preventionist (IP) nurse stood while feeding the resident. Resident 61 was admitted with diagnoses including dysphagia, hemiplegia, and dementia. During an observation in the dining area, the IP nurse assisted Resident 61 with lunch while standing beside the resident, who was seated in a wheelchair at a dining room table, and fed the resident noodle soup with a spoon while remaining standing. During an interview, the IP nurse stated that when providing feeding assistance, staff should be seated at the resident’s level for safety to help prevent aspiration. A concurrent interview and record review with the ADON confirmed the facility’s policy titled Assistance with Meals, revised March 2022, stated that residents who cannot feed themselves should be fed with attention to safety, comfort, and dignity, including not standing over a resident while assisting with meals. The ADON stated staff should not stand over residents while assisting with meals and confirmed that staff did not follow the facility’s policy.
Incorrect MDS Fall History Coding
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident reviewed for history of falls. Resident 92 was admitted with diagnoses including generalized muscle weakness, dementia, and adult failure to thrive. On the quarterly MDS assessment dated January 5, 2026, Section J, Health Conditions, indicated the resident had a history of fall with injury, coded as 1 in J1900. During interview and record review, the MDS Nurse stated the assessment was incorrectly coded as a fall and that there was no history of a fall for this resident in the facility. The MDS Nurse also stated the Resident Assessment Instrument manual was supposed to be followed for coding, but it was not followed. The DON later stated the MDS Nurse did not code the resident's fall correctly and should have coded it as no falls. The CMS RAI v3.0 manual reviewed by surveyors stated that fall history coding should be based on resident/family interview and review of transfer and medical records, with code 0 for no and code 1 for yes.
Incomplete care plans for IV therapy and hospice services
Penalty
Summary
Resident 11 had an IV therapy order initiated for 0.9% Normal Saline at 50 mL per hour continuously, with the IV placed in the lower extremity after staff reported poor venous access and repeated failure to obtain upper-extremity access because the veins were blowing. The resident’s admission record listed diagnoses including protein-calorie malnutrition and metabolic encephalopathy. During record review, the care plan dated January 12, 2026, identified that the resident had poor IV access and was at risk for poor tissue perfusion related to malnutrition, but the ADON confirmed the care plan was not fully completed and had been reviewed on January 21, 2026. The ADON also confirmed that Resident 11’s care plan lacked measurable goals and did not include defined outcomes to evaluate the effectiveness of nursing interventions. The facility’s policy on Goals and Objectives, Care Plans stated that care plans shall incorporate goals and objectives that are resident oriented, behaviorally stated, measurable, and contain timetables to meet the resident’s needs in accordance with the comprehensive assessment. The ADON acknowledged that the care plan for Resident 11 did not meet those expectations. Resident 14 was admitted with diagnoses including encounter palliative care, dementia, and protein-calorie malnutrition, and physician orders dated June 10, 2025 indicated admission to hospice under the resident’s diagnosis of Alzheimer’s disease. During record review, the ADON acknowledged that no comprehensive care plan addressing hospice care was found in the electronic records. The ADON stated hospice residents are expected to have a care plan addressing comfort measures and coordination with hospice services, and confirmed that the facility did not meet the expectation that the comprehensive, person-centered care plan be developed within seven days of the required MDS assessment and no more than 21 days after admission.
Failure to Monitor and Address Resident Weight Loss
Penalty
Summary
The facility failed to ensure nutritional status was monitored for one sampled resident with a documented weight loss. Resident 47 was admitted with diagnoses including cerebral infarction with right-sided hemiplegia, epilepsy, and metabolic encephalopathy. The resident’s MDS showed a BIMS score of 8 and indicated the resident required set-up or clean-up assistance for eating. During observation, the resident was in bed at lunch, awake, and being fed by CNA staff while receiving a fortified pureed diet with thickened liquids and a high-protein supplement. Resident 47’s weight history showed a decline from 147 lbs in November 2025 to 138 lbs in December 2025, with an additional weight of 133 lbs recorded in January 2026. However, no weights were documented from November 11, 2025, through January 4, 2026, despite a physician order dated January 14, 2026 for weekly weights x4. Staff interviews confirmed the missing weights were an oversight, and the RN confirmed no change of condition related to weight loss had been documented in the system. The RD stated she was not aware of the resident’s approximately 11-pound weight loss when completing the December 15, 2025 assessment. Further review showed the facility’s Nutrition (Impaired)/Unplanned Weight Loss clinical protocol required monitoring and documentation of weight and dietary intake, but the ADON acknowledged the process was not followed. The ADON stated that when significant weight loss is identified, the expected process includes SBAR notification, physician and family notification, weekly weights, 72-hour monitoring, and care plan revision. The ADON confirmed that December weights were not entered into the electronic system until January 21, 2026, the SBAR dated January 8, 2026 was not completed until January 21, 2026, no 72-hour monitoring documentation was completed after SBAR initiation, and the care plan did not address the documented 11-pound weight loss.
