Rinaldi Convalescent Hospital: Medication Patch Errors - CA
The patient is identified in inspection records only as Resident 40. He arrived at Rinaldi Convalescent Hospital on January 10, 2026, after suffering an intracerebral hemorrhage, a stroke caused by a blood vessel rupturing inside the brain. He also came in with difficulty swallowing and high blood pressure. Nursing staff depended on him for nothing, handling his toileting, showering, lower body dressing, and footwear entirely themselves. He could communicate and understand others, and needed only partial help with hygiene.
The day after his admission, a doctor ordered a clonidine transdermal patch, a small adhesive patch worn on the skin that slowly releases medication to control blood pressure. The order was specific: apply one patch every Saturday, and alternate the site each time.
The medication administration records tell a different story.
On February 14, nurses removed the patch from his right arm and placed the new one on his right arm. A week later, on February 21, they removed it from his left arm and placed the new one on his left arm. On March 14, they removed it from his right arm and placed the new one on his right arm again.
Three weeks of documented patch changes. Three times the site was not rotated.
When an inspector reviewed those records with Licensed Vocational Nurse 4 on the morning of March 29, the nurse acknowledged what the records showed. The patch should have been rotated on all three of those dates, she said, and it was not. She offered two reasons rotation matters: nurses are supposed to follow doctors' orders, and repeatedly applying the patch to the same location can irritate the skin.
The assistant director of nursing, reviewed the same records later that morning. Her explanation was shorter. Clonidine patches must be rotated, she said, to avoid harm to the skin.
The manufacturer's own instructions, which the facility had on hand, say the same thing. After one week, remove the old patch, choose a different site, place the new one.
Clonidine patches work by releasing medication through the skin over seven days. When a patch is placed repeatedly on the same spot, the skin can become irritated or damaged, which also affects how reliably the medication absorbs. For a stroke patient whose high blood pressure already contributed to a ruptured blood vessel in his brain, inconsistent blood pressure control carries real consequences.
The inspection, completed March 29, 2026, cited the facility for failing to ensure Resident 40 was free from significant medication errors. Inspectors rated the harm as minimal, affecting few residents.
The facility's own medication administration policy, last updated January 29, 2026, states that medications are administered as prescribed in accordance with good nursing principles and practice. Resident 40's admission had been January 10. The policy had been revised nineteen days later. The patch order requiring site rotation had been in place since January 11.
None of that stopped the same mistake from happening on February 14, again on February 21, and again on March 14.
Rinaldi Convalescent Hospital is located at 16553 Rinaldi Street in Granada Hills. The inspection was conducted by the California Department of Public Health on behalf of the Centers for Medicare and Medicaid Services.
Whether Resident 40's skin was ever examined for irritation at those sites, or whether his blood pressure remained controlled through those weeks of repeated applications, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rinaldi Convalescent Hospital from 2026-03-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 18, 2026 · Our methodology
RINALDI CONVALESCENT HOSPITAL in GRANADA HILLS, CA was cited for violations during a health inspection on March 29, 2026.
The patient is identified in inspection records only as Resident 40.
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.