Resident 148 told staff on Monday, February 24, 2025, that she didn't feel well and wouldn't walk during her prescribed restorative nursing session. But Restorative Nursing Aide 1 initialed the treatment record anyway, making it appear the walking therapy had occurred.
Two days later, when inspectors observed Resident 148 during an actual walking session, the aide explained what had really happened. "Resident 148 did not participate in RNA on Monday, 2/24/2025 because Resident 148 was not feeling well," RNA 1 told inspectors. The aide reviewed the February treatment record and acknowledged her initials were entered for February 24. "RNA 1 stated she should have circled the initials for 2/24/2025 to indicate Resident 148 refused to participate."
The aide never documented the resident's reason for refusing treatment on the back of the record, as required. "RNA 1 stated Resident 148's RNA Record for 2/24/2025 was inaccurate."
The Director of Staff Development confirmed the violation. "The DSD stated the RNAs were not supposed to initial or were supposed to circle their initials on the RNA Record when a resident refused treatment. The DSD stated it was not appropriate to initial the RNA record if the treatment was not provided."
But the falsification extended beyond routine therapy sessions.
A licensed vocational nurse altered critical medical documentation involving a resident with life-threatening lab results. Resident 180 had been admitted in late January with pneumonia and sepsis, conditions that can rapidly deteriorate without proper monitoring.
On February 23, 2025, lab results showed Resident 180's blood glucose had dropped to 60 milligrams per deciliter — below the normal range of 65-99. More alarming, the resident's white blood cell count had spiked to 39.59 cells per microliter, nearly four times the upper limit of normal and indicating a serious infection.
The facility's Change in Condition evaluation, dated February 24, stated that at 2:48 AM, LVN 5 had notified the resident's nurse practitioner about the critical results and received orders for antibiotics.
None of that was true.
LVN 5 wasn't working that night. Employee timecards showed she worked only day shifts and was off on both February 23 and February 24. The nurse practitioner confirmed he received no notification about critical lab results at 2:48 AM on February 24.
What actually happened emerged during interviews with inspectors. LVN 5 came to work on February 25 and discovered an incomplete Change in Condition form created at 3:31 AM on February 24. The form indicated the physician had been messaged about the critical results but staff were "still waiting for response."
Nearly 24 hours after the dangerous lab values were reported, LVN 5 called the covering physician at 9:30 AM on February 25. Only then did Resident 180 receive orders for IV antibiotics to treat the infection.
But instead of documenting what really happened, LVN 5 went back and changed the medical record. She revised the February 24 assessment to make it appear the nurse practitioner had been notified and had ordered antibiotics — all backdated to 2:48 AM on February 24.
"LVN 5 stated, on 2/25/2025, after she received order for antibiotics, she revised the physician recommendations on 2/24/2025 at 2:48 AM from waiting for response to NP 1 made aware with new orders for IV antibiotic," inspectors documented.
The nurse admitted multiple errors. She forgot to change the notification time from the false 2:48 AM entry to the actual 9:30 AM call. She acknowledged she should have documented the physician contact in progress notes or a follow-up assessment "to ensure accurate documentation."
Nurse Practitioner 1 confirmed the timeline during his interview: "NP 1 stated he was not notified of the critical lab results on 2/24/2025 at 2:48 AM. NP 1 stated, he received a call in the morning of 2/25/2025 and was informed by LVN 5 about the critical lab results so he ordered IV antibiotics."
The Acting Director of Nursing called the documentation violations unacceptable. "The ADON stated, it was the facility's responsibility to ensure accurate residents' medical record. The ADON stated, LVN 5 should not revise any CIC created by a different LVN. The ADON stated, the resident's medical record must contain accurate information of what actually happened with the correct date and time."
Both residents involved had intact cognitive abilities and could understand what was happening to them. Resident 148's assessment showed clear speech and the ability to express ideas and wants. Resident 180 needed only partial assistance with eating and personal hygiene.
The facility's own policies required accurate documentation. The 2017 Charting and Documentation policy stated all services "shall be document in the resident's medical record" and that documentation "will be objective, complete, and accurate."
A 2022 nursing documentation policy was more specific: "nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the resident's condition, situation, and complexity."
The violations occurred at Rio Hondo Subacute & Nursing Center on East Beverly Boulevard, where inspectors also found the facility's quality assurance committee had failed to address recurring problems identified in previous surveys and complaints.
For Resident 180, the delay in antibiotic treatment meant nearly 24 hours passed between the discovery of critical infection markers and the start of IV medication. For Resident 148, the false documentation obscured whether she was actually receiving the walking therapy prescribed by her physician three times per week.
Both cases revealed a pattern: when residents refused care or when staff failed to provide timely treatment, the response was to alter the medical record rather than document what actually occurred.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rio Hondo Subacute & Nursing Center from 2025-03-01 including all violations, facility responses, and corrective action plans.
Additional Resources
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