The most serious citations on this record
Every nursing-home citation carries a scope-and-severity grade from A (least serious) to L (most serious). The five highest-graded citations at Villa Del Rio are:
F-0880 · September 28, 2023 · Grade K — Immediate jeopardy
Provide and implement an infection prevention and control program.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date October 27, 2023
F-0689 · June 28, 2025 · Grade J — Immediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date July 23, 2025
F-0684 · September 18, 2024 · Grade G — Actual harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date October 9, 2024
F-0688 · April 22, 2024 · Grade G — Actual harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Status: Deficient, Provider has date of correction · correction date May 20, 2024
F-0725 · July 16, 2026 · Grade F — Potential for more than minimal harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Found during a complaint investigation. Status: Deficient, Provider has date of correction · correction date August 7, 2026
What surveyors cited, theme by theme
Grouping the citations by subject shows whether a home's problems are isolated or concentrated in one part of care. At Villa Del Rio, 16 subject areas appear across health and fire-safety inspections.
Infection prevention and control
9 citations between September 28, 2023 and July 16, 2026. The most serious was graded K — immediate jeopardy, affecting a pattern across residents. Surveyors found a situation that caused — or was likely to cause — serious injury, harm, impairment, or death, and that needed immediate correction. 3 of these citations came out of complaint investigations. Correction record: 9 citations show a recorded correction date.
Infection citations matter because infections are a leading cause of hospital transfer and death in nursing homes. Families should ask how the home tracks infections, isolates sick residents, and tells families when an outbreak starts.
F-0880 · September 28, 2023 · Grade K — Provide and implement an infection prevention and control program.
F-0880 · April 24, 2025 · Grade F — Provide and implement an infection prevention and control program.
F-0880 · April 22, 2024 · Grade F — Provide and implement an infection prevention and control program.
Quality of life and daily care
25 citations between April 22, 2024 and July 16, 2026. The most serious was graded J (immediate jeopardy). 10 of these citations came out of complaint investigations. Correction record: 25 citations show a recorded correction date.
This group covers the basics of daily care — help with eating, bathing, toileting, repositioning, and timely treatment. Repeated citations here often match what families notice first: call lights unanswered, soiled briefs, missed care.
F-0689 · June 28, 2025 · Grade J — Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0684 · September 18, 2024 · Grade G — Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F-0688 · April 22, 2024 · Grade G — Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Fire, smoke, and emergency safety
9 citations between April 22, 2024 and July 16, 2026. The most serious was graded F (potential for more than minimal harm). Correction record: 9 citations show a recorded correction date.
Life-safety citations cover alarms, sprinklers, exits, and evacuation readiness. Ask for the date each item was corrected and whether the local fire authority re-inspected.
K-0353 · July 16, 2026 · Grade F — Inspect, test, and maintain automatic sprinkler systems.
K-0353 · April 24, 2025 · Grade F — Inspect, test, and maintain automatic sprinkler systems.
K-0353 · April 22, 2024 · Grade F — Inspect, test, and maintain automatic sprinkler systems.
Freedom from abuse, neglect, and exploitation
8 citations between April 22, 2024 and August 26, 2025. The most serious was graded F (potential for more than minimal harm). 7 of these citations came out of complaint investigations. Correction record: 8 citations show a recorded correction date.
These citations go to the core duty to protect residents. Ask how the home screens and trains staff, how allegations are investigated, and whether the same staff or unit appears in more than one report.
F-0943 · April 22, 2024 · Grade F — Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
F-0605 · August 26, 2025 · Grade E — Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
F-0607 · August 26, 2025 · Grade E — Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Nursing and Physician Services
6 citations between September 18, 2024 and July 16, 2026. The most serious was graded F (potential for more than minimal harm). 4 of these citations came out of complaint investigations. Correction record: 6 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
F-0725 · July 16, 2026 · Grade F — Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F-0726 · July 16, 2026 · Grade F — Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F-0728 · July 16, 2026 · Grade F — Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Gas, Vacuum, and Electrical Systems
6 citations between April 22, 2024 and July 16, 2026. The most serious was graded F (potential for more than minimal harm). Correction record: 6 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0914 · July 16, 2026 · Grade F — Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K-0918 · July 16, 2026 · Grade F — Have generator or other power source capable of supplying service within 10 seconds.
