Rio Hondo Subacute & Nursing Center

In the surveyor’s words

From the most serious findings on record at Rio Hondo Subacute & Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF755Mar 16, 2023

  Based on observation, interview, and record review, the facility failed to provide accurate and safe pharmaceutical services and procedures to nine of nine residents (Residents 134, 174, 9, 133, 67, 98, 68, 7 and 482) when: 1. Resident 134's lisinopril (a medicine used to treat high blood pressure and heart failure) was administered without assessing the heart rate as ordered by the physician prior to medication administration. 2. Resident 134's potassium chloride ER ([ER-Extended Release] a medicine used to prevent or treat low potassium [a mineral] levels in the body) were administered for over one year without accurate indication of its use. 3. […]

• Immediate jeopardy, widespreadF760Mar 16, 2023

  Based on observation, interview, and record review, the facility failed to ensure seven of seven sampled residents (Residents 174, 134, 133, 7, 9, 68 and 482) in Stations 1, 2, and subacute unit to be free from significant medication errors when: 1. Resident 174, a dialysis (a procedure to remove waste product and excess fluid from the blood) resident, did not receive Losartan Potassium (a medicine used to treat high blood pressure) for 52 days from 1/21/23 to 3/13/23. 2. Resident 134 received Potassium Chloride ER ([ER-Extended Release] a medicine used to prevent or treat low potassium levels in the body) for over one year without adequate indication for its use. 3. Resident 134 chewed and swallowed Potassium Chloride ER with less than a glass of water. 4. […]

• Immediate jeopardy, patternF607Sep 9, 2023

  Based on observation, interview and record review the facility failed to ensure that facility staff implement the facility's Abuse Prohibition Policy and Procedure during the provision of care and services for six of six sampled residents (Residents 1, 2, 3, 4, 5, and 6). The facility failed to: 1. Prevent sexual abuse when facility staff did not identify and intervene with Resident 1's sexually inappropriate behaviors that included lying on top of another resident with pants down, masturbating, and wandering (moving around inside the facility or home without awareness of personal safety, potentially putting themselves in harm's way) to Residents 2, 3 and 5's bedside. 2. […]

• Immediate jeopardy, patternF759Mar 16, 2023

  Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Five medication errors out of 29 total opportunities contributed to an overall medication error rate of 17.24 % affecting three of three residents (Residents 174, 134, and 67) observed for medication administration. The medication errors were as follows: 1. Resident 174 failed to receive the physician order of Losartan Potassium (a medicine used to treat high blood pressure) from [DATE] to [DATE]. 2. Resident 134 received the physician order of Potassium Chloride ER ([ER-Extended Release] a medicine used to prevent or treat low potassium [a mineral] levels in the body) for over one year without adequate indication for its use. 3. […]

• Immediate jeopardy, isolatedF684Mar 28, 2025

  Based on interviews and record reviews, the facility failed to ensure that one of two sampled residents (Resident 1), who had a diagnosis of Diabetes Mellitus ([DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin [a hormone that regulates blood sugar levels in the body]) and history of hypoglycemia (a condition were blood sugar levels drop below normal), received treatment and services, in accordance with professional standards of practice, the care plan, and physician orders for the management of DM and hypoglycemia. The facility failed to: 1. […]