Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rancho Bellagio Post Acute during CMS and state inspections, most recent first.
Insufficient CNA staffing hours were provided when the facility failed to maintain the required 2.4 CNA DHPPD across multiple months. Record review showed CNA DHPPD was below the minimum for all of October and November, most of December, and most of January. The DSD confirmed the hours were below the required level, and the DON stated resignations, position changes, reduced hours, and call-offs contributed to the shortfall.
Licensed nurses failed to notify the physician about repeated insulin refusals for a resident with DM and diabetic neuropathy, and failed to report repeated hypotensive blood pressure readings for another resident with HF and moderate cognitive impairment. The records showed multiple consecutive insulin refusals and several BP readings below 100/60 mm/Hg, while interviews confirmed there was no documentation that the physician was notified as required by facility policy.
Failure to care plan repeated insulin refusal: A resident with type 2 DM and diabetic neuropathy repeatedly refused prescribed Humalog insulin after stating he did not believe he needed it. The MAR showed multiple refusals, but the care plan did not include timely problem statements, measurable goals, interventions, or monitoring for the insulin refusal, and the DON stated the plan should have started when the refusals began.
Nursing staff failed to follow a resident’s insulin sliding scale order for diabetes when the resident’s BS was 438 mg/dl. The MAR showed insulin lispro was not given, and there was no documentation that the MD was notified as required by the order. The LVN and DON both stated the nurse should have administered 12 units, called the MD, and documented the notification.
A resident requested copies of nursing progress notes, but the facility did not release the records within the required timeframe. The request was forwarded to the legal department due to the resident's severe cognitive impairment, but there was no documentation that the resident's representative was notified of the need for a signature, and no follow-up occurred. The records were not provided within the facility's policy timeframe.
Two residents were not given the opportunity to choose their attending physician, as required by regulation. Instead, physicians were assigned from a facility panel without informing the residents or their families of their right to select a provider or how to request an outside physician. Staff interviews revealed a lack of awareness and consistent procedures for facilitating physician choice, and facility policy confirming this right was not followed.
A resident with multiple serious health conditions experienced shortness of breath, and both family and physician requested STAT labs and a chest X-ray. Despite these orders, there was no evidence that the STAT diagnostic tests were completed as required, and the DON confirmed the orders were not carried out. The resident's condition deteriorated, resulting in a transfer to the ED. Facility policy required prompt completion of such orders, but this was not followed.
A resident with hemiplegia and hemiparesis was left in a reclining chair with the call light out of reach after being returned to their room by an activity staff member, who did not ensure a proper handoff to nursing staff. The resident was unable to request assistance and was heard calling out for help. Facility policy and the resident's care plan both required that the call light be within reach and that staff communicate when returning residents to their rooms.
A resident with dementia and a history of elopement exited a facility unsupervised through an automatic sliding door, exposing them to immediate danger. The facility failed to monitor the resident according to their care plan, and staff were unaware of the resident's high risk for elopement. The facility's policy on wandering and elopement was not followed, leading to the resident's elopement.
A resident with dementia and other conditions eloped from the facility, with discrepancies found between medical records and video footage regarding the time of departure. Staff interviews revealed inconsistencies in the reported times the resident was last seen, and a CNA was unaware of the resident's high risk for elopement. The facility's policy requires accurate documentation, which was not followed.
The facility failed to properly dispose of garbage, resulting in three dumpsters overflowing with waste and debris scattered around the area. Interviews with the Dietary Supervisor, Maintenance Supervisor, and Registered Dietitian confirmed that the dumpsters should be closed and free of debris to prevent pest infestations and infection control issues. The facility's policy requires daily inspections to ensure cleanliness and closed lids, which was not adhered to.
The facility failed to provide Advance Directive (AD) education and follow-up for three residents, risking their medical preferences not being honored. A resident with cerebral infarction, another with traumatic subdural hemorrhage, and a third with fluctuating decision-making capacity were not screened or educated about ADs. The Social Service Director acknowledged these oversights, which contradict the facility's policy requiring staff to inquire about and assist with ADs.
A LTC facility failed to meet the nutritional needs of residents on renal diets by serving inappropriate foods and incorrect portion sizes. A dietary aide served pudding instead of mandarin oranges to residents on renal diets, and a cook served pureed spinach instead of green beans to a resident on a renal pureed diet. Additionally, incorrect scoop sizes were used for serving desserts, and recipes were not followed, affecting the flavor and nutritional value of meals.
The facility failed to provide appetizing and properly tempered meals to residents, as evidenced by multiple complaints of cold, bland, or overly salty food. A test tray evaluation confirmed these issues, with the RD noting a lack of seasoning in meals. This failure placed residents at risk of decreased nutritional intake.
