Health inspection·July 24, 2025

Regulatory Violations 22 CCR § 72311. Nursing Service - General. (a)Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 72501. Licensee - General Duties. (e) The licensee shall employ an adequate number of qualified personnel to carry out all the functions of the facility and shall provide for initial orientation of all new employees, a continuing in-service training program and competent supervision. 22 CCR §72523 - Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. F689 42 CFR §483.25 Quality of Care (d) Accidents. The facility must ensure that – (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 6/10/2025 the California Department of Public Health (CDPH) conducted an unannounced visit at the Rio Hondo Subacute and Nursing Center to investigate a complaint regarding resident safety and quality of care. As a result of its investigation, CDPH determined that the facility failed to provide adequate supervision and assistance to prevent falls and injury in addition to a failure to properly implement interventions to prevent accidents and hazards such as training on the proper use of a mechanical lift (a device used to assist with transfers and movement of individuals who require support for mobility beyond manual support). In addition, the facility failed to update the comprehensive care plan for use of the mechanical lift when transferring Resident 1 from chair to bed, resulting in injuries to Resident 1. The facility failed to: 1 . Develop or implement a comprehensive care plan that included safe transfers for Resident 1 from her chair to her bed as required under California law. 2. Ensure Certified Nurse Assistants (CNA) 2 and CNA 3 used a full body, extra-large size sling (a flexible strap or belt used in the form of a loop to support or raise a weight) in accordance with Resident 1’s Lift Transfer Assessment and facility policy and procedure for Lifting Machine, Using a Mechanical. 3. Ensure all staff members were adequately trained regarding the identification and use of properly sized slings when using the mechanical lift as required by California law and policy and procedure for Lifting Machine, Using a Mechanical. As a result of these deficient practices, on 05/16/2025 Resident 1 fell when CNA 2 and 3 used an improperly sized sling to transfer the resident from chair to bed using the mechanical lift. As a result of the fall Resident 1 sustained a golf-sized large bump, posterior swelling at the back of the head, pain at the back of the head, nausea/vomiting and transfer to the General Acute Care Hospital (GACH) via 911 emergency services. A review of Resident 1's Admission Record (AR) indicated the facility admitted Resident 1, a 66 year-old female, on 4/22/2008. Resident 1 was readmitted on 5/17/2025 with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted), muscle weakness, lack of coordination, contractures (a permanent tightening of the muscles, tendons [connects muscles to bones], skin, and nearby tissues that causes the joints to shorten and become very stiff) of right hand and right shoulder, osteoarthritis (the swelling and tenderness of one or more joints) of the left hand, abnormalities of gait (manner of walking or moving on foot) and mobility. A review of Resident 1’s "Lift Transfer Reposition" dated 1/7/2025, the record indicated Resident 1 was not able to transfer independently or with staff supervision without using a device. The assessment indicated that Resident 1 required a "total lift (mechanical lift)" and the use of a full body, extra-large size sling. A review of Resident 1's Minimum Data Set (MDS-resident assessment tool), dated 5/12/2025, the MDS indicated Resident 1's cognition (ability to think, remember, and reason) was intact. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort, helper lifts, holds or supports trunk or limbs, but provides less than half the effort) in transfer to and from bed to a chair and in toilet transfer (get on and off a toilet or commode) and needed maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) for tub/shower transfer (get in and out of tub/shower). A review of Resident 1's physician order, dated 5/16/2025, indicated to transfer Resident 1 to the GACH via 911 EMS. A review of Resident 1's "Change in Condition Evaluation," dated 5/16/2025, indicated Resident 1 was transferred to the GACH Emergency Room (ER) due to injury at the back of the head, after slipping out of the sling during transfer from wheelchair to bed. A review of Resident 1's Progress Notes, dated 5/16/2025 timed at 4:48 PM documented by Registered Nurse (RN) 1, indicated Resident 1 was sent to the GACH via 911 at 4:38 PM. A review of Resident 1's Progress Notes, dated 5/16/2025 timed at 5:12 PM documented by Director of Nurses (DON) 2 (previous DON), indicated Resident 1 was sent to the GACH via 911 due to possible hematoma (a closed wound where blood collects) at the back of the head. A review of Resident 1's Progress Notes, dated 5/16/2025 timed at 11:48 PM documented by Licensed Vocational Nurse (LVN) 1, indicated on 5/16/2025 at 4 PM, LVN 1 received Resident 1 during the night shift (11 PM to 7 AM), after a fall from the mechanical lift sling with two CNAs present during the fall. The Note indicated Resident 1 was alert and oriented with vital signs within normal limits (no abnormalities) and no complaint of dizziness or pain. The Note indicated there was a possible hematoma presented on the back of Resident 1's head with the size of "a tennis ball." A review of Resident 1's GACH ED Physician Notes, dated 5/16/2025 electronically signed by the GACH Physician at 8:17 PM, the GACH Emergency Department (ED) Note indicated "[Resident 1] was admitted to the GACH ED via EMS with a chief complaint of fall with head injury that was accidental as she was being transported by [facility] staff and hit her head." The GACH ED Note indicated that [Resident 1] hit her head on the back, reported no pain, but there is a large bump on the back of her head, with physical exam indicating a firm, "4 x 4-centimeter (cm - unit of measurement)" round hematoma on the back of her head. The GACH ED Note indicated a Computerized Tomography (CT, a diagnostic imaging procedure that produces images of the inside of the body) of Resident 1's brain performed on 5/16/2025, indicated a posterior scalp (the back of the scalp, which is the area of skin covering the back of the head) soft tissue (the non-bone parts of the body that connect, support, or surround other structures and organs) swelling and no other acute abnormalities. The GACH ED Note indicated Resident 1's diagnosis as "Closed head injury (a traumatic brain injury where the skull remains intact) without concussion (a mild blow to the head that affects brain function)." The GACH ED Note indicated an ice pack was applied to Resident 1's head and was offered Tylenol (an over-the-counter pain medication) for pain but declined. The GACH ED Note indicated Resident 1 was discharged back to the facility, the same evening, on 5/16/2025. A review of Resident 1's Progress Notes, dated 5/17/2025 documented at 1:22 AM, indicated Resident 1 was readmitted back to the facility from GACH with diagnosis of closed head injury without concussion. A review of Resident 1's Progress Note, dated 5/17/2025, timed at 1:34 AM, documented by LVN 1, indicated Resident 1 had three episodes of nausea and vomiting, LVN 1 was informed by the GACH nurse (unidentified) that Resident 1 had a concussion and would have nausea and vomiting for three days. The Note indicated Resident 1's CT result was "negative (no significant abnormalities seen)" and Resident 1's physician was made aware. A review of Resident 1's Interdisciplinary (IDT) Care Conference (a meeting where healthcare professionals from different disciplines collaborate to discuss a patient's care plan) documentation by DON 2, dated 5/19/2025, indicated an IDT discussion for Resident 1's fall incident on 5/16/2025 at 4 PM. The IDT note indicated Resident 1 slipped out of the sling of the mechanical lift and fell on the floor while being transferred by two CNAs (CNAs 2 and 3). The IDT note indicated the sling was inspected by DON 2 with no signs of tear or breakdown. The IDT note further indicated "Resident 1 was checked for any injury while on the floor. Resident 1 had a golf size area at the back of [the] head and was transferred to the bed with an aid of sheet and five nursing staff. Ice was applied to the back of the head." The IDT note indicated Resident 1 was transferred out via 911 and returned later that evening with no significant injuries identified. The IDT note further indicated "It was noted that the sling used during transfer... may have been too small. This may have contributed to a shift in her balance and a consequence fall. The small sling was removed, and staff were instructed to use a larger size sling." A review of Resident 1's Interdisciplinary Care Conference, dated 5/28/2025, indicated a weekly IDT meeting was held to follow up on the fall incident that happened on 5/16/2025. The note indicated, the facility's Rehabilitation (care that can help a person get back, keep, or improve abilities that you need for daily life) Department reevaluated Resident 1's sling on 5/28/2025, to ensure that they were appropriate and the right size for Resident 1 and three slings were assigned and labeled specifically for Resident 1's use only. the hospital. During a telephone interview on 6/11/2025 at 11:40 AM with CNA 2, CNA 2 stated she was asked to help Resident 1's CNA (CNA 3) in transferring Resident 1 from the wheelchair to her bed on 5/16/2025. CNA 2 stated she did not touch Resident 1. CNA 2 stated she stood in front of Resident 1 and observed CNA 3 