K-0918 · April 24, 2025 · Grade F — Have generator or other power source capable of supplying service within 10 seconds.
Food, nutrition, and hydration
4 citations between April 22, 2024 and July 16, 2026. The most serious was graded F (potential for more than minimal harm). Correction record: 4 citations show a recorded correction date.
Nutrition failures connect directly to weight loss, dehydration, and slow wound healing. Ask for weight records, intake logs, and whether a dietitian reviewed the resident after any decline.
F-0812 · July 16, 2026 · Grade F — Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F-0813 · April 24, 2025 · Grade F — Have a policy regarding use and storage of foods brought to residents by family and other visitors.
F-0812 · April 22, 2024 · Grade E — Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration and leadership
3 citations between April 22, 2024 and July 16, 2026. The most serious was graded F (potential for more than minimal harm). 1 of these citations came out of complaint investigations. Correction record: 2 citations show a recorded correction date; 1 had a plan of correction on file at the last data release.
Administrative citations suggest the problem sits with management systems, not one staff member. Ask who is responsible for quality oversight and what the home's own quality committee changed afterward.
F-0867 · April 22, 2024 · Grade F — Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F-0847 · July 16, 2026 · Grade D — Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
F-0838 · June 26, 2026 · Grade D — Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Services
3 citations between April 22, 2024 and July 16, 2026. The most serious was graded F (potential for more than minimal harm). Correction record: 3 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0521 · April 22, 2024 · Grade F — Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K-0511 · April 24, 2025 · Grade E — Have properly installed electrical wiring and gas equipment.
K-0511 · July 16, 2026 · Grade D — Have properly installed electrical wiring and gas equipment.
Egress
2 citations between July 16, 2026 and July 16, 2026. The most serious was graded F (potential for more than minimal harm). Correction record: 2 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0293 · July 16, 2026 · Grade F — Have properly located and lighted "Exit" signs.
K-0223 · July 16, 2026 · Grade D — Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Resident rights
25 citations between April 4, 2024 and July 16, 2026. The most serious was graded E (potential for more than minimal harm). 11 of these citations came out of complaint investigations. Correction record: 23 citations show a recorded correction date; 2 had a plan of correction on file at the last data release.
Rights citations cover dignity, choice, privacy, grievances, and being told about changes in condition or care. Ask how the home notifies family of changes and how grievances are logged and answered.
F-0552 · July 16, 2026 · Grade E — Ensure that residents are fully informed and understand their health status, care and treatments.
F-0584 · July 16, 2026 · Grade E — Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F-0552 · April 24, 2025 · Grade E — Ensure that residents are fully informed and understand their health status, care and treatments.
Assessments and care planning
17 citations between April 22, 2024 and July 16, 2026. The most serious was graded E (potential for more than minimal harm). 7 of these citations came out of complaint investigations. Correction record: 17 citations show a recorded correction date.
Care-plan citations mean the written plan did not match the resident's known risks. Ask whether the care plan changed after each fall, wound, infection, or hospital return — or whether the same plan stayed in place while the resident declined.
F-0658 · February 27, 2026 · Grade E — Ensure services provided by the nursing facility meet professional standards of quality.
F-0658 · November 18, 2025 · Grade E — Ensure services provided by the nursing facility meet professional standards of quality.
F-0641 · April 24, 2025 · Grade E — Ensure each resident receives an accurate assessment.
Medication and pharmacy services
9 citations between April 22, 2024 and July 16, 2026. The most serious was graded E (potential for more than minimal harm). 2 of these citations came out of complaint investigations. Correction record: 9 citations show a recorded correction date.
Medication citations can involve wrong doses, unnecessary drugs, or poor monitoring. Ask for the medication administration record and whether a pharmacist reviewed the resident's drug regimen each month.
F-0755 · July 16, 2026 · Grade E — Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F-0761 · July 16, 2026 · Grade E — Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F-0755 · April 22, 2024 · Grade E — Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Physical environment and safety
4 citations between April 4, 2024 and February 11, 2026. The most serious was graded E (potential for more than minimal harm). 3 of these citations came out of complaint investigations. Correction record: 4 citations show a recorded correction date.