The facility failed to maintain safe and sanitary food preparation and storage practices, risking foodborne illness for 95 residents. Employees did not follow cleaning procedures, using only sanitizer instead of the required wash, rinse, and sanitize process. The walk-in refrigerator had buildup on shelves and dust on fan covers, and a wet container was improperly stacked with dry ones, all posing risks of cross-contamination.
A resident with GERD did not receive Nexium as prescribed for two days, despite the medication being available. The facility's eMAR confirmed the missed doses, and interviews with LVNs revealed a failure to administer the medication as per the physician's order, potentially worsening the resident's condition.
A facility failed to replace an oxygen humidifier bottle according to its policy for a resident with COPD and immunodeficiency. The nasal cannula was dated 12/7, while the humidifier bottle was dated 11/24 and was less than half filled. The LVN and infection preventionist confirmed that both should be changed every seven days to prevent cross-contamination and infection. The resident's physician orders required oxygen at 2 L/min as needed, with tubing changes every Saturday.
A facility failed to maintain medication error rates below five percent, with two incidents involving incorrect medication administration. An LVN applied a Lidocaine patch to the wrong body location on a resident, and another LVN administered Carvedilol and Metformin without food, contrary to physician orders. Both LVNs acknowledged their errors during interviews.
A CNA failed to perform hand hygiene and wear PPE while caring for a resident with C. diff, despite facility protocols requiring these measures. The resident's care plan included contact precautions, but the CNA did not comply, increasing the risk of pathogen spread.
The facility failed to maintain the dish machine's temperature within the manufacturer's guidelines, with wash temperatures recorded between 142 F and 149 F, and rinse temperatures between 172 F and 178 F. This deficiency was confirmed through observations and interviews with staff, highlighting the risk of cross-contamination and food-borne illnesses due to improperly sanitized dishes.
A resident's call light was not answered timely by a CNA, who walked past the room twice without responding, assuming the assigned nurse would handle it. The resident, who needed assistance with repositioning due to weakness, waited over 20 minutes for help. Interviews with staff confirmed that all personnel are expected to respond to call lights promptly, as per facility policy, to ensure residents' needs are met.
A resident in an LTC facility had half side rails installed on her bed instead of the quarter side rails specified in her assessment. The resident expressed discomfort and difficulty in transferring to her wheelchair due to the longer rails. The discrepancy was confirmed by the MDS coordinator and acknowledged by the DON, who noted that the installation did not align with the resident's re-admission assessment.
A CNA failed to perform hand hygiene after caring for a resident on Enhanced Barrier Precautions, potentially spreading pathogens. The CNA admitted to forgetting to wash her hands, and both the IP and DON confirmed the importance of hand hygiene to prevent infection. The resident had a care plan requiring EBP due to a PICC line, and the facility's policy mandates handwashing to prevent infection spread.
A facility failed to notify a resident's family of a change in condition within 24 hours, as required by policy. The resident, who had cognitive impairment and relied on her daughter for decision-making, experienced a change in condition on August 9, 2024, but the family was not informed until five days later. The facility's policy mandates notification within 24 hours for significant changes, which was not adhered to in this case.
The facility failed to report allegations of sexual abuse involving two residents within the required two-hour timeframe to CDPH. Resident A, with a history of depression and schizoaffective disorder, reported inappropriate touching by another resident, which was not reported by the RN or LVN to CDPH. Similarly, an allegation involving Resident C was not reported by a CNA, and the DON was unaware of the incident. The facility's policy mandates reporting all abuse allegations within two hours.
Insufficient CNA Staffing Hours
Penalty
Summary
Sufficient nursing staff were not provided to meet resident needs because the facility did not maintain the required minimum actual total CNA Direct Care Hours Per Patient Day (DHPPD) of 2.4 hours during October 2025, November 2025, December 2025, and January 2026. On January 28, 2026, the staffing records were reviewed and showed CNA staffing levels below the minimum required DHPPD on multiple dates across those months, including all of October and November, most of December, and most of January. During a concurrent interview and record review with the DSD, the facility’s Census and Direct Care Service Hours Per Patient Day report showed CNA DHPPD hours were below 2.4 hours for the entire months of October 2025 and November 2025, for 30 of 31 days reviewed in December 2025, and for 24 of 27 days reviewed in January 2026. The DSD stated the CNA DHPPD hours should be maintained at 2.4 hours to ensure safe and quality resident care. The DON stated staff resignations, position changes, reductions in hours, and call-offs contributed to the facility’s inability to meet the required CNA DHPPD hours. The facility policy titled Staffing stated the facility provides sufficient numbers of staff to provide care and services for all residents.
