Federal inspectors found these infection control violations at Rio Hondo Subacute & Nursing Center during a March 1, 2025 survey that documented dangerous gaps between safety policies and actual practice.
Treatment Nurse 5 was observed treating a resident's right gluteal fold pressure ulcer after touching the patient's privacy curtains without changing gloves. The resident had enhanced barrier precautions in place due to multi-drug-resistant organisms, requiring staff to use proper protective equipment and perform hand hygiene before and after care.
Treatment Nurse 4 committed similar violations while treating a different resident's wounds. The nurse touched privacy curtains and a window blind's beaded chain with clean gloves, then proceeded with wound care treatments without changing gloves.
"There could be bacteria or viruses on the privacy curtains or beaded chain that may be transferred to the resident's open pressure ulcer, which could lead to infection of the pressure ulcer," Registered Nurse 3 told inspectors.
Both residents had multiple severe pressure ulcers. One patient had a stage 4 pressure ulcer on the sacrococcyx extending to bilateral buttocks, requiring daily cleaning with normal saline and application of specialized ointments. The other resident had one stage 4 pressure ulcer and three unstageable pressure ulcers upon admission.
The facility's own policy stated that "important facets of infection prevention include educating staff and ensuring that they adhere to proper techniques and procedures."
Oxygen equipment presented additional infection risks. Inspectors found nasal cannula tubes lying on the floor in two residents' rooms, with no labeling to indicate when the tubes were first used or when they should be changed.
Resident 54, who had a physician order for oxygen therapy at 3 liters per minute for shortness of breath, was found with her nasal cannula on the floor. "The nasal cannula was for oxygen use, and she did not know why it was on the floor," she told inspectors.
Licensed Vocational Nurse 7 acknowledged the problem: "Resident 54's nasal cannula should be labeled with date when it was first used and when to change and discard the nasal cannula and the nasal cannula should not be on the floor when not in use."
A similar situation occurred with Resident 63, whose nasal cannula was also found on the floor without proper labeling. The Licensed Vocational Nurse assigned to that resident said she wasn't aware the patient had a physician order for oxygen therapy and hadn't checked the oxygen equipment during her 7 AM rounds.
"Not labeling the nasal cannula and having the nasal cannula on the floor put the resident at risk for lung infection," the Acting Director of Nursing explained to inspectors.
The facility's bed safety systems also failed basic requirements. Inspectors found dangerous gaps between mattresses and footboards in three residents' rooms that could cause entrapment injuries or death.
Resident 138, who has quadriplegia and depends on staff for all positioning, had a gap so large that his drop foot boot was wedged between the mattress and footboard. The bed rail evaluation from January 2025 incorrectly documented no gaps between the headboard, footboard, and mattress.
Similar gaps existed for Residents 110 and 166. A family member told inspectors the gaps had existed since the resident was admitted to the facility. Pillows and linens were observed stuck in the spaces between mattresses and footboards.
The Maintenance Department Director admitted he only tested side rails for entrapment, not the head and foot of beds. "He did not test the gap between the head of the bed and the mattress or the gap between the footboard and the mattress," inspectors documented.
"A resident's body part could be trapped between the bedrail and the mattress or the bedframe and the mattress, which could lead to injury such as a fracture or even death if the resident's neck was caught in between the gap," the Acting Director of Nursing told inspectors.
The facility's bed safety policy required providing "a properly fitting mattress and/or side rails to reduce the hazards of resident entrapment" and ensuring "no gap exists between the mattress, bedframe, or side rail is wide enough to entrap a resident's head, body, arm, or legs."
Call light failures left residents unable to summon help. Three residents in one room had non-functioning call lights that didn't illuminate the hallway indicator when pressed.
Resident 171, who has bilateral below-knee amputations, told inspectors he "had pressed the call light over and over for a while and no one had come to assist as he wanted a snack because he was hungry."
Certified Nursing Assistant 14 confirmed the problem, testing all three call lights in the room and verifying none activated the hallway indicators. The maintenance supervisor said he wasn't aware of the problem and would have replaced the bulbs if nursing staff had notified him.
All three residents had care plans requiring call lights within reach due to fall risks, but the broken system prevented them from requesting assistance.
The facility's quality assurance program showed additional systemic failures. The administrator acknowledged that the Quality Assurance committee hadn't developed plans to ensure nursing staff competency in delivering care, assessing residents accurately, recognizing changes in condition, or administering medications safely.
"The administrator stated it was important that the nursing staff were competent to care for the residents to ensure quality of care and safety of the residents," inspectors noted.
Despite implementing improvement plans for skin and wound management starting February 10, 2025, the administrator said she "did not know why they did not identify the missed weekly skin/wound assessment and the new changes or worsened of the skin condition and wound for some residents."
The facility also lacked competency checklists for registry nursing staff and hadn't conducted performance evaluations for some nursing personnel.
These violations occurred at a 99-bed facility that serves residents with complex medical conditions including quadriplegia, pressure ulcers, respiratory failure, and diabetes. The inspection found that basic infection control, equipment safety, and quality assurance systems had broken down across multiple departments.
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.
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