Rio Hondo Subacute & Nursing Center
RIO HONDO SUBACUTE & NURSING CENTER in MONTEBELLO, CA — inspection on March 1, 2025.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 491's History and Physical (H&P, a comprehensive physician's note regarding the assessment of the resident's health status), dated 2/15/2025, the H&P indicated Resident 491 does have the capacity to understand and make decisions.
During a review of Resident 491's Minimum Data Set (MDS, a federally mandated resident assessment), dated 2/20/2025, indicated Resident 491's cognition (a person's mental process of thinking, learning, remembering, and using judgement) was severely impaired.
The MDS indicated Resident 491 required moderate assistance (helper does less than half the effort) when transferring from sitting to lying in bed, lying to sitting on the side of the bed and the ability to sit to stand from the chair.
The MDS indicated Resident 491 was frequently incontinent (involuntary loss of bladder or bowel control) of urine and stool.
The MDS indicated Resident 491 did not have any history of falls prior to admission to the facility.
During a review of Resident 491's care plan, dated 2/15/2025, the care plan indicated Resident 491 was at risks for falls related to confusion, gait (the way a person walks) balance problems.
The care plan goals indicated the resident will be free of falls by target date 5/16/2025.
The care plan interventions included anticipating and meeting the residents needs and ensuring the resident's call light was within reach.
During a review of Resident 491's Nursing Documentation Evaluation document, dated 2/15/2025, the document indicated Resident 491's had a risk factor of falls related to disorientation and confusion.
056487
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056487 B.
Wing 03/01/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640
During a review of Resident 14's Admission Record, the facility admitted Resident 14 on 1/19/2022 and readmitted Resident 14 on 8/22/2024 with diagnoses of Chronic Respiratory Failure (long term condition where the lungs cannot get enough oxygen), Neuromuscular Dysfunction of Bladder (damage to the nerves that control the bladder), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness that affected one side of the body) following cerebral infarction (stroke, that occurred when blood flow to the brain was blocked) affecting the right dominant side.
During a review of Resident 14's History and Physical (H&P, a comprehensive physician's note regarding the assessment of the resident's health status), dated 10/31/2022, Resident 14 did not have the capacity to understand and make decisions.
During a review of Resident 14's Minimum Data Set (MDS, a resident assessment tool), dated 12/13/2024, the MDS indicated Resident 14 rarely made decisions regarding tasks for daily life.
The MDS indicated Resident 14 was dependent (helper does all the effort) on staff for activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily) such as toileting and was dependent on staff to assist in turning from his back to his left or right side and turning to lie on his back on the bed.
The MDS indicated Resident 14 had an indwelling suprapubic catheter (a tube that drains urine from the bladder) and was always incontinent (loss of control) of bowel.
The MDS indicated Resident 14 had neurogenic bladder and obstructive uropathy (condition where the urinary tract was blocked).
During a review of Resident 14's Order Summary Report (physician order), start date of 8/22/2024, Resident 14's order indicated to monitor for signs and symptoms of new onset of: fever, hematuria (blood in urine), cloudy urine output, foul odor urine, or decrease urine output.
This order's instructions included for every day and night shift, to start a Change of Condition (CoC) documentation if any of the following symptoms were noted and to notify the physician, supervisor, and family.
056487
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056487 B.
Wing 03/01/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640
(pharmacy services- medication administration)
The facility failed to:
1.
Develop a QAPI plan on how ensure residents with significant change in condition were assessed, monitored, intervention provided, evaluated and reported to the physician immediately.
2.
Evaluate the QAPI plan to ensure residents who were admitted to the facility without pressure ulcer (a skin breakdown due to prolonged unrelieved pressure or friction in the bony part of the body) does not develop new or worsened pressure ulcer and MASD (Moisture-Associated Skin Damage is an inflammation, irritation, skin breakdown characterized by redness, shininess, and feelings of burning, itching or pain, especially in areas exposed to moisture).
3.
Develop a QAPI plan on how to ensure the medications was administered as ordered by the physician and in accordance with professional standard of practice to prevent medication errors.
4.
Did not develop a QAPI plan to ensure competency check and performance evaluation for some of the facility ' s nursing staff and verified the competency of the registry nursing staff to ensure that the registry nursing staff were competent of caring for the residents in the facility.
As a result of these deficient practices the facility continued to have deficient practices under substandard quality of care and does not meet the care and treatments needed by the residents which results in the resident ' s hospitalization and decline in wellbeing.
Cross reference:
During an interview on 2/28/2025 at 6:25 PM with the Administrator (ADM), the ADM stated the QAA committee had not developed a QAPI plan to ensure the nursing staff were competent of delivering care to
potential for actual harm administering medications.
The ADM stated it was important that the nursing staff were competent to care for the residents to ensure quality of care and safety of the residents.
2.
During a concurrent interview and record review on 2/28/2025 at 6:30 PM with the Administrator (ADM), System Improvement, Implementation and Re-evaluation on Skin and Wound Management, dated as the starting date on 2/10/2025, was reviewed.