Failure to Notify Physician of Repeated Medication Refusals and Low Blood Pressure
Penalty
Summary
Licensed nurses failed to promptly notify the physician of repeated medication refusals for a resident with type 2 diabetes mellitus and diabetic neuropathy. Resident 8 stated he had insulin ordered but had been refusing it because he believed he did not need it. The record showed multiple consecutive refusals of Humalog insulin in December 2025 and January 2026, including refusals on several consecutive days during evening, early morning, and midday doses. The chart contained no documentation that the physician was notified of these repeated refusals. Interviews with an LVN, RN supervisor, and DON confirmed that repeated refusals should have been reported to the physician, and the facility policy stated the attending physician should be promptly notified when treatment or medications are refused two or more consecutive times. Licensed nurses also failed to notify the physician of repeated low blood pressure readings for a resident admitted with heart failure and moderate cognitive impairment. Resident 110’s record showed multiple blood pressure readings below 100/60 mm Hg over several days, including readings of 68/49, 96/52, 87/66, 98/68, 97/77, and 98/70. The care plan directed staff to monitor vital signs and report abnormal findings to the physician, and the facility policy stated hypotension below 100/60 mm/Hg should be reported. Interviews with an LVN and the DON confirmed there was no documented evidence that the physician was notified of the low blood pressure readings.
Failure to Care Plan Repeated Insulin Refusal
Penalty
Summary
The facility failed to develop a comprehensive care plan to address a resident's repeated refusal of prescribed insulin. Resident 8 was admitted with diagnoses including type 2 diabetes mellitus and diabetic neuropathy, and the record showed an order for Humalog insulin to be given on a pre-sliding scale. The resident stated in interview that he had insulin ordered but refused to take it because he believed he did not need it. The Diabetic Administration Record showed the resident first refused the prescribed insulin on December 16, 2025, and refused it a total of 23 times during December 2025. Although the comprehensive care plan included a psychosocial refusal-of-care entry with a January 16, 2026 initiation date for refusal of blood sugar checks and insulin, there was no care plan initiated on or after the first insulin refusal to address the repeated refusals. The record contained no documentation of identified problem statements, measurable goals, interventions, or monitoring related to insulin refusal between December 16, 2025, and January 16, 2026. During interview and record review, the DON stated the care plan should have been initiated when the resident first refused insulin and that continuation of care was important so staff were aware of the plan.
Failure to Follow Insulin Sliding Scale Order and Notify MD
Penalty
Summary
Nursing staff failed to follow the physician’s insulin sliding scale order for a resident with diabetes. The resident’s care plan directed staff to administer medication as ordered, perform blood glucose checks as ordered, and report to the physician if blood glucose was outside set parameters. On December 3, 2025, at 9:08 p.m., the resident’s blood sugar was documented as 438 mg/dl, which was above the ordered threshold of greater than 350 mg/dl requiring 12 units of insulin lispro and a call to notify the MD. The MAR showed that insulin lispro was not administered at that time, and the eMAR medication administration note contained no documentation that the physician was notified as required by the order. During interview and record review, the LVN and DON both stated that the nurse should have administered 12 units of insulin lispro, notified the physician, and documented that notification in the resident’s record. The DON acknowledged there was no evidence in the medical record that the physician was notified when the resident’s blood sugar was 438 mg/dl.
Failure to Timely Release Resident Medical Records Upon Request
Penalty
Summary
The facility failed to ensure that, upon written request, a resident's medical records were released within the required timeframe. A resident who had been admitted and later discharged with a diagnosis including aftercare following surgical amputation submitted a written request for copies of nursing progress notes for personal use. The request was signed and dated by the resident. The facility's Released Records Log indicated that the request was made, but there were no further notations regarding the records being provided or picked up until several months later. An internal electronic communication from the facility's legal analyst noted that the resident had severe cognitive impairment and stated that the resident's wife would need to sign the request form for the records to be released. However, there was no documentation that the resident's representative was notified of this requirement. Interviews with the Medical Records Director (MRD) and the Director of Nursing (DON) confirmed that the process for releasing records involves verification, legal department approval, and release within two business days. The MRD acknowledged that after forwarding the request to the legal department, there was no follow-up with the resident's wife when she did not arrive to pick up the records, and the records were not provided within the required timeframe. The DON also confirmed that the records should have been provided within two business days of the request, as per facility policy.
