Rialto Post Acute Center

In the surveyor’s words

From the most serious findings on record at Rialto Post Acute Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 8, 2026

  Based on observation, interviews, and record reviews, the facility failed to ensure adequate supervision and safe environment to prevent elopement for one of five residents (Resident 175), reviewed for accidents. On January 7, 2026, Resident 175 (a resident diagnosed with Parkinson's disease [a brain disorder that causes tremors, slowed movement, poor balance, and difficulty with walking and coordination, increasing fall and wandering risks] and at high risk for falls) exited the facility through an alarmed emergency exit door, unsupervised. […]

• Immediate jeopardy, isolatedF689Apr 11, 2025

  Based on interview, and record review, the facility failed to provide one-on-one supervision, (continuous monitoring of residents by a staff for safety reason. This may involve staff member staying within arm's reach at all times) and the wander guard (wander management system designed to help protect residents, particularly those with memory impairment, from elopement) was not applied for one of four sampled residents (Resident 1) who was a recent admit and on parole. These failures resulted in Resident 1's elopement ( refers to a resident leaving the facility without permission or staff knowledge) and possibly contributed to his death. […]

• No harm, potential for more than minimal, patternF686Aug 14, 2026

  Based on interview and record review, the facility failed to ensure their wound care policy was implemented for one of three sampled residents (Resident 1) when Resident 1's back wound did not have consistent documentation pertaining to its ongoing assessment, monitoring and evaluation from May 10, 2026 through June 28, 2026. This failure potentially caused Resident 1 to be identified with a stage 4 pressure ulcer (full-thickness skin and tissue loss with directly exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone) to the mid-back with purulent drainage (a thick, opaque fluid-commonly known as pus-that oozes from a wound or sore) when Resident 1 was transferred to the acute care hospital on June 28, 2026.Findings: During a review of Resident 1's admission Record… […]

• No harm, potential for more than minimal, patternF690Aug 14, 2026

  Based on interview and record review, the facility failed to ensure laboratory results were followed up in a timely manner for one of three sampled residents (Resident 1) when Resident 1, who had an indwelling foley catheter (a tube place into the bladder that stays in place to drain urine into a bag), developed hematuria (blood in the urine), confusion, and altered mental status. The facility failed to notify the physician when the result of urinalysis and urine culture and sensitivity (UA/CNS, test used identify a urinary infection and determine appropriate antibiotic treatment) was reported as contaminated, obtain additional physician orders, or repeat the urine test. This failure resulted in a delay in the further evaluation and treatment of Resident 1's urinary infection. […]

• No harm, potential for more than minimal, patternF760Jan 7, 2022

  Based on observation, interview, and record review, the facility failed to ensure one of 37 residents receiving insulin (Residents 49) was free of significant medication errors when Resident 102 received insulin (a medication used to reduce high levels of sugar in the blood) that was past the manufacturer's specified beyond-use date (BUD- last date a product can be safely used after it has been altered for patient use) from January 1, 2022 to January 5, 2022. This failure had the potential to place Resident 102 at risk of infection due to potentially being administered a contaminated medication. In addition, medication that is past the BUD may not be as effective as intended by the manufacturer or prescriber which increases the risk for adverse events. […]