Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rancho Mirage Health And Rehabilitation Center during CMS and state inspections, most recent first.
Inadequate assessment and monitoring before lorazepam orders: A resident with anxiety and impaired decision-making capacity received PRN lorazepam without a documented pre-order assessment, target behavior, or explanation for the order. The record also showed combative and striking-out behaviors, but the LNs did not document monitoring or evaluation before a routine lorazepam order was obtained for anxiety manifested by striking out, and the eMAR lacked target-behavior documentation for administered doses.
Failure to assess and report combative incident with skin discolorations: A resident with dementia became increasingly agitated and extremely combative during care, hitting, scratching, biting, and kicking. The incident was not documented as reported to the LPN on duty, and there was no record of a prompt assessment, physician notification, or family notification. The next day, staff observed multiple fading purplish yellow discolorations on the resident’s face and arms, and interviews confirmed the prior shift had not communicated the event.
Expired COVID-19 test kits were found in two medication rooms during surveyor observations. An LVN in one room and another LVN in the second room acknowledged the expired kits, and the IP confirmed they were expired. The CP stated expired kits should be discarded in the medication waste bin, while the IP stated the facility had no policy for expired supplies and that expired kits were supposed to be discarded one week before expiration. The DON stated the kits should not have been in the medication rooms and could cause false readings if used.
Improper labeling and storage of DuoNeb was observed in two medication carts. One resident’s opened DuoNeb box had an open date that did not match the pharmacy fill date, and another resident’s DuoNeb box had no open date at all. In addition, DuoNeb doses for a resident were stored in a clear plastic bag instead of the foil pouch required to protect the medication from light. The LVN, CP, DSD, and DON all acknowledged the labeling and storage problems.
Food Served at Improper Temperatures: Multiple residents reported that hot foods were cold or not hot enough and that cold foods were not cold as expected. During meal service observation, trays were held briefly before being covered and sent to meal carts, and two tested items measured below the facility's expected hot-holding temperature of 120 F. The DM and RD stated the temperatures did not meet expected standards and that food should be served promptly at appropriate temperatures.
An LVN failed to follow EBP for a resident with a G-tube by not wearing a gown during medication administration. The same staff member also failed to wipe the tip of a prefilled insulin pen before attaching the needle for one resident and did not properly disinfect a shared glucometer between two residents, using alcohol swabs instead of approved disinfecting wipes. Facility staff stated gowns were required for G-tube care and that the glucometer needed approved sanitizing wipes between residents.
Delayed Meal Service Affected Resident Dignity: A resident seated with two other residents in the dining room did not receive her meal tray at the same time as the others and waited about 11 minutes while they began eating. CNA stated the tray was not ready, and the RD confirmed residents seated together were expected to receive meals at the same time to preserve dignity and avoid leaving residents waiting while others ate.
Failure to Notify Resident of Grievance Findings: A resident with depression and intact cognition filed a grievance after a physician allegedly called her a troublemaker, but she reported no follow-up. The grievance form was incomplete, the SSD did not complete follow-up after speaking with the physician, and the DON confirmed the resident was not informed of the outcome and the grievance remained unresolved.
Medication Given Without Ordered Food: An LVN administered metoprolol tartrate to a resident with only water, despite the physician’s order to give it with food. The LVN stated food was not given because it was too early for dinner, while the CP, DSD, and DON all confirmed the medication should have been administered with food or with a meal/snack as ordered.
A resident with metabolic encephalopathy, significant hearing loss, and impaired decision-making capacity relied on bilateral hearing aids, with the care plan directing staff to apply them each morning and remove and store them at bedtime. A family member discovered that one hearing aid was missing, and staff later found it damaged in the laundry, indicating it had not been removed and safeguarded before clothing was laundered. During observation, the resident wore only one hearing aid and did not respond to a CNA until a family member repeated the question loudly. The LS, LVN, DON, and a CNA all described expectations that CNAs and laundry staff check clothing for personal items and that hearing aids be removed before showers and stored securely, and facility policy assigned licensed nurses responsibility for hearing aid removal and storage and prohibited exposure to moisture, but these procedures were not followed, leading to the device’s damage.
A cognitively impaired, wheelchair-bound resident with hemiplegia and hemiparesis was allowed to exit through automatic doors to an unsupervised front patio and parking lot area that lacked caution signage, barriers, or staff monitoring. The resident’s MDS showed moderate cognitive impairment, but the care plan did not include interventions for injury risk related to impaired cognition. While self-propelling in the parking lot, the resident was struck on the side of the wheelchair by a backing SUV whose driver did not see the resident, resulting in elbow pain. Multiple staff, including the DON, LVNs, CNA, and COTA, acknowledged that cognitively impaired residents required supervision outside and should not be in the front patio or parking lot alone.
