Rialto Post Acute Center

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse to the California Department of Public Heath (CDPH) for one of three sampled residents (Resident 1), when Resident 1 claimed she was sexually abused by a treatment nurse (TN). This failure had the potential to place Resident 1 at risk for further abuse and physical or psychological harm. During a review of Resident 1's admission Record (form with health information), the admission Record indicated an admission date of June 4, 2026, with diagnoses which included history of falling, left artificial hip joint (a man made part that replaces the natural hip when it is damaged), and type 2 diabetes mellitus (when the body cannot process sugar appropriately and results in too much sugar in the bloodstream). [...]

Inspectors wroteBased on interview and record review, the facility failed to identify signs of developing pressure ulcer (a tissue damage that results in full thickness loss of skin) in a timely manner for one of three sampled residents (Resident 1). This failure had the potential for Resident 1's pressure ulcer to worsen due to not receiving the proper treatment that it needs.

Inspectors wroteBased 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. As a result, Resident 175 was found by the local police approximately one mile from the facility and was then transported by ambulance to the hospital for evaluation. This failure placed Resident 175 at risk for serious harm, injury or death including but not limited to traffic injury, exposure to environmental hazards, and inability to seek help. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents were provided with a dignified dining experience for two of six sampled residents (Resident 94 and 185) when Certified Nursing Assistants (CNA 1, 2, and 4) were standing over residents while assisting them to eat. This failure has the potential to cause Residents 94 and 185 to feel disrespected and negatively affect their psychosocial well-being and individuality. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure confidentiality of resident's Electronic Health Records (EHR- medical records kept on a computer system) when a Licensed Vocational Nurse (LVN 7) left Resident 96's health information on the computer screen, unattended and visible to the public in the hallway. This failure had the potential to place Resident 96's private information to be at risk of being disclosed by an unauthorized person. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan (a personalized, written document that details an individual's health conditions, specific needs, goals, preferences, and the support required to achieve them) for two of ## sampled residents (Residents 162 and 23) was developed and implemented when: Resident 161 did not have a care plan allowing medication at his bedside. Resident 23 did not have a care plan for smoking. These failures had the potential for Resident 161 and Resident 23 to be at risk of injury, due to delayed intervention and supervision.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications (medications that are controlled by government due to potential abuse or addiction) for one of six sampled medication carts (Medication Cart A-1) with narcotics when the Narcotic Count Sheet (a narcotic log used by the facility to verify counting of controlled medications at the change of shift, signed by the incoming and outgoing licensed nurses) had one missing signature for the outgoing licensed nurse on January 2, 2026,This failure had the potential to result in drug diversion (illegally obtaining or using prescription drugs), undetected medication discrepancies, or medication errors which could compromise the health and safety for the vulnerable population of 159 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure storage of medications were properly secured for one of 12 medication carts (Medication Cart A-1) when one Licensed Vocational Nurse (LVN 7) left the medication cart keys, on top of the medication cart, unattended in the hallway in Wing A. This failure had the potential to result in unauthorized access to medications, including controlled substances, which could result in medication diversion (illegally obtaining or using prescription drugs), unauthorized access, misuse, and harm to a highly vulnerable population of 159 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician-ordered therapeutic diet was provided for one of six sampled resident (Resident 7), when nutritional supplements (Health shake and Sherbert) listed on the meal ticket were omitted in the lunch tray. This failure had potential to place Resident 7 at risk for weight loss and nutritional decline. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when: One Certified Nursing Assistant (CNA 6) entered Resident 184's room, without performing hand hygiene and used the same gloves after emptying Residents 67's urinal (portable container, often bottle-shaped used to collect urine for urination) to turn off the call light,Resident 184's intravenous catheter (IV- a small, flexible plastic tube that a healthcare provider puts into a vein to deliver fluids, medicine, nutrition, or blood directly into the bloodstream) on the left wrist was found unlabeled. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light (a device that allows patients to communicate with nursing staff when they need assistance) was within reach for two of 32 sampled residents (Resident 24 and 120). This failure had the potential to place Residents 24 and 120 at risk of harm when they are unable to summon staff during an emergency or when needing assistance. 1. During a review of Resident 120's admission Records (a document that gives a summary of resident information), the admission Records indicated, Resident 120 was admitted to the facility on [DATE], with diagnoses which included, end stage renal disease, (chronic kidney disease where kidneys lose almost all function) and history of falling. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to cross check discharge medications according to the facility policy for one of four residents (Resident 4), when a Licensed Vocational Nurse (LVN 1) improperly transferred Resident 4's Atorvastatin (a medication intended to lower cholesterol and prevent strokes, heart attacks, and chest pain), as well as Eliquis (a blood thinner that reduces blood clotting) to the caregiver of Resident 1 during discharge, despite Resident 1 not being prescribed these medications. This failure led to the loss of medications and increased the risk of a stroke for Resident 4, while also exposing Resident 1 to potential adverse effects from the medications, which could result in injury and harm.

