Rio Hondo Subacute & Nursing Center in Montebello: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, CDPH made an unannounced visit on May 12, 2026, to investigate a complaint about resident care. Resident 1 was a non-verbal woman with dementia, one-sided paralysis after a stroke and a left knee contracture (a joint locked in a bent position), fully dependent on staff. Her care plan called for two-person help with bed mobility and transfers.

CDPH determined that on May 7, 2026, at 4:30 a.m., CNA 1 turned Resident 1 on her side alone during a linen change. She slid off the bed, struck her head on the nightstand and landed on the floor. Inspectors found CNA 1 put her back in bed before a licensed vocational nurse assessed her, and the director of nursing and administrator did not interview CNA 1 or update her care plan. She had a bleeding scratch, swelling and bruising by her right eye. The 2567 report states a nursing note the next morning said no witnessed fall had been reported. She was sent to a hospital on May 8, about 29.5 hours after the fall, and was found to have a complete dislocation of both sides of her jaw. She had jaw surgery at a trauma center on May 11, 2026.

The citation also states staff did not assess her pain with a dementia pain scale or treat her pain when she was bleeding and agitated. CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F689 (severity G), on accident hazards, supervision and assistive devices.

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According to the 2567 report, Resident 6 was admitted on January 7, 2026, with paraplegia (paralysis of the legs and lower body), muscle weakness and poor coordination, and had no pressure ulcer on admission. Therapy notes said the resident needed maximal help to roll in bed.

Inspectors found the facility did not complete a skin assessment and pressure ulcer risk evaluation on admission or weekly during the first month, as its own skin policy required, and had no care plan with steps to prevent pressure ulcers from January 7 through January 16, 2026. When a wound was first found on January 13, a licensed vocational nurse did not measure it, and the treatments the physician ordered were not given on January 13 and 14. The report states Resident 6 developed a deep tissue injury and a stage 3 pressure ulcer (a deep wound through the skin into the fat layer, also called a bed sore) on the tailbone, measuring 5 by 7 centimeters. The wound required surgical debridement (removal of damaged tissue).

The 2567 report cites F686 (severity G), on care to prevent and heal pressure ulcers. It also cites F607 (severity D), on developing and implementing abuse and neglect policies, and F609 (severity D), on reporting of alleged violations. The full narrative for those two findings is in the linked report.

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According to the citation, CDPH made an unannounced visit on November 1, 2025, to investigate a complaint about quality of care. Resident 1 was a woman with a history of a right ankle fracture and a bone density disorder in her right lower leg. On July 28, 2025, she was found on the floor after, she said, she pulled herself to the side and rolled off the bed.

CDPH determined that after the fall the facility did not accurately assess her pain or check whether treatment worked. Physical therapy notes from August and September 2025 recorded right ankle and leg pain and her refusal to walk because of it, but inspectors found nurses did not tell the nurse practitioner or physician on six dates. On some days therapy reported pain, the medication record showed a pain level of zero and no pain medication given. An X-ray reported on August 8, 2025, showed a right ankle fracture of uncertain age, and the physician ordered no weight on that ankle.

According to the citation, these failures left her pain poorly controlled and she did not want to walk in therapy. The citation states her refusal to walk had the potential to lead to a deep vein thrombosis (a blood clot in a leg vein), that a clot broke off and lodged in her right lung, and that she was transferred to a general acute care hospital on September 25, 2025. CDPH issued a Class A citation with a $60,000 penalty.

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According to the citation, CDPH made an unannounced visit on June 10, 2025, to investigate a complaint about resident safety and quality of care. Resident 1 was a 66-year-old woman with one-sided paralysis after a stroke. Her lift assessment said she needed a total mechanical lift with a full-body, extra-large sling. On May 16, 2025, CNA 2 and CNA 3 moved her from her chair to bed using an improperly sized sling, and she slipped out and fell. She had a large bump on the back of her head, head pain and nausea and vomiting, and was taken to a hospital by 911.