Environmental citations cover the building itself — safe water temperatures, clean and working equipment, hazard-free spaces. Ask what was repaired, when, and what checks are in place now.
F-0921 · June 28, 2025 · Grade E — Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F-0919 · April 22, 2024 · Grade E — Make sure that a working call system is available in each resident's bathroom and bathing area.
F-0914 · February 11, 2026 · Grade D — Provide bedrooms that don't allow residents to see each other when privacy is needed.
Miscellaneous
4 citations between April 24, 2025 and July 16, 2026. The most serious was graded E (potential for more than minimal harm). Correction record: 4 citations show a recorded correction date.
Ask the facility what this citation required it to change, when the correction was verified, and what monitoring is in place so the same failure does not recur.
K-0712 · July 16, 2026 · Grade E — Have simulated fire drills held at unexpected times.
K-0712 · April 24, 2025 · Grade D — Have simulated fire drills held at unexpected times.
K-0753 · April 24, 2025 · Grade D — Have restrictions on the use of highly flammable decorations.
Fire, smoke, and emergency safety
2 citations between April 24, 2025 and April 24, 2025. The most serious was graded C (minimal or no harm potential). Correction record: 2 citations show a recorded correction date.
Life-safety citations cover alarms, sprinklers, exits, and evacuation readiness. Ask for the date each item was corrected and whether the local fire authority re-inspected.
E-0032 · April 24, 2025 · Grade C — Provide primary/alternate means for communication.
E-0039 · April 24, 2025 · Grade C — Conduct testing and exercise requirements.
How to read the severity grades
CMS grades combine how many residents were affected with how much harm occurred. Grades J–L are immediate jeopardy: a situation that caused, or was likely to cause, serious injury or death. Grades G–I mean a resident was actually harmed. Grades D–F mean no harm was found but the failure could have caused more than minimal harm, and A–C carry only minimal-harm potential. The second dimension matters too: the grade also tells you whether surveyors saw an isolated case, a pattern, or a facility-wide problem.
Survey and penalty timeline
Villa Del Rio appears in CMS data on 24 survey dates between September 28, 2023 and July 16, 2026. Complaint surveys happen because someone reported a problem; standard surveys are the routine inspections every home receives.
July 16, 2026
Health survey including complaint investigations — 23 citations, worst grade F (potential for more than minimal harm)
July 16, 2026
Fire-safety survey — 8 citations, worst grade F (potential for more than minimal harm)
July 13, 2026
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
June 26, 2026
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
May 27, 2026
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
February 27, 2026
Complaint health survey — 2 citations, worst grade E (potential for more than minimal harm)
February 11, 2026
Complaint health survey — 4 citations, worst grade D (potential for more than minimal harm)
November 18, 2025
Complaint health survey — 2 citations, worst grade E (potential for more than minimal harm)
August 26, 2025
Complaint health survey — 4 citations, worst grade E (potential for more than minimal harm)
June 28, 2025
Complaint health survey — 3 citations, worst grade J (immediate jeopardy)
May 28, 2025
Complaint health survey — 3 citations, worst grade D (potential for more than minimal harm)
April 24, 2025
Health survey including complaint investigations — 22 citations, worst grade F (potential for more than minimal harm)
April 24, 2025
Fire-safety survey — 14 citations, worst grade F (potential for more than minimal harm)
January 16, 2025
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
January 11, 2025
Complaint health survey — 2 citations, worst grade E (potential for more than minimal harm)
December 11, 2024
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
September 18, 2024
Complaint health survey — 4 citations, worst grade G (actual harm)
September 5, 2024
Complaint health survey — 3 citations, worst grade E (potential for more than minimal harm)
June 20, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
May 29, 2024
Complaint health survey — 1 citation, worst grade D (potential for more than minimal harm)
April 22, 2024
Health survey including complaint investigations — 24 citations, worst grade G (actual harm)
April 22, 2024
Fire-safety survey — 4 citations, worst grade F (potential for more than minimal harm)
April 4, 2024
Complaint health survey — 2 citations, worst grade D (potential for more than minimal harm)
September 28, 2023
Complaint health survey — 1 citation, worst grade K (immediate jeopardy)
Penalties imposed
June 28, 2025 — Fine of $45,078
September 5, 2024 — Fine of $12,048
April 4, 2024 — Fine of $67,649
April 4, 2024 — Payment denial · Medicare/Medicaid payments denied for 27 days from May 17, 2024
September 28, 2023 — Fine of $22,253
Payment denials are the stronger federal sanction: CMS stops paying for new admissions until the home corrects the problems. Villa Del Rio has 1 denial period on record totalling 27 days.
