MONTEBELLO, CALIFORNIA - Federal inspectors documented serious patient safety violations at Rio Hondo Subacute & Nursing Center during a March 1, 2025 inspection, finding that multiple residents experienced preventable injuries, infections, and medical emergencies due to inadequate care and monitoring by facility staff.
Critical Medical Emergency Following Delayed Response to Lab Results
The most severe violation involved a resident who developed life-threatening septic shock after facility staff failed to promptly respond to critical laboratory findings. The 180-year-old resident, admitted on January 29, 2025 with pneumonia and sepsis, had an indwelling urinary catheter placed for benign prostatic hyperplasia.
On February 23, 2025, laboratory tests revealed dangerously abnormal results - a white blood cell count of 39.59 cells per microliter (normal range is 4-11) and blood glucose of 60 mg/dL (below the normal minimum of 65). Despite these critical values being reported at 11:48 PM, the primary physician was not notified until approximately 14.5 hours later.
During this delay, the resident's condition deteriorated significantly. Family members reported that by February 24, the resident had stopped eating and was unresponsive to voice or touch, responding only to painful stimuli. Staff placed a towel over the resident's head but failed to monitor vital signs for approximately 24 hours between February 24 and 25.
When finally transferred to the emergency department on February 25 at 3:19 PM, the resident arrived with dangerously low blood pressure of 64/44 mmHg and elevated heart rate of 115 beats per minute. In the intensive care unit, physicians diagnosed septic shock with obstructive uropathy and drained 700 milliliters of purulent urine from the bladder.
The facility's nurse practitioner later stated that if informed of the laboratory results and mental status changes when the resident became unresponsive on February 24, he would have immediately recommended hospital transfer, rating the condition as "9/10 urosepsis."
Multiple Falls Result in Fractures Due to Inadequate Prevention Measures
Inspectors identified systematic failures in fall prevention that led to serious injuries for multiple residents. A resident with dementia and documented fall risk experienced five falls between October 9, 2024 and November 26, 2024. Despite facility policies requiring care plan updates and root cause analysis after falls, staff failed to implement adequate preventive measures.
The resident's falls on October 9, October 21, November 6, and November 25 were not properly investigated to determine causes or develop targeted interventions. On November 27, 2024, X-rays revealed the resident had sustained a non-displaced acute fracture of the left ankle. Staff acknowledged that proper monitoring and supervision after the previous falls could have prevented the injury-causing incident.
Another resident experienced a preventable fall on December 23, 2024 when they slipped on Nystatin powder that had been applied for a skin condition but left on the floor. The resident, who was independent in transfers and walking with a walker, fell while standing from bed and sustained a left proximal humerus fracture. The resident stated they "pushed the call light after the fall, but nobody came for at least 10 minutes," eventually having to knock over a bedside table to summon help.
The facility's post-fall investigation incorrectly identified the cause as "poor balance and not asking for assistance," despite documentation showing the resident was independent with transfers. Staff failed to include the resident in the investigation meeting, which would have revealed the true cause - the presence of powder creating a slippery surface.
Pressure Ulcer Development Despite Being Wound-Free at Admission
A particularly concerning case involved a resident admitted January 31, 2025 with intact skin who subsequently developed multiple pressure ulcers while in the facility's care. Documentation confirmed the resident had no skin breakdown upon admission. However, by February 1, nursing staff documented a Stage 2 coccyx pressure ulcer measuring 2 centimeters by 2 centimeters.
Despite physician orders for wound care and a Low Air Loss mattress on February 14, the pressure ulcer worsened to Stage 3 by February 13, with wound edges becoming macerated and easily irritated. By February 18, the resident had developed an additional vascular ulcer on the left heel measuring 3 centimeters by 3 centimeters.
Staff members admitted the deterioration likely occurred because the resident was not repositioned every two hours as required and remained in wet or soiled briefs for extended periods. Certified nursing assistants caring for the resident were never informed about the pressure ulcers, with one stating "it was never reported to her by the Licensed Nurses that Resident 186 had a pressure ulcer."
The facility also failed to properly manage specialized equipment for residents with healed pressure ulcers. Low Air Loss mattresses, designed to redistribute body weight and prevent skin breakdown, were found improperly set. One mattress was set for 150 pounds when the resident weighed 101 pounds, while documentation showed multiple shifts where required equipment checks were not performed.
Additional Issues Identified
Beyond these major violations, inspectors documented numerous other care failures affecting resident safety and wellbeing. A resident with moderate physical limitations waited approximately 90 minutes for assistance changing a wet incontinence brief after calling for help. When staff finally responded, they informed the resident they could not assist because the resident was not assigned to them.
Multiple residents with indwelling or suprapubic catheters experienced recurrent urinary tract infections. Documentation revealed incomplete daily nursing assessments, with catheter and urine characteristics not recorded for days at a time. Several residents were hospitalized for severe sepsis secondary to urinary tract infections.
The facility demonstrated systemic documentation failures, with daily nursing assessments missing for extended periods. Critical monitoring parameters ordered by physicians were not tracked, and communication between shifts about residents requiring close observation was inadequate.
Staffing issues compounded these problems, with inspectors finding insufficient nursing staff to provide necessary treatments and services. During one night shift observation, a certified nursing assistant assigned to a nursing station was not physically present in the building during break time and had not informed the supervising nurse of their location.
Medical analysis reveals these violations create cascading health risks. Delayed response to critical laboratory values allows infections to progress to life-threatening sepsis. When white blood cell counts indicate severe infection, every hour of delayed treatment increases mortality risk. Pressure ulcers that progress from Stage 2 to Stage 3 indicate deep tissue damage that significantly extends healing time and increases infection risk.
Fall-related fractures in elderly residents often trigger functional decline, reducing mobility and independence. Industry standards require immediate post-fall assessments, environmental hazard evaluation, and individualized prevention planning - none of which occurred consistently at this facility.
The inspection findings demonstrate patterns of inadequate monitoring, delayed medical interventions, insufficient staffing, and failure to implement basic preventive care measures. These systemic issues placed vulnerable residents at risk for preventable injuries, infections, and life-threatening medical emergencies.
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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