Failure to Ensure Resident Right to Choose Attending Physician
Penalty
Summary
The facility failed to ensure that residents were afforded their right to choose their attending physician, as required by federal and state regulations. For two residents, the facility assigned attending physicians from a pre-selected panel without involving the residents or their families in the decision-making process. In one case, a resident with multiple complex medical conditions, including immunodeficiency, diabetes, hypertension, COPD, and cancer, was admitted under the care of a physician from the facility's panel, despite the resident's family requesting a different physician who had previously cared for the resident for 27 years. The family was informed by the business office that only panel physicians could be selected and was not provided with instructions on how to request an outside physician. Facility staff, including the Director of Business Development, Medical Records Director, and Social Services Director, were unaware of the family's request and did not facilitate the process for credentialing or reactivating the requested physician, who had previously been credentialed at the facility but was no longer active in the system. In another instance, a resident admitted for physical therapy following a hospital stay was assigned an attending physician from the facility's panel without being informed of the right to choose a physician. The resident reported not being involved in the selection process and was unaware that such a choice was available. Interviews with facility staff revealed a lack of consistent procedures for informing residents of their rights regarding physician choice and for processing requests for non-panel physicians. Staff responses indicated that requests for outside physicians would require written statements and credentialing, but there was no evidence that residents or families were guided through this process. A review of the facility's policy confirmed that residents have the right to choose their attending physician and participate in care decisions. However, the facility's practice of assigning physicians from a limited panel, without informing residents of their rights or providing a clear process for requesting outside physicians, resulted in residents not being involved in the selection of their attending physician. This deficiency was identified through interviews, record reviews, and policy examination, demonstrating a failure to uphold residents' rights as outlined in facility policy and regulatory requirements.
Failure to Complete STAT Diagnostic Orders as Directed
Penalty
Summary
The facility failed to ensure that STAT chest radiology and laboratory orders were completed as ordered by the physician for a resident with multiple complex medical conditions, including immunodeficiency, anemia, diabetes, hypertension, COPD, cancer, and chronic kidney disease. The resident experienced shortness of breath, and both the family and physician requested STAT labs and a chest X-ray. Despite these orders, there was no documented evidence that the STAT X-ray and laboratory tests were performed as required. The DON confirmed during an interview and record review that these orders should have been completed within a couple of hours but were not carried out. Subsequently, the resident's condition worsened, with documented desaturation and altered mental status, leading to a transfer to the emergency department. Facility policy required prompt action for emergency diagnostic orders, but this was not followed in this case. The deficiency was identified through interviews and record reviews, which confirmed the failure to carry out STAT diagnostic orders as instructed by the physician.
Call Light Not Accessible to Resident After Return from Activities
Penalty
Summary
A deficiency occurred when a resident's call light was not within reach, preventing the resident from being able to request assistance from nursing staff. Certified Nursing Assistants (CNAs) and the Director of Nursing (DON) confirmed that call lights should always be accessible to residents. On observation, the resident was found sitting in a reclining chair at the foot of the bed, with the call light placed at the head of the bed, out of reach. The resident was heard calling out for help and expressed a desire to go to bed. Staff interviews revealed that the resident had been returned to the room by an Activity Assistant (AA) after group activities, who activated the call light to notify nursing staff but did not wait for staff to respond or ensure the call light was within the resident's reach before leaving. The Activities Director (AD) stated that activity staff are required to hand off care directly to nursing staff when returning a resident to their room, a process that was not followed in this instance. The resident's care plan indicated a need for assistance with activities of daily living and encouraged the use of the call light for help. Facility policy also required that call lights be within easy reach of residents when in bed or confined to a chair. The resident involved had a history of diabetes mellitus, hemiplegia, and hemiparesis, and was at risk for decline in mobility and activities of daily living.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to a resident diagnosed with dementia and a history of elopement. The resident exited the facility through an automatic sliding door that led directly to a parking lot and a two-way street, exposing them to immediate danger. The resident was not monitored according to their care plan, which required frequent checks due to their high risk of elopement. On the day of the incident, the resident was last seen by staff at 4 p.m. in their room, but was not located during a subsequent check at 5 p.m. Video surveillance footage showed the resident leaving the facility at 3:08 p.m. without re-entering. Staff interviews revealed that the resident's risk for elopement was not communicated effectively among the staff, and the automatic sliding door was left open, allowing the resident to exit unsupervised. The facility's policy on wandering and elopement was not followed, as there was no documented evidence of frequent monitoring of the resident's whereabouts. Staff members were unaware of the resident's high risk for elopement, and the necessary interventions to prevent such incidents were not implemented. This lack of supervision and communication led to the resident's elopement and subsequent exposure to potential harm.