Unlabeled IV Dressing on Resident with Peripheral IV
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids for a resident when needed was not followed for Resident 61. Resident 61 was admitted with diagnoses including dysphagia and dementia and had a physician order for 0.9% Sodium Chloride IV fluids at 60 mL per hour for dehydration starting January 19, 2026. During an observation in the resident’s room, the resident was lying in bed with an IV bag infusing and a peripheral IV catheter inserted in the right arm. The IV insertion site and dressing were unlabeled, with no staff initials and no date and time of insertion or dressing change documented on the dressing. During a concurrent observation and interview, the DON confirmed the IV site dressing should be labeled with the date, time, and initials so staff can identify when the IV was inserted and when the dressing was changed. RN 1 also stated the IV dressing was not labeled and that the dressing should include the date it was applied, time, and staff initials for infection control purposes and to allow staff to track when the IV and dressing need to be changed. The facility’s policy for Peripheral and Midline IV Dressing Changes stated that a new dressing should be labeled with the date and time of the dressing change and initials, and the ADON stated the policy was not followed.
Incomplete Controlled Medication Count Records
Penalty
Summary
The facility failed to ensure accurate records of controlled medications were maintained for one of three medication carts, Medication Cart B. During observation, interview, and record review, the 8-hour Controlled Drugs-Count Record for Medication Cart B was reviewed with an LVN, who stated that two licensed nurses verify the log during shift change. The record showed 17 missing signatures across multiple shifts, including missing signatures for oncoming and off-going nurses on several morning, evening, and night shifts in January 2026. The LVN confirmed the missing signatures and stated it was important to do a shift narcotic count so there are no discrepancies. During interview and record review with the DON, the facility’s policy titled Controlled Medication Storage, dated April 2019, was reviewed. The policy stated that at each shift change, a physical inventory of all controlled medications shall be conducted by two licensed nurses and documented on the controlled substances accountability record. The DON stated the facility did not follow the policy and stated it was important to do shift-to-shift narcotic counts to ensure the count is accurate and to make each staff member accountable for their carts.
Improper Storage of Catheter and Respiratory Equipment
Penalty
Summary
The facility failed to maintain effective infection prevention and control practices for three sampled residents when medical equipment was observed stored or handled improperly. Resident 4 had a urinary catheter bag hanging off the bed frame and resting on the floor during an observation in the resident’s room. CNA 3 stated the urinary catheter should not be touching the floor, and LVN 1 stated the catheter should have a dignity bag, should be hanging on a lower level, and should not touch the floor. The resident’s record showed diagnoses including pressure ulcer, sepsis, and neuromuscular dysfunction of the bladder. Resident 14 was observed with nebulizer equipment on the nightstand and a clear storage bag hanging from the nightstand, while the oxygen tubing connected to the breathing treatment mask was hanging downward under the bed and touching the floor. CNA 1 confirmed the tubing was touching the floor and stated that once oxygen tubing contacts the floor, it should be discarded because it is considered contaminated. LVN 1 stated respiratory equipment must be stored properly inside the plastic bag and labeled to prevent contamination. Resident 14’s record showed diagnoses including dysphagia, gastrostomy, and dementia, and the resident had an order for ipratropium-albuterol inhalation solution every 4 hours for congestion/shortness of breath. Resident 68 was observed with nebulizer equipment, including tubing and a breathing treatment mask, on top of the nightstand, uncovered and unlabeled. LVN 2 stated the equipment should be stored inside a designated breathing treatment bag, dated and labeled, but it was not. The resident’s record showed diagnoses including cerebral infarction affecting the right dominant side, dysphagia, and hemiplegia/hemiparesis. The ADON reviewed the facility policies for catheter care and respiratory therapy infection prevention and acknowledged that staff did not follow the policies in these observations.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 2,031 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 1 | 0 |
| Ontario Grove Healthcare & Wellness Centre, Lp | 1.2 mi | ★★★★★ | 1 | 0 |
| Las Colinas Post Acute | 1.5 mi | ★★★★★ | 24 | 0 |
| Rancho Mesa Care Center | 2.7 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Villa Mesa Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.