The ADM stated they had been doing 24-hour communication and daily audits of the skin and wound issue by the DON from Mondays to Fridays, and the weekly interdisciplinary team meeting to review the physician orders and status of the skin and wounds for each resident who had a skin issue or a wound.
The ADM stated she had a list of residents that were having a skin issue or a wound.
The ADM stated if they found a change of condition, they would report to the MD, get an order and revise the care plan.
The ADM stated she thought they have been doing well on following up with each resident ' s skin and wound status, but she did not know why they did not identify the missed weekly skin/wound assessment and the new changes or worsened of the skin condition and wound for some residents which should had been evaluated.
3.
During a concurrent interview and record review on 2/28/2025 at 6:25 PM with the Regional Clinical Resource (RCR), System Improvement, Implementation and Re-evaluation on Medication Management, dated as the starting date on 12/1/2024, was reviewed.
The facility did not have a written QAPI plan to ensure that residents received medications as ordered by the physician or ensure residents were free of medication error.
4.
During an interview on 2/28/2025 at 6:25 PM with the Administrator (ADM), the ADM stated the QAA committee was aware that the facility had not conducted the competency check and performance evaluation for some of the facility ' s nursing staff.
The ADM stated the facility did not have a competency checklist for the registry nursing staff to ensure that the registry nursing staff were competent of caring for the residents in the facility.
During a review of the facility ' s policy and procedure (P&P) titled, Quality Assurance and Performance Improvement Plan, revised on 4/2014, the P&P indicated This facility shall develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems, and the QAPI Plan are to: 1.
Provide a means to identify and resolve present and potential negative outcomes related to resident care and services; 2.
Reinforce and build upon effective systems and processes related to the delivery of quality care and services; 3.
Provide structure and processes to correct identified quality and/or safety deficiencies; 4.
Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome; 5.
Help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively, and to delineate lines of authority, responsibility, and accountability; 6.
Provide a means to centralize and coordinate comprehensive QAPI activities in order to meet the needs of the residents and the facility; and 7.
Establish systems and processes to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program.
056487
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056487 B.
Wing 03/01/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640
During a review of Resident 148 ' s Admission Record (AR), the AR indicated the facility admitted Resident 148 on 8/12/2024 with diagnoses including ventral hernia (abdominal wall muscles weaken, allowing organs or tissues to bulge through) with obstruction (blockage), perforation of the intestine (hole that develops in the wall of the intestine causing the content to leak into the abdomen), peritonitis (swelling of the lining of the abdomen), and Type 2 Diabetes Mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 148 ' s History and Physical (H&P) Examination, dated 8/12/2024, the H&P indicated Resident 148 had capacity to understand and make decisions.
During a review of Resident 148 ' s Minimum Data Set ([MDS] a resident assessment tool), dated 11/15/2024, the MDS indicated Resident 148 had clear speech, expressed ideas and wants, understood verbal content, and had intact cognition.
056487
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056487 B.
Wing 03/01/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640
During a review of Resident 180 ' s Minimal Data Set (MDS-a federally mandated resident assessment), dated 2/4/2025, indicated Resident 180 ' s cognition (ability to think, remember, and reason with no difficulty) was intact and needed partial assistance (helper does less than half the effort) in eating and personal hygiene.
During a review of Resident 180 ' s phone orders, dated 2/22/2025, indicated Resident 180 had a physician order on 2/22/2025 at 7:39 PM for CBC (complete blood count, a blood test that measures the number and size of different types of blood cells), CMP (a routine blood test that measures 14 different substances in a sample of the blood), and UA with C&S (urinalysis with culture and sensitivity).
During a review of Resident 180 ' s Laboratory Results Report, dated 2/23/2025 timed at 11:48 PM, indicated Resident 180 had critical lab values for BG level of 60 milligrams (unit of weight) per deciliter (a metric unit of capacity) (mg/dL- reference range 65-99 mg/dL) and WBC count of 39.59 cells per microliter (unit of volume) of blood (normal reference range was 4-11 cells per microliter of blood).
During a review of Resident 180 ' s Change in Condition (CIC) Evaluation, dated 2/24/2025, indicated Resident 180 had critical lab results with low glucose of 60, high WBC of 39.59 with no fever, clear breath sounds, and vital signs within normal range.
The CIC indicated, on 2/24/2025 at 2:48 AM, LVN 5 notified Resident 180 ' s Nurse Practitioner (NP) 1 about critical lab results of low blood glucose and high WBC and received a new order for antibiotics (medication given to treat infection).
Further review of the CIC indicated no order was written for antibiotics.
056487
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056487 B.
Wing 03/01/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640
During a review of Resident 171 ' s Admission Record, the facility admitted Resident 171 on 1/3/2025 and readmitted Resident 171 on 2/6/2025 with diagnoses that included infection of the amputation stump, left lower extremity, and infection of amputation stump, right lower extremity.
During a review of Resident 171 ' s History and Physical (H&P, a comprehensive physician ' s note regarding the assessment of the resident ' s health status), dated 2/6/2025, the H&P indicated Resident 171 had the capacity to understand and make decisions.
056487
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056487 B.
Wing 03/01/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640