Villa Del Rio Gardens
7004 East Gage Avenue · Bell Gardens, CA · 90201 · 5629276586
84 certified beds For profit - Corporation Chain: Rollins-Nelson Healthcare Management
Why this verdict
- Staffing levels are well below research benchmarks for safe care.
- Inspection results are getting worse cycle over cycle, not better.
- No federal fines or payment denials in CMS’s 3-year window.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
No standard inspection in over 2 years
The inspection record here is older than usual — conditions may have changed since.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 3 of 5 Staffing: 1 of 5 Quality measures: not rated
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | none |
Inspection citations (28 in the current record)
-
Actual harm · G February 10, 2022
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected March 24, 2022 · Quality of Life and Care
-
Potential for harm · D February 10, 2022
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected March 24, 2022 · Resident Rights
-
Potential for harm · D February 10, 2022
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected March 24, 2022 · Resident Assessment and Care Planning
-
Potential for harm · E February 10, 2022
Ensure each resident receives an accurate assessment.
Corrected March 24, 2022 · Resident Assessment and Care Planning
-
Potential for harm · D February 10, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 24, 2022 · Resident Assessment and Care Planning
-
Potential for harm · D February 10, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 24, 2022 · Quality of Life and Care
-
Potential for harm · D February 10, 2022
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected March 24, 2022 · Nursing and Physician Services
-
Potential for harm · E February 10, 2022
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.
Corrected March 24, 2022 · Pharmacy Service
-
Potential for harm · F February 10, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 24, 2022 · Nutrition and Dietary
-
Potential for harm · E February 10, 2022
Provide and implement an infection prevention and control program.
Corrected March 24, 2022 · Infection Control
-
Potential for harm · D August 14, 2019
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected September 18, 2019 · Resident Rights
-
Potential for harm · D August 14, 2019
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected September 18, 2019 · Resident Assessment and Care Planning
-
Potential for harm · D August 14, 2019
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected September 18, 2019 · Nursing and Physician Services
-
Potential for harm · D August 14, 2019
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected September 18, 2019 · Nutrition and Dietary
-
Potential for harm · E August 14, 2019
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected September 18, 2019 · Nutrition and Dietary
-
Potential for harm · D August 14, 2019
Implement a program that monitors antibiotic use.
Corrected September 18, 2019 · Infection Control
-
Potential for harm · D August 14, 2019
Keep all essential equipment working safely.
Corrected September 18, 2019 · Environmental
-
Potential for harm · D August 14, 2019
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected September 18, 2019 · Environmental
-
No harm found · B August 14, 2019
Provide and implement an infection prevention and control program.
Corrected September 18, 2019 · Infection Control
-
Potential for harm · E August 1, 2018
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected August 31, 2018 · Resident Rights
-
Potential for harm · D August 1, 2018
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected August 31, 2018 · Resident Rights
-
Potential for harm · E August 1, 2018
Keep residents' personal and medical records private and confidential.
Corrected August 31, 2018 · Resident Rights
-
Potential for harm · D August 1, 2018
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected August 31, 2018 · Resident Assessment and Care Planning
-
Potential for harm · D August 1, 2018
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected August 31, 2018 · Quality of Life and Care
-
Potential for harm · D August 1, 2018
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected August 31, 2018 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 555780 · certified since January 1, 2002. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.