CDPH found the facility failed to include safe transfers in her care plan, make sure the right sling was used, and train staff on choosing sling sizes. The 2567 report from the same visit also describes Resident 3, a man with quadriplegia and chronic pain syndrome who used a fentanyl pain patch every 72 hours. Inspectors found he missed doses on June 1 and June 4, 2025, because the physician had not signed a refill form and nurses did not follow up. The patch was applied on June 7, six days late. He told inspectors he was in severe pain, while a June 5 nursing summary said he had no pain.

CDPH issued a Class A citation in the patient rights category with a $25,000 penalty. The federal 2567 report cites F697 (severity G), on pain management, and F689 (severity G), on accident hazards, supervision and assistive devices.

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According to the citation, CDPH made an unannounced visit on April 3, 2025, to investigate a fire in a resident's room caused by smoking. The citation states that on April 2, 2025, at 12:50 a.m., Resident 7 was smoking in bed and set the bed linen on fire while three roommates were in the room. The fire department was called, and staff found burn marks on a towel and bedding. Facility notes reviewed by inspectors said no one was injured.

CDPH determined the facility failed to supervise, monitor and reevaluate Resident 7, who was known not to follow the smoking policy. His smoking evaluation said he needed supervision because of poor safety judgment, and his care plan said staff would keep his smoking materials at the nurses' station. The interim director of nursing told inspectors she did not know he kept cigarettes and a lighter. Inspectors also found the facility did not hold team meetings on smoking safety for Residents 8, 9, 10 and 11 before letting them keep smoking materials. During the visit, Resident 8 had a cigarette and a lighter in his wheelchair pocket.

According to the citation, after the fire a lighter was confiscated, police were notified, Resident 7 was placed on one-to-one monitoring, and he agreed to discharge to a lower level of care. The citation states the failures could have led to a larger fire, smoke inhalation and death. CDPH issued a Class A citation with a $25,000 penalty.

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According to the citation, CDPH made an unannounced visit on April 3, 2025, as a revisit for the facility's annual recertification survey. Resident 1 was a man admitted on March 27, 2025, with a urinary tract infection, a right shoulder and upper arm injury and muscle weakness. His admission assessment said he was at risk for falls because of recent falls and an unsteady gait, and his physician noted he could not make his own decisions.

CDPH found that Resident 1 had three unwitnessed falls. On March 28, 2025, one day after admission, he was found on the floor next to his bed with a skin tear and swelling on his right elbow. On March 30 he had pain in his head and right arm after a second fall. On March 31 he had a cut on his right knee and a small hematoma (a collection of clotted blood) on top of his head. After the first fall, his care plan called for close monitoring, a call light within reach and floor mats on both sides of the bed.

Inspectors found the facility failed to assess him to find the cause of the falls, did not revise his care plan after each fall to address causes such as answering the call light promptly and anticipating his daily care needs, did not make sure his floor mat was in place, and did not follow its own fall and call light policies. CDPH issued a Class A citation with a $25,000 penalty.

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According to the citation, CDPH made an unannounced visit on March 25, 2025, to investigate a complaint about a resident's death. Resident 1 had diabetes and a history of hypoglycemia (low blood sugar), and returned to the facility from a hospital on February 14, 2025, after a low blood sugar episode. The hospital discharge orders called for blood sugar checks before meals and at bedtime and a long-acting insulin at bedtime.

CDPH found a registered nurse did not review the hospital records or verify the readmission orders with the physician, and Resident 1 was not monitored for high or low blood sugar from February 14 to 18. On February 17 a licensed vocational nurse entered an order for 10 units of insulin at bedtime without a physician's order, and another LVN gave it without first checking blood sugar. On the morning of February 18, Resident 1 had an altered level of consciousness and a blood sugar of 27 (normal is 70 to 100), and inspectors found two LVNs did not adequately assess Resident 1 or notify the physician. According to the 2567 report, Resident 1 was taken by 911 to a hospital, admitted to intensive care, and died there on March 4, 2025.

CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F684 (severity J), on quality of care, F610 (severity D), on investigating and correcting alleged violations, and F600 (severity D), on freedom from abuse and neglect. According to the report, inspectors called an immediate jeopardy on March 26, 2025, and removed it on March 28 after the facility retrained nurses and reviewed the care plans of 91 diabetic residents.

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According to the citation, CDPH made an unannounced visit on February 25, 2025, for the facility's annual recertification survey. Resident 1 was a man admitted on January 29, 2025, after pneumonia and sepsis (a life-threatening blood infection). He had an indwelling urinary catheter (a tube placed in the bladder to drain urine) because of an enlarged prostate and blocked urine flow. The 2567 report states no care plan was developed for his catheter.

CDPH found nurses did not document daily assessments of his catheter and urine output from February 15 to 25, 2025. Critical lab results, a high white blood cell count and low blood sugar, were reported late on February 23, and the physician was not informed for about 14.5 hours. Inspectors also found nurses did not keep monitoring his vital signs, mental status and food intake on February 24 and 25 as he became more lethargic and responded only to a sternal rub (rubbing the chest to get a response), and did not promptly call the physician. He reached a hospital by ambulance on February 25 with a blood pressure of 64/44 and was admitted to intensive care with septic shock and blocked urine flow. In the ICU, 700 milliliters of pus-filled urine was drained from his catheter.

CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report from the same survey cites F690 (severity G), on incontinence, catheter care and urinary tract infections, a finding that also covers four other sampled residents. It also cites F686 (severity G), on pressure ulcers, and F689 (severity G), on accident hazards and supervision.

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According to the citation, CDPH made an unannounced visit on February 25, 2025, for the facility's annual recertification survey. CDPH determined the facility failed to make sure Residents 1, 2, 3 and 4 received care to protect their skin, promote healing and prevent pressure ulcers (bed sores) from forming or getting worse, as its policies, the residents' care plans and physician orders required.

The citation states that Resident 1 had no pressure ulcer on admission but developed a stage 2 pressure ulcer (a shallow open sore) on the tailbone that worsened to stage 3 (full-thickness skin loss, where dead tissue may be visible). Resident 1 also developed a vascular ulcer (an open sore caused by poor blood circulation) on the left heel while at the facility. Inspectors found Resident 1's daily skin assessments were not documented from February 12 to 14 and from February 18 to 21, 2025. CDPH also found the facility did not make sure the low air loss mattresses used by Residents 2 and 3 were set for their weight. The full narrative is in the linked report.

CDPH issued a Class A citation with a $20,000 penalty. The federal 2567 report from the same survey cites F686 (severity G), on care to prevent and heal pressure ulcers, F690 (severity G), on incontinence, catheter care and urinary tract infections, and F689 (severity G), on accident hazards and supervision.

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According to the citation, CDPH made an unannounced visit on February 25, 2025, for the facility's annual recertification survey. CDPH determined the facility failed to provide a hazard-free environment and adequate supervision for Residents 1, 2 and 3, who were assessed as high risk for falls, as its own fall management policy required.

The citation states Resident 1, a man with dementia and a history of falls, fell on October 9 and 21 and November 6, 25 and 26, 2024, and the facility did not analyze the hazards and risk factors to reduce repeat falls. Inspectors found no team meeting was held after the first fall. On November 27, 2024, he was found to have a non-displaced fracture of the left ankle. On December 23, 2024, Resident 2 slipped on nystatin powder (an antifungal skin medication) left on the floor, and the call light was not answered right away after the fall. Resident 2 fractured the upper part of the left arm bone (proximal humerus), with pain and reduced mobility. Resident 3 was found crawling on the floor on February 18, 19 and 26, 2025, and CDPH found the facility did not reevaluate him or increase his supervision.

CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report from the same survey cites F689 (severity G), on accident hazards and supervision, F686 (severity G), on pressure ulcers, and F690 (severity G), on incontinence, catheter care and urinary tract infections.

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According to the 2567 report, Resident 1 was a woman admitted from a hospital on January 6, 2025, with ovarian cancer, epilepsy, sepsis and chronic kidney disease, and was receiving hospice care. Hospital records showed her skin was intact. On admission the facility rated her at moderate risk for pressure ulcers and noted skin problems in the groin from a Foley catheter (a tube that drains urine from the bladder).

Inspectors found the facility did not provide pressure ulcer prevention measures after its admission assessments, and did not put in place the low air loss mattress and frequent turning identified on January 7, 2025. After hospice staff found groin redness and a stage 1 pressure ulcer (intact skin that is red, blue or purple from pressure) on the left buttock on January 15, the facility did not apply barrier cream or turn her every two hours as the hospice plan called for. Inspectors also found staff did not perform wound observations and daily monitoring as the facility's skin policies required.

The 2567 report states her skin breakdown worsened into two stage 3 pressure ulcers (full-thickness skin loss with fat visible in the wound) on the right and left buttocks, which required wound debridement (removal of dead or infected tissue) on January 23, 2025. The report cites F686 (severity G), on care to prevent and heal pressure ulcers.

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According to the 2567 report, Resident 1 was a woman admitted on December 2, 2024, for care after spinal fusion surgery, with incisions on her neck. Nursing notes reviewed by inspectors show drainage from the incision on the back of her neck on December 8 and light yellow fluid on December 13, 2024. Her care plan called for staff to notify the physician of any significant change.

Inspectors found that by December 21, 2024, the incision had dehisced (split open along the stitched line), and the wound had grown from 0.5 by 0.5 centimeters on December 19 to 4 by 4 centimeters. The facility did not notify her physician or the wound care physician assistant or get new orders, as her care plan and the facility's skin policy required. Inspectors also found staff did not record all wound details such as color, size and drainage, and records did not explain why a foam dressing was stopped on December 15.

The report states Resident 1 was transferred to a general acute care hospital on December 23, 2024, with an enlarging neck wound that had pus and a separation of about 3 to 5 centimeters. She received irrigation and debridement (flushing the wound and removing infected tissue), a wound vacuum device, and surgery to close the wound. The 2567 report cites F684 (severity G), on quality of care.

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According to the 2567 report, inspectors found the facility failed to make sure Residents 3, 4 and 5 were free from neglect and mistreatment, because staff did not help them with daily care or answer their call lights, leaving them in bed in soiled briefs. Resident 4, a woman with one-sided paralysis who had had spinal surgery, told inspectors that on her first night in September 2024 she pressed the call light at 11 p.m. to have a urine-soaked brief changed, and no one came until 2:45 a.m. She said it happened again the next two nights, that a CNA told her they were short staffed, and that she felt "depressed and neglected." Resident 3 said it usually took 30 to 45 minutes for a CNA to answer her call light, and that CNAs usually responded late after 7 p.m.

Inspectors also found the facility did not manage the pain of Resident 2, a woman with a compression fracture of a lower spine bone. Her medication record for September 2024 listed acetaminophen for mild pain as her available pain medication. The report states she reported neck, head and body pain as high as 10 out of 10 that month, and nurses did not notify the physician to get a different pain medication. On September 4, 2024, she could not wait for a scheduled ambulance and 911 was called. The hospital discharge summary listed a compression fracture of the L1 vertebra.

The 2567 report cites F600 (severity G), on freedom from abuse and neglect, and F697 (severity G), on pain management.