How Villa Del Rio compares with peer homes
Raw citation counts mean more in context. The table below compares Villa Del Rio with the median reviewed facility in Los Angeles County (181 homes in this research set) and across California (350 homes), using the same CMS data. On health citations alone, Villa Del Rio sits above 80% of its reviewed county peers — near the top of the county for citation volume.
Measure
Villa Del Rio
Los Angeles Co. median
California median
Health citations on record
110
84
74
Citations from complaint investigations
48
31
27
Citations at actual-harm level or worse
4
3
2
Immediate-jeopardy citations
2
1
0
Total fines in CMS penalty records
$147,028
$57,906
$43,467
Penalty records (fines + payment denials)
5
3
2
What families should ask Villa Del Rio
- Ask for the plan of correction and follow-up monitoring for the infection prevention and control citations — most recently F-0880 on September 28, 2023 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the quality of life and daily care citations — most recently F-0689 on June 28, 2025 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the freedom from abuse, neglect, and exploitation citations — most recently F-0943 on April 22, 2024 — and the records showing the fix held.
- Ask for the plan of correction and follow-up monitoring for the nursing and physician services citations — most recently F-0725 on July 16, 2026 — and the records showing the fix held.
- Ask what conduct led to the fines — CMS records 4 totalling $147,028, the most recent dated June 28, 2025 — and what changed afterward.
- What changed in the resident's condition, and when did staff at Villa Del Rio first document the change?
- Were recent complaint-related citations at Villa Del Rio connected to the same kind of issue your family noticed?
Records to preserve
Connect this record to what your family saw
A citation record is context. The warning sign your family noticed is the starting point for a resident-specific review — match the two, then preserve the records listed above. Start with how facility research works.
Warning sign
Bed sores
Warning sign
Falls
Warning sign
Bruises
Warning sign
Weight loss
Facility research
Inspection deficiencies
Facility research
Civil penalties
Facility research
Abuse citations
Facility research
Complaint surveys
CMS facility facts
CMS certification number
555781
Legal business name
Legal Business Name Not Available
Ownership type
For profit - Corporation
Provider type
Medicare and Medicaid
First approved for Medicare/Medicaid
January 1, 2002
Chain name
ROLLINS-NELSON HEALTHCARE MANAGEMENT
Certified beds
12
Average residents per day
169.7
Overall CMS rating
1 star
Health inspection rating
1 star
Staffing rating
3 star
Reported nurse staffing hours per resident day
3.72264
Total nursing staff turnover
58.9%
Public records are a starting point, not a conclusion
This profile of Villa Del Rio uses official CMS provider data as a research starting point. It does not state that Villa Del Rio abused or neglected any resident. A citation, fine, or rating becomes meaningful only when it is compared with the resident's own chart, the facility's explanation, and source documents with dates and outcome status.
Citation and penalty detail on this page comes from the CMS Provider Data health-deficiency, fire-safety, and penalties datasets, pulled October 12, 2026. Figures describe the facility's public inspection record; they do not by themselves prove what happened to any individual resident.
Sources for Villa Del Rio
Senior Justice Help is a public-information and facility-research website. We are not a law firm, medical provider, government agency, or nursing home regulator. We may help families understand what kind of lawyer to contact or connect with legal resources, but this site does not provide legal or medical advice.
Editorial review
Written and editorially reviewed for family clarity
Written by: Senior Justice Help Editorial Team, Family questions and nursing home records research team
Pages are written for families, checked against public agency sources, and reviewed for clarity, sourcing, and overclaiming. The site does not provide medical advice or legal advice.