Villa Del Rio Gardens

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 4 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 11 most serious are shown; the remaining 17 are one tap away and print in full.

• Actual harm · G2022-02-10 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Resident 76 and 179) received care to prevent pressure ulcer (localized areas of injury that occur when skin and underlying tissue are compressed between a bony prominence and an external surface such as a mattress) development, by failing to: 1. Implement Resident 179's care plan which indicated staff were to check the resident's skin for presence of sores, breakdown, impairment, and skin trauma, and use pressure reducing devices. 2. Implement its policy which indicated to initiate a care plan to address Resident 76's newly developed deep tissue injury ([DTI] an injury to a residents underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) to the left heel, obtain treatment orders, and monitor the effectiveness of the treatment. This deficient practice resulted in Resident 179 developing an unstageable pressure ulcer on the sacrococcygeal (base of the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2022-02-10 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were followed in the kitchen when: 1. The foods were not labeled with opened dates, there was no received dates, foods were stored in bins, refrigerator, and freezer without removing from original packaging. 2. The ice machine was not maintained in a clean and sanitary condition to ensure the ice was safe to consume. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for 80 of 81 medically compromised residents who received food and ice from the kitchen. Findings. a. During a concurrent kitchen observation and interview with Dietary Aide 1 (DA 1) on 2/8/22 at 9:11 a.m., there was one box of orange juice concentrate and one box of grape juice concentrate observed without received and opened dates. DA 1 stated both juice concentrates should be dated with the received date and use by…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2022-02-10 · tag F0641 — pattern
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess two of eight sampled residents' skin integrity (Residents 76 and 179). Cross Referenced F686. This deficient practice resulted in Resident 179 developing an unstageable pressure ulcer (localized areas of injury that occur when skin and underlying tissue are compressed between a bony prominence and an external surface such as a mattress) on the sacrococcygeal (base of the spine, tailbone) area and Resident 76 developing a deep tissue injury ([DTI] an injury to a residents underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) on the left heel. Findings: a. A review of Resident 179's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 179's diagnoses included status post left hip surgery, diabetes mellitus (high levels of sugar in the blood), polyneuropathy (weakness, numbness, and pain from nerve damage, usually…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2022-02-10 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
  Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to perform psychotropic assessments and provide non-pharmacological interventions to Residents 6, 33, 43, and 49 prior to start of psychotropic medications (medication that affects brain activities associated with mental processes and behavior) to ensure the use of psychotropics were necessary to treat a specific condition; and perform a gradual dose reduction ([GDR] an attempt to decrease or discontinue psychotropic medication after no more than three months after starting on the psychotropic medication) for Resident 49. These deficient practices had the potential to result in Residents 6, 33, 43, and 49 receiving unnecessary medications. Findings: A review of Resident 43's admission Record indicated Resident 43 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 43's diagnoses included chronic obstructive pulmonary disease ([COPD] group of lung diseases that block airflow and make it difficult to breathe), anxiety…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2022-02-10 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of the coronavirus disease ([COVID-19 a disease caused by virus called SARs-CoV-2}) an illness caused by a virus that can easily spread from person to person) by failing to: 1. Ensure housekeeping that was assigned to clean the hallway at the green zone (a room or group of rooms designated for residents who do not have nor were exposed to Covid-19) was wearing an N-95 (a type of mask worn over the face to cover the nose and mouth that provides respiratory protections against aerosols [a suspension of fine solid particles or liquid droplets in air] and prevent infections). 2. Ensure one of one residents (229) was cohorted (creating distinct roommates or small groups of COVID-19 positive residents or Covid-19 exposed residents that stay together to ensure minimal or no interaction with residents who do not have COVID-19) at the yellow zone (an area housing covid 19…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2022-02-10 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to enhance a resident's dignity and respect by failing to ensure for one of eight residents (13) that Resident 13's wet clothes and bedding were changed timely to prevent strong urine odors. This deficient practice had the potential to negatively affect the resident's psychosocial and physical wellbeing by feelings of being neglected and possible skin breakdown. Findings: During a review of Resident 13's admission record, the record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of, but not limited to overactive bladder (a condition that causes a frequent and sudden urge to urinate that may be difficult to control), stress incontinence (happens when physical movement or activity - such as coughing, laughing, sneezing, running or heavy lifting - puts pressure (stress) on your bladder, causing you to leak urine), major depression (a mood disorder that causes a persistent feeling of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2022-02-10 · tag F0636 — isolated
  Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to: a. Ensure the facility offered/implemented non-pharmacological interventions for one of one Residents 33, before starting Anti-Psychotic (a type of psychiatric medication which is used to treat psychosis [a mental disorder characterized by a disconnection from reality]) medication. b. Ensure that Residents 33 was assessed for the appropriateness of anti-psychotic medication before starting the medications. These deficient practices had the potential to result in Resident 33 receiving unnecessary medications, and adverse effects from those medications. Findings: During a review of the admission record, the record indicated Resident 33 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included diabetes mellitus (irregular levels of blood sugar), hepatic failure (loss of liver function), Depression (a mood disorder resulting in feelings of sadness that can affect quality of daily life), and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2022-02-10 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to develop a person- centered care plan for two of two sampled residents (46 and 43), who were taking anti- psychotic (a type of psychiatric medication which is used to treat psychosis [a mental disorder characterized by a disconnection from reality]) medication. This deficiency had the potential to result in a delay in delivery of care and services. Findings: During a review of the admission record, the record indicated Resident 46 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors) chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), and schizophrenia (a mood and thought disorder that causes a break from reality). During a review of the Minimum Data Set (MDS- a comprehensive assessment tool) dated 12/22/2021, indicated Resident 46…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2022-02-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure Resident 20 received the necessary care and services needed to attain the highest practicable level of physical, mental, and psychosocial well-being. These deficient practices had the potential to result in Residents 20 not receiving the quality of care that was needed. Findings: During a review of Resident 20's Face Sheet (admission record), the Face Sheet indicated Resident 20 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 20's diagnoses included essential hypertension (high blood pressure), history of falling, hyperlipidemia (high level of fat particles in the blood), chronic obstructive pulmonary disease ([COPD] a condition involving constriction of the airways and difficulty or discomfort in breathing, pressure-induced deep tissue damage of left buttock (injury caused by pressure to areas of skin when resting in a position for too long). During a review of Resident 20's Minimum Data Set (MDS a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2022-02-10 · tag F0710 — isolated
  Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the resident's physician took an active role in supervising the skin impairment of one of eight sampled residents (Resident 76), who was admitted to the facility with intact skin integrity, as per their policy. This deficient practice had the potential for delay in necessary services, poor continuity of care and follow up on Resident 76's deep tissue injury ([DTI] an injury to a residents underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) to the left heel. Findings: A review of Resident 76's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 76's diagnoses included diabetes mellitus (high levels of sugar in the blood), Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), dementia (disorder affecting memory, thinking and social abilities severely enough to interfere…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2019-08-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to: a. Maintain the correct concentration of chlorine (a chemical sanitizing agent) sanitizing agent used in the low-temperature dishwasher, according to the manufacturer's guidelines. b. Ensure one Kitchen Staff performed hand washing before starting work, and prior to handling foods, when in the kitchen area. These deficient practices had the potential to increase the risk of food contamination, which could cause foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for the residents. Findings: a. On 08/08/2019 at 8:24 a.m., during a concurrent observation and interview in the initial kitchen tour, Assistant Dietary Supervisor (ADS 2) checked the concentration of sanitation on the newly washed dishes with a chlorine test strip. The test strip measured less than 10 parts per million ([ppm] unit of concentration). ADS 2 repeated the test process five times on various dishes that came out of the automated dish washer. All five test strip resulted in less than 10…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported −$18K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CA