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According to the citation, CDPH made an unannounced visit on March 26, 2024, for the facility's annual recertification survey and reviewed the closed record of Patient 1. Patient 1 had a recent history of polysubstance abuse (dependence on several drugs) and an intravenous (IV) line in place. CDPH found Patient 1 had been found with illicit drugs and drug paraphernalia on January 22 and March 15, 2024, and had left the facility before without a physician's order or permission.

CDPH determined the facility failed to provide monitoring and supervision to prevent illicit drug use and intoxication, did not develop behavioral health care plans for substance use at admission in August 2023 or after the drugs were found, did not assess the risk of Patient 1 leaving to obtain drugs, did not monitor the IV line to prevent its use for injecting drugs, and did not arrange drug counseling. The full narrative, including what happened to Patient 1, is in the linked report.

The 2567 report from the same survey also states Resident 121, who had an inoperable hip fracture, did not receive scheduled morphine from March 21 to 24, 2024, because the pharmacy needed a physician's sign-off and nurses did not document contacting the pain management physician. Resident 121 told inspectors the pain was 10 out of 10 and kept her from sleeping for three to four days. CDPH issued a Class A citation with a $60,000 penalty. The federal report cites F740 (severity J), on behavioral health services, F689 (severity J), on accident hazards and supervision, and F697 (severity G), on pain management.

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According to the 2567 report, Resident 1 was a man with Alzheimer's disease and dementia. Inspectors found that on August 24, 2023, around 2 a.m., Resident 1 lay on top of Resident 2 in bed with his pants and underwear down, which Resident 6 saw. Staff then moved Resident 1 to another room, where Resident 4 reported seeing him often wander to Resident 3's bedside at night and masturbate. The report states Residents 2 and 3 experienced sexual abuse and unwanted, nonconsensual sexual contact. Resident 2 reported feeling angry and afraid, and Resident 5 said she could not sleep at night out of fear.

Inspectors found staff did not treat these reports as allegations of sexual abuse, did not act right away to protect Resident 2, did not increase supervision of Resident 1's wandering, and did not investigate or report the allegations to the administrator and the required agencies within two hours, as the facility's abuse policy required. CDPH visited on September 6, 2023, to investigate a facility-reported incident and called an immediate jeopardy.

According to the 2567 report, the facility's removal plan included notifying the reporting agencies, one-to-one CNA supervision of Resident 1 until discharge to a secured dementia unit, psychiatric and psychology evaluations, trauma evaluations for affected residents, and staff training on abuse reporting and on wandering residents. The immediate jeopardy was removed on September 9, 2023. The report cites F607 (severity K), on developing and implementing abuse and neglect policies, F600 (severity J), on freedom from abuse and neglect, and F609 (severity D), on reporting of alleged violations.

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According to the 2567 report, inspectors observed medication administration and found 5 errors in 29 opportunities, an error rate of 17.24 percent, affecting all three residents observed. The federal requirement is a rate below 5 percent. Errors included a blood pressure drug never given, potassium given for over a year without a documented reason, a heart rate not checked before a blood pressure drug, eye drops not given as ordered, and a liquid multivitamin not shaken first.

Inspectors also found significant medication errors for seven residents. Resident 174, a dialysis patient, did not receive the blood pressure drug losartan for 52 days, from January 21 to March 13, 2023, because the order was never entered on the medication record. His recorded systolic blood pressure was often in the 150s to 170s, and he reported dizziness. Other residents received expired insulin, in one case for 26 days past the expiration date, and expired Tylenol with codeine. Lorazepam was not refrigerated for 16 days. The report states these errors put residents at risk of complications including high blood pressure, stroke, hospitalization or death.

According to the report, inspectors called an immediate jeopardy on March 15, 2023, and removed it on March 16 after the facility notified the nurse practitioner, stopped the potassium and checked a potassium level, which was normal, replaced expired medications and trained nurses. The 2567 report cites F759 (severity K), on medication error rates of 5 percent or more, F760 (severity L), on significant medication errors, and F755 (severity L), on pharmacy services, procedures and records.

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