A resident recovering from joint replacement surgery was awakened late at night by a CNA, at the direction of an RN, to discuss a non-urgent room change, despite facility policy and standard practice to address such matters when residents are awake. This action failed to respect the resident's dignity and right to self-determination.
A resident at risk for falls due to impaired mobility and a history of falls was not provided with a tab monitor while in a wheelchair, as required by the care plan. The resident experienced a fall after attempting to ambulate without assistance. Staff interviews confirmed the oversight, and facility policy mandates the use of tab alarms for such residents.
The facility failed to properly dispose of garbage, as observed when three dumpsters had open lids and trash scattered around them. The Dietary Supervisor and Maintenance Supervisor confirmed the dumpsters should have been closed and the area clean to prevent pest infestations. The facility's policy requires dumpsters to be closed and free from litter.
The facility failed to properly label and store medications, including bisacodyl suppositories without proper labels, multi-dose medications without open dates, and a ferrous sulfate solution with an illegible expiration date. Additionally, the medication room temperature exceeded recommended levels, potentially affecting medication efficacy.
The facility failed to maintain sanitary food preparation and storage practices, as observed during a survey. A puree blender had food residue, spilled oatmeal was on the storage room floor, and ovens had grime buildup. A staff's cup was improperly stored, and a cook's beard was uncovered during food preparation. These issues posed a risk of foodborne illness to residents.
A facility failed to maintain a functioning paper towel dispenser in a resident's bathroom, impacting hand hygiene and infection prevention. Despite the resident reporting the issue to the Case Manager and Infection Preventionist nurse, the problem was not resolved due to a lack of follow-up and communication breakdown. The Director of Nursing highlighted the importance of hand hygiene in preventing infection spread.
A facility failed to notify the LTC Ombudsman of a resident's discharge to a hospital at the same time the resident received the notice, as required by policy. The resident, who was cognitively intact and diagnosed with fatty liver, was discharged due to jaundice. The notice was sent to the Ombudsman 27 days late, as admitted by the Case Manager responsible for the task.
The facility failed to remove expired medications from use, as observed during an inspection of medication carts. A discontinued hydroxyzine bubble pack and an expired Humalog Qwikpen were found in the carts. Staff acknowledged that these items should have been removed according to the facility's medication labeling and storage policy, which requires multi-dose vials to be discarded within 28 days.
A facility failed to transcribe a physician's order for oxygen therapy into the electronic medical record for a resident with pneumonia and dementia under hospice care. The order was placed in the physical chart by a hospice nurse but was not entered into the electronic system, leading to an incomplete medical record. Staff interviews revealed that the responsibility for transcription lay with the licensed nurse who received the order, but it was overlooked.
A facility failed to provide a CNA with education on the risks and benefits of the COVID-19 vaccine, as required by their policy. The CNA's last vaccination was three years prior, and there was no documentation of the necessary education being provided. The Infection Preventionist admitted to not providing the education, despite being responsible for it. This deficiency was identified through interviews and record reviews.
A resident with limited mobility and cognitive impairment was found unable to reach her call light, which was tied to the bed rail and hanging towards the floor. Staff confirmed that the call light should have been clipped to the resident's clothing for accessibility, as per facility policy and expectations.
A resident with a brain hemorrhage and mild cognitive impairment was not provided with a care plan addressing her hearing impairment, despite wearing hearing aids and reporting difficulty hearing. The facility's baseline and comprehensive care plans failed to include her hearing issues, and staff interviews revealed a lack of communication and documentation regarding her condition. The DON acknowledged the oversight, which was contrary to the facility's policy on comprehensive, person-centered care plans.
A facility failed to implement fall prevention measures for two residents, leading to one resident sustaining a scalp hematoma after a fall. The first resident, assessed as a fall risk, did not have a care plan or interventions in place, despite requests for a bed alarm. The second resident's bed alarm was not properly attached, rendering it ineffective. The facility lacked a specific policy for bed alarm use, contributing to these deficiencies.
A facility failed to follow up with a physician regarding a dietitian's recommendation to reduce a resident's high protein nourishment (HPN) intake, contributing to a significant weight gain. Despite the resident's cognitive awareness and the dietitian's monitoring, the recommendation to limit HPN to breakfast was not communicated to the physician, and the resident continued receiving HPN with all meals. The Director of Nursing confirmed that the recommendation was not implemented, as no physician order was obtained.
