COVINA, CA - Federal inspectors cited The Rowland nursing home for multiple serious safety violations during a June 2024 inspection, including two immediate jeopardy situations that created life-threatening conditions for residents.
Critical Fire Safety Violations Trigger Emergency Response
The most serious violations involved smoking safety failures that prompted inspectors to declare an immediate jeopardy situation on June 4, 2024. Two residents with significant safety concerns were found with cigarettes and lighters in their possession, creating substantial fire hazards in a facility housing 90 residents.
Resident 8, who was taking antipsychotic medication for paranoid schizophrenia and hearing voices telling him to hurt himself and others, had four packs of cigarettes and three working lighters in his room. The resident had recently been hospitalized on a psychiatric hold for threatening to kill staff and blow up a hospital. Despite these serious mental health concerns, he was smoking without staff supervision and storing ignition sources in his room.
"Resident 8 should not be in possession of cigarettes and lighters because it was an accident hazard," the Director of Nursing stated during the inspection. "The lighter could cause burns to Resident 8 or cause fire in the facility."
The second smoking-related violation involved Resident 36, who had poor vision and required supervision when smoking according to her care plan. Inspectors found seven functional lighters and cigarette packs in her room, despite a posted "Danger - Oxygen, No Smoking, No Open Flames" sign outside her door due to her roommate's oxygen equipment.
These violations violated the facility's own smoking policy, which prohibited residents without independent smoking privileges from possessing smoking materials and required supervision for those with restricted privileges. The policy also specifically prohibited smoking in areas with oxygen equipment.
Contaminated Ice Exposes 42 Residents to Health Risks
A second immediate jeopardy situation emerged when inspectors discovered systematic food safety failures that exposed nearly half the facility's residents to contaminated ice. The ice scoop used to serve all residents was stored in a container with approximately 100 milliliters of brown liquid substance, creating potential for waterborne illness transmission.
The contamination affected 42 of 90 residents who received ice during breakfast and lunch service. Three certified nursing assistants used the contaminated scoop to fill ice chests for distribution throughout the facility.
"The brown liquid substance was approximately 100 ml. The ice scoop was touching the brown liquid substance inside the ice scooper container," the Dietary Supervisor reported. Staff acknowledged the ice was contaminated and could cause residents to develop diarrhea, vomiting, and other water-related illnesses.
The facility's own policy required daily cleaning and sanitization of ice handling equipment, but no records existed showing this protocol was followed. The contaminated equipment may have been in use for an extended period, as staff could not determine when it was last properly cleaned.
Medical Care Deficiencies Create Additional Health Risks
Beyond the immediate jeopardy situations, inspectors identified multiple medical care violations that compromised resident safety and treatment effectiveness:
Positioning and Pressure Sore Prevention: Staff failed to properly reposition a resident at risk for pressure ulcers, allowing her to remain on her left side for extended periods despite having open foot lesions. The resident was observed in the same position during multiple checks over several days, contradicting facility policy requiring position changes every two hours.
Oxygen Therapy Management: Four residents receiving oxygen therapy had equipment safety violations, including unlabeled tubing that prevented staff from knowing when equipment was last changed for infection control purposes. One resident was found with her oxygen nasal cannula displaced under her chin, preventing proper oxygen delivery.
Medication Administration Errors: Staff improperly crushed an enteric-coated aspirin tablet, which could reduce the medication's effectiveness. Enteric coatings protect medications from stomach acid and should not be altered without physician approval.
Feeding Tube Care: Two residents with gastrostomy feeding tubes did not receive proper care according to physician orders, including uncapped tubing that increased infection risk and missing protective dressings at tube insertion sites.
Understanding the Medical Implications
These violations represent serious departures from established medical standards that protect vulnerable nursing home residents. Pressure ulcers can develop within hours when residents remain in the same position, particularly those with limited mobility and existing health conditions. Proper repositioning prevents tissue damage and painful wounds that are difficult to heal.
Oxygen therapy requires precise monitoring because displaced equipment can quickly lead to respiratory distress in residents dependent on supplemental oxygen. Regular equipment changes prevent bacterial growth in tubing that residents breathe through continuously.
Medication crushing violations can render treatments ineffective or cause harmful side effects. Enteric coatings serve specific medical purposes and removing them can expose residents to stomach irritation or reduce drug absorption.
Feeding tube complications can lead to serious infections, skin breakdown, and nutritional problems in residents who depend entirely on tube feeding for survival.
Systemic Food Safety Concerns
Beyond the contaminated ice scoop, inspectors found widespread food storage violations throughout the facility. Expired salad dressings remained in refrigeration past their two-week shelf life, frozen foods lacked proper date labeling, and personal food items in unit refrigerators were unmarked with resident names or storage dates.
These practices violate basic food safety protocols designed to prevent foodborne illnesses in vulnerable populations. Nursing home residents often have compromised immune systems that make them particularly susceptible to food-related infections.
Additional Issues Identified
The inspection revealed several other compliance failures:
- Staffing Information: Required daily staffing notifications were not posted in accessible locations for residents and families to review - Restorative Services: Ordered physical therapy exercises were not consistently provided, potentially leading to decreased mobility - Dialysis Safety: Emergency bleeding control kits were not available for residents receiving dialysis treatment - Infection Control: Enhanced barrier precautions were not properly implemented for residents with medical devices - Medication Storage: Refrigeration temperatures were not properly maintained, potentially affecting medication stability
Immediate Corrective Actions
The facility implemented emergency measures to address the immediate jeopardy situations within 48 hours. For smoking safety, all cigarettes and lighters were confiscated and placed under nursing supervision. The facility established designated smoking areas, scheduled supervision times, and provided staff training on revised smoking policies.
To address food contamination, the facility replaced all ice equipment, sanitized ice storage containers, purchased new water pitchers and cups for all residents, and implemented daily cleaning logs with supervisory oversight.
These violations highlight the importance of consistent policy implementation and staff training in maintaining resident safety standards. While the facility took prompt corrective action once violations were identified, the scope and severity of the deficiencies indicate systemic oversight failures that required comprehensive intervention to protect resident health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Rowland from 2024-06-10 including all violations, facility responses, and corrective action plans.
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