Removal Plan
- Facility followed the policy and procedure in searching for the resident missing upon knowledge of resident not being in the facility.
- Staff searched inside the facility while other staff searched around the vicinity. The facility notified the police department as well calling emergency rooms around the area and called the homeless shelter where she was at prior, to see if she checked in there. Staff continued driving around the area to search for the resident.
- The facility created a plan to close BC wing sliding door and have a designated staff to monitor the door. Signage was also placed of the time the sliding door will be closed and when it will be available for entrance and exit.
- In-services were given by the RN supervisor and the Director of Staff Development to staff regarding the facility policy and protocol on elopement and wandering of the residents, as well as, providing staff an update on the plan discussed by IDT.
- The DON reviewed all current residents who were at high risk for elopement. The facility identified 1 resident. This resident was placed on 1:1 sitter immediately.
- Facility identified all residents who are considered high risk for elopement and necessary interventions were placed such as 1:1 Sitter, activity monitoring every hour, every two hours. The Emergency IDT meeting with all the department managers was held to discuss a plan to prevent resident elopement.
- The facility created an elopement risk binder with the face sheet and photos of residents who are high risk for elopement and this binder is kept in nursing station and in the front lobby with the receptionist, for the staff to be aware of the residents at risk for elopement. Binders are updated by the DON and updated as needed.
- On admission a wandering evaluation will be conducted and when resident scores 10 and above or noted to have high risk of wandering, staff will initiate preventative measures and ensure proper documentation and notify DON accordingly.
- The maintenance supervisor or designee will check all the emergency doors, making sure the alarm is placed and working daily. Any findings will be corrected immediately.
- Facility Administrator contacted wander guard vendor for installation quotes and installing schedule. Estimated installation schedule is anticipated to be completed.
- The maintenance supervisor will conduct random checks on different shifts to monitor the alarms of the emergency door and report the response time of the staff when the alarm goes off biweekly for 3 months.
- Findings will be reported during the QA Meeting to monitor trends and compliance.
- The DON will report on monthly QA those residents at risk for elopement or any resident identify score of 10 or above on elopement assessment and discuss effectiveness of measure provided and monitor for trends.
Inaccurate Documentation of Resident's Whereabouts
Penalty
Summary
The facility failed to ensure accurate documentation for a resident, as discrepancies were found between the resident's medical records and video surveillance footage. The resident, who had diagnoses of dementia, paranoid schizophrenia, and psychoactive substance abuse, was recorded in the medical records as last seen at 3:45 p.m. on December 20, 2024, while video footage showed the resident leaving the facility at 3:08 p.m. This discrepancy resulted in an inaccurate account of the resident's whereabouts, potentially impacting the accuracy of their care documentation. Interviews with staff revealed inconsistencies in the reported times the resident was last seen. A CNA reported the resident missing at 5 p.m., stating she last saw the resident between 3:45 p.m. and 4 p.m., while an LVN mentioned seeing the resident at 2:30 p.m. before attending a meeting. The facility's policy on charting and documentation requires that records be objective, complete, and accurate, which was not adhered to in this case. Additionally, the CNA was unaware of the resident's high risk for elopement, indicating a lack of communication regarding the resident's care needs.
Improper Garbage Disposal and Overflowing Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal of garbage, as observed on December 8, 2024. During an inspection of the dumpster storage area, it was noted that three dumpsters were overflowing with garbage and cardboard boxes, and their lids could not be closed. Additionally, debris was scattered around the dumpsters. This situation was confirmed during interviews with the Dietary Supervisor, Maintenance Supervisor, and Registered Dietitian, all of whom acknowledged that the dumpsters should be closed and free of surrounding debris to prevent pest infestations and potential infection control issues. The facility's policy, titled 'Miscellaneous Areas: Garbage and Trash Procedure,' dated 2023, mandates daily inspections to ensure that no debris is on the ground or surrounding area and that dumpster lids are closed. The policy highlights that the trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. The failure to adhere to this policy was evident in the observations and interviews conducted, indicating a lapse in maintaining the cleanliness and proper management of the dumpster area.
Failure to Provide Advance Directive Education
Penalty
Summary
The facility failed to provide Advance Directive (AD) education, materials, and follow-up for three residents, which could potentially lead to their medical preferences not being honored during critical healthcare decisions. Resident 35, who was admitted with a diagnosis of cerebral infarction, was found to have the capacity to make decisions but was not screened or provided with AD education. The Social Service Director (SSD) confirmed that Resident 35 was not screened or educated about ADs, acknowledging the potential risk of not honoring the resident's preferences. Similarly, Resident 69, admitted with a traumatic subdural hemorrhage and moderate cognitive impairment, was not screened or provided AD education. The SSD admitted that AD discussions were not held during the IDT meeting. Resident 19, with fluctuating decision-making capacity, also did not receive AD education or resources. The SSD acknowledged the importance of providing AD resources and education, yet failed to do so for Resident 19. The facility's policy requires staff to inquire about ADs and offer assistance if none exist, but this was not followed for these residents.
