BELL GARDENS, CA - Federal inspectors identified significant deficiencies at Del Rio Convalescent Center during an April 2025 survey, citing the facility for failing to provide required rehabilitation services to residents and multiple infection control violations that placed residents at risk.
Rehabilitation Services Denied to Vulnerable Residents
The most concerning violations involved two stroke patients who were denied essential physical and occupational therapy evaluations despite physician orders and clinical indications for these services. Both residents had severe functional limitations that warranted comprehensive rehabilitation assessments.
Resident 114, who had diagnoses including dementia, stroke with right-side paralysis, and required tube feeding, was ordered to receive physical and occupational therapy evaluations in January 2023. However, inspection records showed no evidence these evaluations were ever completed. The resident was entirely dependent on staff for basic activities like bathing, toileting, and transferring from bed to chair, yet received no specialized therapy services to maintain existing function or prevent further decline.
During interviews, the facility's Minimum Data Set Nurse acknowledged that "every diagnosis, including stroke, should have been care planned to ensure all proper interventions are implemented and tracked." The nurse confirmed that Resident 114 lacked care plans addressing stroke recovery and risk for functional decline, stating this "placed Resident 114 at risk for ADL decline."
Resident 28, diagnosed with multiple sclerosis and a stage four pressure ulcer, faced similar neglect. Despite physician orders for therapy evaluations in October 2024, no formal assessments were conducted. When observed by inspectors, the resident was found with both elbows bent and hands in closed fist positions - signs of potential contracture development. The resident told inspectors: "he does not receive any therapy with the rehab department nor with the RNAs."
Medical Consequences of Denied Therapy Services
The failure to provide ordered rehabilitation services carries serious medical implications for residents with neurological conditions. Stroke patients require ongoing therapy to maintain existing function and prevent secondary complications like contractures, where muscles and joints become permanently shortened or stiffened.
Range of motion exercises and specialized positioning are critical interventions that help maintain joint flexibility and prevent painful contractures. When these services are withheld, residents face irreversible loss of function, increased pain, and reduced quality of life.
The Director of Rehabilitation acknowledged during interviews that both residents "would have benefited from long-term RNA [Restorative Nursing Assistant] services to maintain ADL abilities and range of motion." He stated that the lack of proper evaluations and services "placed residents at risk for the development of contractures and ADL decline."
Facility policies required that residents with existing range of motion limitations be referred to the therapy department for focused assessment. The policies also mandated providing rehabilitative services when required by resident assessments and care plans. These requirements were not met for either resident.
Widespread Infection Control Failures Endanger Residents
Inspectors documented extensive infection control violations affecting 13 residents, including failures to implement enhanced barrier precautions for high-risk residents and improper hand hygiene during wound care procedures.
The facility failed to implement Enhanced Barrier Precautions (EBP) for 12 residents who qualified for these protective measures. EBP are specialized infection control interventions designed to prevent transmission of dangerous antibiotic-resistant bacteria. Residents with feeding tubes, open wounds, or multidrug-resistant organisms require these precautions to protect both themselves and other residents.
Among the affected residents, several had gastrostomy tubes for feeding, while others had serious conditions like stage four pressure ulcers or were receiving hemodialysis. Despite meeting clear criteria for enhanced precautions, none of these residents had appropriate signage posted outside their rooms or protective equipment readily available for staff use.
The Infection Preventionist confirmed during interviews that the facility "was not currently implementing EBP for any facility residents," despite acknowledging that these precautions were required for residents with indwelling medical devices and open wounds.
Critical Hand Hygiene Lapses During Wound Care
Inspectors observed a Treatment Nurse performing wound care on a resident with a stage four pressure ulcer without following proper hand hygiene protocols. The nurse changed gloves multiple times during the procedure but failed to perform hand hygiene between glove changes, a fundamental infection control requirement.
The nurse later acknowledged to inspectors that "hand hygiene was supposed to be performed throughout the wound treatment, especially after taking off gloves and before applying new gloves." She admitted not performing hand hygiene during the treatment, stating this practice "put him at risk of infection due to his open wound."
Stage four pressure ulcers represent the most severe category of wounds, with exposure of muscle, tendon, or bone. These wounds are highly susceptible to infection, which can spread to bone and cause life-threatening complications. Proper hand hygiene during wound care is essential to prevent introducing harmful bacteria into these vulnerable areas.
The facility's own policies required staff to perform hand hygiene before initiating treatment, during treatment when gloves are changed, and after completing treatment. The policy specifically stated that "the use of gloves does not replace hand washing."
Water Management System Failures Create Legionella Risk
The facility's maintenance supervisor was unable to provide documentation of the water management system implementation, including required annual effectiveness reviews. This system is designed to prevent dangerous bacteria growth in water systems that could cause serious illness in vulnerable nursing home residents.
The Infection Preventionist acknowledged being assigned to the water management team but confirmed not participating in any related activities. He noted that facility residents were "at risk of severe illness in the event of a Legionella, or other opportunistic pathogens and outbreaks from bacteria growth in the facility's water systems."
Additional Issues Identified
Inspectors documented several other concerning violations:
- A resident with cognitive impairment was observed eating food from another resident's partially consumed meal tray left on a hallway cart, creating cross-contamination risks - One resident was not offered the pneumococcal vaccine as required by facility policy, despite having chronic lung disease that increases infection risk - A registry nurse providing direct patient care had not received required abuse prevention and reporting training before beginning work
The facility's Licensed Vocational Nurse admitted to inspectors that her nursing agency did not provide abuse training and she "did not receive any abuse training from the facility prior to her first shift." She acknowledged not knowing the facility's abuse reporting requirements, stating "it was important to know the abuse reporting requirements to ensure the safety of the facility residents."
These violations highlight systemic breakdowns in resident care and safety protocols at Del Rio Convalescent Center. The denied rehabilitation services particularly affected residents' long-term functional outcomes, while infection control failures created ongoing risks for the entire resident population.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Del Rio Convalescent Center from 2025-04-24 including all violations, facility responses, and corrective action plans.
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