Federal inspectors found Rio Hondo Subacute & Nursing Center failed to assess, treat, or evaluate pain for Resident 4, who had been receiving stronger pain medications at the hospital but was given only basic acetaminophen upon readmission on April 21.
The resident had just undergone leg surgery and was diagnosed with acute osteomyelitis at the hospital. Her discharge records showed she had been receiving acetaminophen-hydrocodone for severe pain, with her last dose administered at 2:34 AM on April 21. But those stronger pain medications never appeared on her discharge medication list sent to the nursing home.
When Resident 4 returned to Rio Hondo that evening, she told inspectors she was "in horrific pain." Staff documented her as having "no complaint of pain" at 9:22 PM, despite her history of chronic pain syndrome and recent surgery.
The next morning, Resident 4 pressed her call light around 9:30 AM but nobody came, she told inspectors. When a nursing assistant finally responded at 11:02 AM, the resident reported her leg pain.
During a dressing change at 11:15 AM, inspectors observed Resident 4 "guarding her left leg, with facial grimacing and making fists while verbalizing to TXN 4 to be careful, because her left leg really hurts." The treatment nurse continued the procedure without stopping to assess the resident's pain.
After the nurse left, Resident 4 told the inspector her pain level was "10 out of 10."
When Licensed Vocational Nurse 8 entered the room at 11:20 AM, he informed Resident 4 that only acetaminophen was available for pain management. The resident responded that acetaminophen wasn't enough.
"Acetaminophen was the only pain medication she had," the nurse told her, then left the room.
"I feel I'm going to be laying with pain forever," Resident 4 said after the nurse departed. "They do not seem to understand. I have so much pain and it's their responsibility to take care of my need."
The nurse later admitted he never assessed the resident's pain level when he started his shift that morning, nor when he told her no stronger medication was available. "I should have asked Resident 4's pain level and pain description at that time," LVN 8 told inspectors.
Only after the nurse called the physician was a stronger pain medication ordered at 12:21 PM on April 22 — nearly 16 hours after the resident's return from the hospital. The resident finally received acetaminophen-codeine at 2:10 PM for a documented pain level of seven.
But facility records revealed another problem: the medication was prescribed for "severe pain" (levels 8-10) yet administered for "moderate pain" (level 7). The facility had no pain medication specifically ordered for moderate pain levels.
The resident's medical records showed active diagnoses including chronic pain syndrome, osteoarthritis of the knee, sciatica, femur fracture, and tibia fracture. Her most recent assessment indicated she "frequently" experienced pain in the previous five days and "occasionally could not sleep because of the pain."
During interviews, Resident 4 described her experience: "When she was readmitted to the facility on [DATE], Resident 4 was in horrific pain." She said the pain "would shoot up and down her left side and she had a real bad headache." The pain was so severe "she wanted to go back to the GACH."
The facility's pain management policy requires staff to "identify, assess, treat, and evaluate pain" and states residents should be evaluated for pain "upon admission/re-admission" and "with change in condition or change in pain status."
The Interim Director of Nursing acknowledged the facility should have added the stronger pain medication to the resident's orders because "that is what Resident 4 was receiving at the GACH."
Inspectors also found the facility failed to implement infection control protocols for the same resident, who had a drug-resistant urinary tract infection requiring enhanced barrier precautions. Staff were observed providing care without proper protective equipment, with no signage posted to alert workers of the isolation requirements.
The inspection also revealed failures in wound care and fall prevention, including a resident who fell when wheelchair brakes malfunctioned and staff failed to conduct proper post-fall assessments.
The violations carry minimal harm ratings but demonstrate systemic failures in basic nursing care protocols at the 273 E Beverly Boulevard facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rio Hondo Subacute & Nursing Center from 2025-04-23 including all violations, facility responses, and corrective action plans.
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