Menu and Recipe Non-Compliance in LTC Facility
Penalty
Summary
The facility failed to ensure that the lunch menu on December 9, 2024, met the nutritional needs of residents on renal diets. Dietary Aide 1 served pudding instead of mandarin oranges to five residents on a renal diet, which was not in accordance with the menu and physician orders. The pudding contained high phosphorus content, which could be harmful to residents with kidney disease. The Dietary Supervisor confirmed that the residents should not have received pudding, and the Registered Dietitian emphasized the importance of following the menu to meet residents' nutritional needs. Additionally, Cook 1 served pureed spinach instead of green beans to a resident on a renal pureed diet. Spinach is high in potassium, which may not be safe for residents with kidney disease. Cook 1 admitted to not checking the meal card or following the menu, which led to the incorrect food being served. The Dietary Supervisor and Registered Dietitian both confirmed that the resident should not have been served spinach due to its high potassium content. Furthermore, Dietary Aide 1 used an incorrect scoop size to serve dessert, resulting in portions that were almost double the intended size. This could lead to residents receiving too many calories. Cook 1 also failed to follow the recipe for garlic parmesan spinach, resulting in a lack of flavor, which could lead to residents not wanting to eat the food. The Registered Dietitian noted that not following recipes could result in low calorie intake or malnutrition.
Failure to Provide Appetizing and Properly Tempered Meals
Penalty
Summary
The facility failed to adhere to its Meal Service policy, resulting in the provision of unappetizing and improperly tempered food to 14 of 96 sampled residents. Multiple residents reported that the food served was cold, bland, or overly salty, and did not match the menu. Specific complaints included food being cold at all meals, food tasting bad or bland, and inconsistencies in seasoning. A test tray evaluation confirmed these issues, with the Registered Dietitian noting a lack of seasoning in the Garlic Parmesan Cheese Spinach, which was supposed to contain garlic and parmesan cheese. The Registered Dietitian acknowledged that the cooks did not follow recipes, which contributed to the unappealing and unpalatable meals. This failure to provide appetizing food at appropriate temperatures placed residents at potential risk of decreased nutritional intake, which could affect their nutritional status. The facility's policy indicated that meals should meet the nutritional needs of residents and be served at appropriate temperatures, but this was not consistently achieved, as evidenced by the residents' feedback and the test tray evaluation.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen, which had the potential to cause foodborne illness among the 95 residents receiving food prepared there. Food and Nutrition Service employees did not adhere to the facility's cleaning procedures for food preparation surfaces and stationary equipment. Specifically, employees were observed using only sanitizer instead of the required wash, rinse, and sanitize process. This deviation from protocol was confirmed through interviews with the Dietary Supervisor and several kitchen staff members, as well as the Registered Dietitian, who emphasized the risk of cross-contamination and foodborne illness due to improper cleaning. Additionally, the facility's walk-in refrigerator had unsanitary conditions, including buildup on storage shelves and dust on fan covers, which were verified by the Dietary Supervisor. These conditions posed a risk of cross-contamination and mold growth. Furthermore, a wet plastic container was improperly stacked with dry containers, which could create an environment for bacterial growth. The facility's policies and procedures for sanitation and dishwashing were not followed, as confirmed by the Registered Dietitian, who highlighted the potential for cross-contamination and foodborne illness due to these oversights.
Failure to Administer Nexium as Prescribed
Penalty
Summary
The facility failed to administer the medication Nexium to a resident according to the physician's order, which was intended to manage the resident's gastroesophageal reflux disease (GERD). The resident, who was admitted with diagnoses including gastroparesis and GERD, reported experiencing nausea and stated that she had not received her Nexium medication for two consecutive days. The physician's order specified that Nexium should be given in the morning before breakfast, but the electronic Medication Administration Record (eMAR) confirmed that the medication was not administered on the specified dates. Interviews with the facility's licensed vocational nurses (LVNs) revealed that the medication was not available on the days it was missed, despite having been delivered earlier in the month. The facility's policy on administering medications requires that medications be administered safely, timely, and as prescribed, which was not adhered to in this instance. This oversight had the potential to exacerbate the resident's GERD condition.
