MONTEBELLO, CA - State inspectors found multiple serious violations at Rio Hondo Subacute & Nursing Center during a March 2025 inspection, including failures in diabetes management that contributed to a resident's death, inadequate investigation of alleged abuse between residents, and systemic problems with medical equipment management and dialysis care coordination.
Critical Diabetes Care Failures Lead to Resident Death
The most severe violation involved the facility's failure to provide appropriate diabetes care for a resident with Type 2 diabetes mellitus and a history of hypoglycemia. The resident died at an area hospital after experiencing dangerously low blood sugar levels of 27 mg/dL (normal range is 70-100 mg/dL).
The resident had been readmitted to the facility from a hospital stay with specific discharge orders requiring blood sugar monitoring before meals and at bedtime, along with routine insulin injections. However, nursing staff failed to implement these critical orders upon readmission, leaving the diabetic resident without proper monitoring for five days.
When Licensed Vocational Nurse (LVN) 3 finally entered an insulin order three days after readmission, she did so without physician authorization. More critically, LVN 4 administered the insulin without first checking the resident's blood sugar level, a fundamental safety requirement for diabetes management.
The consequences were severe. On the morning the resident was found in distress, Licensed Vocational Nurse 1 discovered alarming vital signs: blood sugar at 27 mg/dL and critically low blood pressure. "The resident appeared very weak" and required glucose gel administered directly into their mouth because they were too unresponsive to eat normally, according to nursing documentation.
Emergency Medical Technicians initially refused to transport the resident via basic ambulance, determining that the combination of severe hypoglycemia, low blood pressure, and altered mental status required advanced life support. The resident's blood sugar had dropped further to 27 mg/dL by the time paramedics arrived, and they were transported to the hospital's intensive care unit, where they died.
Medical Context: Why Diabetes Management Protocols Matter
Diabetes management in nursing homes requires strict adherence to monitoring protocols because residents are at high risk for both hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). Blood sugar levels below 70 mg/dL are considered hypoglycemic, while levels below 50 mg/dL constitute severe hypoglycemia requiring immediate intervention.
Proper diabetes care protocols mandate blood sugar monitoring before insulin administration to prevent hypoglycemic episodes. When facilities fail to monitor blood glucose levels, residents can experience rapid deterioration leading to altered consciousness, seizures, coma, and death. The normal protocol requires checking blood sugar levels before meals and at bedtime, with specific parameters for when to contact physicians.
Residents with diabetes and kidney disease face additional complications, as kidney dysfunction affects how the body processes both glucose and insulin. This makes consistent monitoring even more critical for preventing life-threatening episodes.
Inadequate Response to Alleged Resident-on-Resident Violence
Inspectors found serious deficiencies in how staff handled an alleged physical altercation between two residents. One resident reported being struck with a wheelchair armrest by another resident, stating "that crazy guy said he's going to kill me and my family. I told him to turn his TV down and he threw water at me. He grabbed the armrest and started to hit me."
The investigation revealed multiple procedural failures. Staff failed to conduct a thorough investigation within the required two-hour timeframe, and Registered Nurse 2 admitted to copying one resident's statement into both residents' documentation rather than conducting separate interviews. The nurse acknowledged that "no other investigation or reassessment was completed" for the incident.
The facility's policy requires causative factors to be investigated within two hours of an allegation, with thorough documentation of all findings. Proper investigation protocols should include separate witness statements, physical assessments, environmental evaluation, and development of prevention strategies.
Medical Equipment Management Failures
A resident experienced significant delays in gastrostomy tube removal due to poor communication and follow-up procedures. After a Physician Assistant was unable to remove the feeding tube due to "severe resistance," she recommended referral to a gastrointestinal specialist. However, facility staff failed to schedule the specialist appointment for over a month, despite the tube being unused and unflushed for several weeks.
The resident stated "he wanted the GT removed because there was no need for it and that he has been tolerating oral diet" for six weeks. Medical equipment left in place unnecessarily creates infection risks and patient discomfort. The feeding tube remained in the resident for over two months beyond the initial removal attempt, creating potential for complications including infection and tube blockage.
Standard medical practice requires prompt follow-up on specialist recommendations, particularly when unused medical devices remain in patients. Gastrostomy tubes that are no longer needed should be removed expeditiously to prevent complications and improve patient comfort.
Systematic Dialysis Care Coordination Problems
The facility demonstrated poor coordination of dialysis services for a resident requiring hemodialysis three times weekly. Transportation delays of 20-30 minutes became routine, causing the resident's dialysis sessions to start late and finish as late as 8 PM instead of the scheduled 6 PM completion time.
On one documented occasion, the resident wasn't picked up from the dialysis center until 10:30 PM due to transportation coordination failures. The resident reported being "upset, tired, and was unable to get sleep that night" following the late return to the facility.
Nursing staff also failed to complete required post-dialysis assessments. Documentation was missing for vital signs, dialysis site monitoring, and assessment for post-treatment complications such as dizziness, nausea, or blood pressure changes. These assessments are critical for detecting dialysis-related complications that can be life-threatening if not promptly identified.
Industry Standards and Required Protocols
Federal regulations require nursing homes to provide services according to professional standards of practice and residents' care plans. For diabetes management, this includes blood glucose monitoring as ordered, proper insulin administration protocols, and immediate physician notification for abnormal readings.
Abuse prevention protocols mandate immediate separation of involved parties, thorough investigation within specified timeframes, and comprehensive documentation. Medical equipment management requires timely follow-up on physician recommendations and prompt removal of unnecessary devices.
Dialysis care coordination involves precise scheduling, comprehensive pre- and post-treatment assessments, and clear communication between the facility and dialysis center. Transportation must be reliable to ensure residents receive treatments as scheduled and return safely to the facility.
Additional Issues Identified
Inspectors documented several other concerns including inaccurate weight documentation for a dialysis patient, showing a 53-pound discrepancy between recorded weights that could affect treatment decisions. The facility also had problems maintaining accurate medical records in accordance with professional standards.
These violations represent systemic issues with care coordination, communication protocols, and adherence to basic safety standards. The California Department of Public Health classified the diabetes care failure as immediate jeopardy, requiring an emergency response plan that was implemented and verified during the inspection.
The facility has initiated corrective measures including staff retraining, policy updates, and enhanced monitoring systems. However, these violations highlight the critical importance of consistent adherence to established medical protocols and the potential consequences when facilities fail to meet professional care standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rio Hondo Subacute & Nursing Center from 2025-03-28 including all violations, facility responses, and corrective action plans.
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