Inspectors wroteBased on interview and record review, the facility failed to uphold the dignity of one of three residents (Resident 1) when two Certified Nursing Assistants (CNAs) were observed by a surveyor exposing resident 1 ' s body while assisting with transferring Resident 1 in bed. This failure has the potential to expose clinically compromise Resident 1 to the public when they pass by the room.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to report two of three sampled residents (Resident 1 and Resident 2) per their policy and procedure to the California Department of Public Health (CDPH) of alleged abuse, when a staff member allegedly twisted Resident 1's wrist and when a Certified Nurse Assistant (CNA) allegedly pushed Resident 2's leg forcibly while on a mechanical lift resulting in pain . This failure has potential to affected (Resident 1 and Resident 2)'s health, safety, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was able to exercise the right to access personal and medical records for one of three residents (Resident 1), when medical records for Resident 1 were requested by a law firm for a legal matter but were not delivered within two working days of the request as per the facility's policy. This failure resulted in a violation of Resident 1's right to have access to medical records as requested by a law firm.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to protect a resident's right to be free from resident-to-resident physical abuse for 1 (Resident #216) of 3 residents reviewed for abuse. Specifically, Resident #88 hit Resident #216 with a plastic water pitcher after a verbal disagreement on 11/09/2024.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 3 (Residents #22, #97, and #119) of 33 residents reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure potentially hazardous medications were secured to prevent potential accidents for 2 (Resident #104 and Resident #75) of 3 residents reviewed for accidents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide urinary catheter care in a manner to minimize the potential for urinary tract infection (UTI) or other complications for 1 (Resident #52) of 2 residents reviewed for urinary catheter care and services. Facility staff failed to follow clean technique and rinse the soap from the resident's skin during urinary catheter care and failed to properly position the urinary catheter drainage bag to facilitate drainage.

Inspectors wroteBased on interview and record review, the facility failed to report a discoloration on back of head for one of three sampled residents (Resident 1) per there policy and procedure to the state agency for an unusual occurrence for (Resident 1). This failure has the potential to put (Resident 1) health, safety, and well-being at risk.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) had retained use of personal possessions when Resident 1 was moved from her previous room to her new room, but the facility left her belongings in the previous room while being occupied by a newly assigned resident (Resident 2). This failure had the potential for Resident 1's personal belongings to be inappropriately used by another resident and prevent Resident 1 to retain personal use of her possessions.

Inspectors wroteBased on interview and record review the facility failed to follow their Policy when the licensed nurse failed to follow physician medication order for one of three sampled Residents (Resident 1) This failure had the potential to place a clinically compromised Residents (Resident 1) health and safety at risk. When not getting glucose checks as ordered and not receiving the necessary insulin as prescribed by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with respect and dignity when two staff members (Registered Nurse [RN 1] and Certified Nursing Assistant [CNA 1]) were yelling and arguing in front of her in her room. This failure compromised Resident 1's dignity and environment, which had the potential for Resident 1 to experience psychosocial harm (mental harm and suffering).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) when there were missing documentation for bowel and bladder elimination for one of three sampled residents (Resident 1). These failures had the potential to cause unsafe conditions and poor quality of life for Resident 1.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. There was a black grime and grease build-up in between and behind the oven and stove, and trash on the floor behind the stove. 2. A microwave available to heat resident food was not kept in sanitary condition, which could be transferred to resident food during reheating. 3. There was water dripping from black rubber drainage pipe of the freezer fan and turned into ice on top of the sealed raw roast beef in the walk-in freezer. These failures had the potential to attract pests, contaminate residents' food, and cause foodborne illnesses to a population of 134 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper disposal of garbage and refuse when four of five of the dumpsters were overflowing with bags of trash. This failure had the potential to attract insects and pests that could affect the health and safety of a highly vulnerable population of 139 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS- a facility assessment tool) assessment was completed and submitted to the Centers of Medicare and Medicaid Services (CMS) in accordance with federal submission timeframes, for one resident reviewed for resident assessment (Resident 1). This failure resulted in inadequate monitoring of Resident 1's progress and decline, and the lack of resident specific information to CMS for payment and quality measure monitoring.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was re-evaluated after a Significant Change in Status Assessment (SCSA- a comprehensive Minimum Data Set [MDS- a facility assessment tool] assessment done for a resident that must be completed when a resident meets the significant change guidelines for either improvement or decline), for two of two residents reviewed for PASRR (Residents 109 and 118). These failures had the potential for Residents 109 and 118 not to receive the care and services most appropriate for their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate intervention was provided after a dialysis treatment (process of removing excess water and cleaning the blood in people whose kidneys no longer work) for one of three residents reviewed for dialysis (Resident 81) when Resident 81's dialysis access dressing was not removed in a timely manner for two consecutive days. This failure had the potential for infection and/or clotting to Resident 81's dialysis access site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure insulin (drug used to lower blood sugar) was used in accordance with manufacturer's recommendations or direction for storage, use, and disposal for three of 37 residents receiving insulin (Residents 102, 32, and 124) when: 1. Resident 102's insulin was actively in use and available past the manufacturer's beyond-use date (BUD- last date a product can be safely used after it has been altered for patient use). 2. Resident 32's and 124's insulins were actively in use and available without an open date. These failures had the potential for Residents 102, 32, and 124 to receive insulin with reduced potency which could cause inadequate blood sugar control. These may result in the physician increasing insulin doses based on the blood sugar results placing the residents at risk for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents reviewed for environment (Resident 34), was provided with a functioning call light (system used by resident to signal a need for assistance from staff). This failure had the potential for Resident 34 to have unidentified care concerns and/or needs, which had the potential to deprive him of care.