Failure to Replace Oxygen Humidifier Bottle as Per Policy
Penalty
Summary
The facility failed to replace the oxygen humidifier bottle in accordance with its policy and procedure for a resident receiving respiratory care. During an observation and interview, it was noted that the nasal cannula was labeled with a date of 12/7, while the humidifier bottle was labeled with the date 11/24 and was less than half filled. The Licensed Vocational Nurse (LVN) stated that both the nasal cannula and humidifier bottle should be changed every seven days, but it appeared they were not changed together as required. This discrepancy was confirmed by the infection preventionist, who reiterated the importance of changing these items every seven days to prevent cross-contamination and infection. The resident involved had a medical history that included immunodeficiency and Chronic Obstructive Pulmonary Disease (COPD), conditions that make them more susceptible to infections and respiratory issues. The resident's physician orders indicated the use of oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath, with instructions to change the oxygen tubing every shift on Saturdays. The facility's policy on respiratory equipment, revised in November 2011, specified changing the pre-filled humidifier when the water level is low and the oxygen tubing every seven days or as needed. The failure to adhere to these guidelines posed a risk of ineffective oxygen therapy and potential health decline for the resident.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that medication error rates were below five percent, as evidenced by two specific incidents involving medication administration errors. In the first incident, a Licensed Vocational Nurse (LVN) applied a Lidocaine patch to the wrong body location on a resident. The physician's order specified that the patch should be applied to each knee for pain management, but the LVN applied it to the resident's back near the right shoulder blade. The LVN acknowledged the error during an interview and stated that if the resident was experiencing pain in a different area, the physician should have been contacted to change the application site. In the second incident, another LVN administered Carvedilol and Metformin to a resident without food, contrary to the physician's orders. The orders specified that both medications should be given with food or a meal. The LVN admitted during an interview that she did not follow the physician's instructions to administer the medications with food. The facility's policy on medication administration procedures emphasized the importance of administering oral medications safely and accurately, including the requirement to provide food when necessary for certain medications.
Infection Control Breach Due to Non-Compliance with PPE and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection control measures when a Certified Nurse Assistant (CNA) did not perform hand hygiene or wear personal protective equipment (PPE) upon entering and while providing care to a resident who was positive for Clostridium Difficile infection (C. diff). This incident was observed on December 10, 2024, when the CNA entered and exited the resident's room without washing hands or donning PPE, despite the presence of a contact precaution sign on the wall. The CNA acknowledged the requirement for hand hygiene and PPE use, stating that she should have washed her hands and worn gloves and a gown to prevent the spread of pathogens and infection. The resident involved was admitted with a diagnosis of enterocolitis due to C. diff, and their care plan included isolation with contact precautions. The facility's policies and procedures, as well as the infection preventionist's statements, emphasized the necessity of hand hygiene and PPE use to prevent cross-contamination and infection. However, these protocols were not followed by the CNA, as evidenced by the observation and the CNA's admission of non-compliance.
Dish Machine Temperature Deficiency
Penalty
Summary
The facility failed to maintain the dish machine's temperature within the manufacturer's guidelines, which is essential for effective cleaning and sanitization of dishes. During an observation and interview, it was noted that the dish machine's wash temperature was recorded at 143 F and the rinse temperature at 175 F, both below the manufacturer's recommended minimums of 150 F for wash and 180 F for rinse. Subsequent observations confirmed that the temperatures remained below the required levels, with the wash temperature fluctuating between 142 F and 149 F, and the rinse temperature between 172 F and 178 F. Interviews with the Maintenance Supervisor, Infection Preventionist, and Registered Dietitian confirmed the importance of maintaining the correct temperatures to prevent cross-contamination and food-borne illnesses. The facility's policy and procedure for dishwashing also emphasized the need for the dish machine to operate within the manufacturer's temperature guidelines. Despite these guidelines, the dish machine consistently failed to meet the required temperatures, posing a risk to the 95 residents who could be exposed to improperly sanitized dishes.
Failure to Respond Timely to Resident's Call Light
Penalty
Summary
The facility failed to ensure timely response to a resident's call light, which was observed during an unannounced visit. A Certified Nursing Assistant (CNA) was seen walking past the resident's room twice without responding to the call light, despite having no other residents to assist at the time. The CNA acknowledged seeing the call light but assumed the nurse assigned to the room would respond. The CNA admitted that he should have answered the call light immediately, regardless of room assignment, to check on the resident and communicate any needs to the appropriate staff. This inaction placed the resident at risk for harm or injury, as immediate help would not have been known if needed. The resident involved was alert and oriented, having pressed the call light over 20 minutes prior to receiving assistance. The resident required help with repositioning due to weakness and discomfort. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Staff Development (DSD) confirmed that all staff were expected to respond to call lights promptly, regardless of room assignment, to avoid delays in meeting residents' needs. The facility's policy, dated October 2010, also emphasized the importance of answering call lights as soon as possible. The resident's care plan indicated a risk for decline in activities of daily living and mobility, necessitating staff assistance to meet her needs.
