Rio Hondo Subacute: Pain Reports Ignored for Weeks - CA
That gap, between what the resident said and what the medical team knew, sat at the center of a complaint inspection completed in November 2025.
The physical therapy assistant who worked with the resident remembered it clearly. During an interview with inspectors on November 21, she said the resident complained of right leg pain during a physical therapy session on September 8, 2025, and that she reported it directly to the nurse in charge of the resident that same day. She believed she had done her part. The information went no further.
The nurse practitioner, interviewed the same morning, said he was never told about the resident's continued right leg pain during ambulation, not on August 5, not on August 29, not on August 30, not on September 8, and not on September 14. Five separate physical therapy sessions. Five dates on which the resident's pain went unreported up the chain. "If Resident 1 had continued right leg pain," he told inspectors, "the resident should be evaluated for pain or sent to the hospital."
Nobody sent for an evaluation. Nobody sent the resident to the hospital.
The director of nursing, interviewed that same morning, offered a different picture. He pointed to nursing progress notes and the medication administration record, which showed the resident had a zero pain level on four of those same dates, August 29, August 30, September 8, and September 14. According to those records, the resident had no complaints of pain during nursing assessments on any of those days. The director of nursing said he was not aware the resident had reported pain during physical therapy, and he explained that at the time licensed staff assessed the resident, the resident did not report pain to them.
That is the contradiction at the center of this case. The physical therapy assistant documented pain during ambulation. The nursing staff documented no pain during their own assessments. The nurse practitioner received neither account. And the resident, by the time inspectors arrived, had already stopped walking.
The nurse practitioner did visit the resident on September 19. He noted the resident denied acute pain at that point, and he observed a small bruise on the right leg and ankle that appeared to be healing.
Inspectors cited the facility under F0697, the federal tag covering pain management, and classified the level of harm as minimal harm or potential for actual harm, with some residents affected.
What the citation does not resolve is the simpler question of how a resident can report pain during therapy, have a therapist relay that report to a nurse, and still have the prescribing provider learn nothing about it across more than six weeks. The nursing records said zero pain. The therapy notes said otherwise. The two sets of records never met in any conversation that reached the person with authority to order an evaluation or a hospital transfer.
The nurse practitioner said plainly what should have happened. Continued pain during ambulation warranted evaluation. The resident was not evaluated for pain. The resident stopped ambulating.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rio Hondo Subacute & Nursing Center from 2025-11-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 8, 2026 · Our methodology
RIO HONDO SUBACUTE & NURSING CENTER in MONTEBELLO, CA was cited for violations during a health inspection on November 7, 2025.
That gap, between what the resident said and what the medical team knew, sat at the center of a complaint inspection completed in November 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.