strap the mechanical lift sling into the mechanical lift. CNA 2 stated she asked CNA 3 if the sling straps were secured, and CNA 3 said yes. CNA 2 stated she then proceeded to operate the mechanical lift and lift Resident 1. CNA 2 stated one of the sling straps came loose causing Resident 2 to fall off the mechanical lift from her back side and hit her head on the floor. CNA 2 stated she went to call an LVN. CNA 2 stated she was not aware that the resident's slings use for the mechanical lift come in different sizes. CNA 2 stated she had not been instructed on how to use the mechanical lift or slings at the facility. During a concurrent observation and interview on 6/10/2025 at 11:55 AM with Resident 1, inside her room, Resident 1 was observed sitting on the wheelchair. Resident 1 stated on 5/16/2025, two CNAs (CNAs 2 and 3) used the mechanical lift to transfer her from her wheelchair to the bed. Resident 1 stated one CNA (could not recall which CNA) hooked the four corners of the slings to the mechanical lift. Resident 1 stated she felt the sling that was being used by the CNAs (CNAs 2 and 3) were too tight and asked the CNAs (CNAs 2 and 3) to wait, but CNAs 2 and 3 did not wait and started lifting her up in the air with the mechanical lift. Resident 1 stated while in the air, Resident 1 saw one of the sling connectors at the left upper corner come off the hook of the mechanical lift. Resident 1 then stated she slipped out of the sling and fell to the floor. Resident 1 stated she hit the back of her head onto the floor. Resident 1 stated that after the fall, she experienced pain in the back of the head and had nausea and vomiting. Resident 1 stated after the fall, the nurses came to help her, and she was sent to During a telephone interview on 6/11/2025 at 12:06 PM with CNA 3, CNA 3 stated that on 5/16/2025, Resident 1 asked to be changed so she asked CNA 2 to help her transfer Resident 1 from the wheelchair to the bed using the mechanical lift. CNA 3 stated, she hooked up three sling ties to the mechanical lift and CNA 2 hooked the fourth tie of the mechanical lift. CNA 3 stated she remembered telling CNA 2 that she was ready; as the mechanical lift went up, CNA 3 remembered Resident 1 moving to fix her buttocks and then fell to the floor. CNA 3 stated, the previous DON of the facility (DON 2), came into Resident 1's room after Resident 1's fall incident and explained to her (CNA 3) and CNA 2 that the "blue sling" used in Resident 1's mechanical lift was too small because the "hole" where Resident 1's buttock went in was too small. CNA 3 stated she did not understand what DON 2 meant about the color of the sling. CNA 3 stated she was not trained by the facility on the colors/sizes of the slings to differentiate the correct sling size to use when moving the resident with the mechanical lift. CNA 3 stated, she was only trained on how to hook the mechanical lift sling into the mechanical lift when moving a resident. During a concurrent interview and record review on 6/11/2025 at 3:46 PM with the MDS Nurse (MDSN), Resident 1's Lift Transfer Reposition, dated 1/7/2025, and the Comprehensive Care Plans developed from facility readmission dated 5/17/2025 to 6/11/2025, were reviewed. The MDSN stated, the facility had assessed Resident 1 for the use of a mechanical lift for transfers on 1/7/2025 and the CNAs had been using the mechanical lift to transfer Resident 1, but the licensed nurse did not updated the comprehensive care plan to address the use of mechanical lift for the safety of Resident 1's transfers that addresses the appropriate slings to use. During a concurrent observation and interview on 6/11/2025 at 11:15 AM with Laundry Staff (LS) 1, multiple blue slings with numbers written on the corner of the slings were hung in the facility's Laundry Room. LS 1 stated that whenever CNAs would use the mechanical lift for residents, the CNAs would go and ask LS 1 for a sling. LS 1 stated the blue slings were used for transferring. LS 1 stated the blue slings had different color edges, light blue and purple. LS 1 stated the slings of the mechanical lift were the same size regardless of the color difference on the edge on the blue slings (light blue and purple). LS 1 stated she just gives the CNAs any blue slings when the CNAs asked her for a sling. During a concurrent observation and interview on 6/11/2025 at 11:17 AM with LS 1, LS 1 held one blue sling with the light blue edge and one blue sling with purple edge overlapping each other, and observed the blue sling with the light blue edge was larger than the sling with the purple edge. LS 1 stated she did not know the slings with different color edges were different sizes. LS 1 stated no one informed her or given her in-service of what sling sizes to provide the CNAs when they ask for a sling. During an interview on 6/11/2025 at 11:28 AM with the Maintenance Dir