Incorrect Bed Rail Installation for a Resident
Penalty
Summary
The facility failed to ensure the correct size bed rails were installed on a resident's bed as indicated in the resident's bed rails admission assessment. This deficiency was identified for one of seven sampled residents, referred to as Resident 2. Upon observation and interview, it was found that Resident 2 had half side rails installed on her bed instead of the quarter side rails specified in her assessment. Resident 2 expressed discomfort with the longer side rails, stating they made her feel closed in and hindered her ability to transfer to her wheelchair. The discrepancy was confirmed by the Minimum Data Set (MDS) coordinator, who noted that the half side rails could potentially make the resident feel entrapped and limit her mobility. Further investigation revealed that the facility's standard practice involved assessing residents for side rail use upon admission, with quarter side rails being the standard unless a change was requested by the resident or family. The Director of Nursing (DON) acknowledged that Resident 2's re-admission assessment indicated the need for quarter side rails, and the installation of half side rails was not in accordance with the assessment. The facility's policy on bed safety and bed rails emphasized the importance of resident assessments to determine the risk of entrapment and other hazards, which was not adhered to in this case.
Infection Control Lapse Due to Inadequate Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection control practices when a Certified Nurse Assistant (CNA) did not perform hand hygiene after providing care to a resident on Enhanced Barrier Precautions (EBP). On October 31, 2024, the CNA was observed removing her gown and gloves and exiting the resident's room without washing her hands. She then proceeded to handle a meal tray cart, potentially spreading pathogens. During an interview, the CNA admitted to forgetting to wash her hands and acknowledged the risk of cross-contamination and infection spread. The Infection Preventionist (IP) and the Director of Nursing (DON) both confirmed that hand hygiene is mandatory before and after patient care to prevent infection transmission. The resident involved had a care plan indicating the use of EBP due to a peripherally inserted central catheter (PICC) and was at risk for complications. The facility's handwashing policy, dated August 2019, requires all personnel to follow hand hygiene procedures to prevent infection spread. This incident highlights a lapse in adherence to these procedures, posing a risk to resident safety.
Failure to Notify Family of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the family of a resident about a change in the resident's condition within the required 24-hour period. On August 9, 2024, a change in the resident's condition was documented, specifically the onset of diarrhea, which was reported by a CNA. Despite the resident's cognitive impairment, indicated by a BIMS score of 10, and the resident's reliance on her daughter for decision-making, the facility did not notify the resident's family until August 14, 2024, five days after the change in condition was noted. The facility's policy requires that a resident's representative be notified within 24 hours of a significant change in the resident's condition. However, the records show that the notification was delayed, and there was no documentation of the family being informed on the day of the change. The RN confirmed that the resident's cognitive impairment necessitated notifying the resident's representative, which was not done in a timely manner, as per the facility's policy.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse within the required two-hour timeframe to the California Department of Public Health (CDPH) for two residents. Resident A reported being inappropriately touched by another resident, Resident B, three weeks prior. Despite the report being made to the Registered Nurse (RN) and Licensed Vocational Nurse (LVN) on May 26, 2024, the incident was not reported to CDPH within the mandated time. The Director of Nursing (DON) was informed but did not report the incident, believing it did not occur. Resident A had a history of depression and schizoaffective disorder, with a cognitive impairment score indicating moderately impaired cognition. Additionally, Resident C was reported by another resident, Resident D, to have been inappropriately touched by Resident B. This allegation was made to a Certified Nursing Assistant (CNA), who did not report it to her supervisor, assuming it had already been reported. The DON was unaware of this incident, and there was no documentation of an investigation or report to CDPH. Resident C had a diagnosis of major depressive disorder. The facility's policy requires all allegations of abuse to be reported within two hours, regardless of the perceived validity of the claim.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Moreno Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Village Healthcare Center | 8 mi | ★★★★★ | 4 | 0 |
| Centinela Grand Inc | 8.2 mi | ★★★★★ | 2 | 0 |
| Redlands Comm Hosp D/p Snf | 8.7 mi | ★★★★★ | 8 | 0 |
| Redlands Healthcare Center | 8.7 mi | ★★★★★ | 6 | 0 |
| Madison Grove Post Acute | 8.8 mi | ★★★★★ | 17 | 0 |
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