A resident with cognitive capacity and a diagnosis of left shoulder osteoarthritis was not monitored following an allegation of physical abuse by a CNA, who reportedly caused pain during a transfer. Despite the facility's standard practice to monitor for 72 hours after such allegations, there was no documentation of monitoring for emotional distress or physical injuries. Interviews with the LVN and DON confirmed the oversight, highlighting a deviation from expected practices.
A resident with diabetes was administered 100 units of Lantus insulin instead of the prescribed 10 units, leading to hospital transfer for blood sugar monitoring. The error was acknowledged by the LVN and DON, who noted that such a high dose should have been questioned and verified against the physician's order and MAR.
Inadequate assessment and monitoring before lorazepam orders
Penalty
Summary
The facility failed to ensure an appropriate assessment and evaluation were completed before obtaining a PRN order for lorazepam for a resident with anxiety and impaired decision-making capacity. The resident was admitted with anxiety, and the history and physical dated January 26, 2026, indicated she did not have the capacity to understand and make decisions. A physician order was entered on June 21, 2026 for lorazepam 0.5 mg by mouth every 12 hours as needed for anxiety for 14 days, but the PRN order did not specify a target behavior. The record contained no documented assessment or evaluation by a licensed nurse or physician to justify the PRN lorazepam order, and there was no documentation explaining why the licensed nurse obtained the order. The resident was observed on July 16, 2026 in bed, alert, interviewable, and confused, with multiple fading purplish yellow skin discolorations on the forehead, around both eyes, the bridge of the nose, both arms, and the hands. The resident stated she did not know how she got the discolorations. A CNA stated the resident was confused, combative during care, and sometimes physically struck staff. The record review showed CNA notes documenting agitation and combative behavior, including hitting, scratching, biting, and kicking during care, but there was no documented evidence that the licensed nurse reported, monitored, or addressed the combative behavior noted on June 24, 2026 and July 5, 2026. The resident received the PRN lorazepam on multiple occasions between July 1 and July 4, 2026, but the eMAR did not indicate the target behavior for the medication before administration. The record also showed two episodes of inability to relax during that period, but there were no documented non-pharmacological interventions attempted or offered. Monitoring for aggressive or combative behavior did not begin until July 6, 2026. A change-in-condition evaluation completed on July 6, 2026 documented increased combativeness and multiple discolorations to the face and upper extremities, but it did not include an assessment, monitoring, or evaluation of the resident's combative and striking out behavior before the routine lorazepam order was obtained that day for anxiety manifested by striking out.
Failure to Assess and Report Combative Incident With Skin Discolorations
Penalty
Summary
The facility failed to ensure a licensed nurse appropriately assessed and monitored a resident after a combative incident that resulted in multiple areas of skin discoloration. The resident had a diagnosis of dementia and was observed on July 16, 2026, in bed, alert, interviewable, and confused, with fading purplish yellow skin discolorations on the left forehead, both inner periorbital areas, bridge of the nose, both arms, and anterior hands. The resident stated she did not know how she got the discolorations. Record review showed that on July 5, 2026, a CNA documented that after dinner the resident became increasingly agitated and extremely combative during care, including hitting, scratching, biting, and kicking, and recommended two staff for safety. The nursing progress notes for that evening did not show that the incident was reported to a licensed nurse or that the resident was assessed after the combative behavior. The record also did not show that the physician or responsible party were notified of the incident before July 6, 2026. On July 6, 2026, a licensed nurse documented being called to assess discoloration to the resident’s arms and noted discoloration to the nose bridge, bilateral inner canthus, left temporal site, and multiple discolorations to the upper extremities. Interviews confirmed that the morning CNA noticed the discolorations and reported them to both the night and morning licensed nurses, but neither nurse knew what happened and no incident report had been received from the prior shift. The DON stated the resident had a history of combative behavior and striking out, and that the nurse assigned during the evening shift should have reported the incident to the physician and family and documented the event and change in condition monitoring.
Expired COVID-19 Test Kits Found in Medication Rooms
Penalty
Summary
The facility failed to meet professional standards of quality when expired COVID-19 test kits were found in two medication rooms during surveyor observations. In one medication room, an opened box of COVID-19 test kits was present, and the LVN stated the kit had expired and would be removed. In the second medication room, six boxes of COVID-19 test kits were found with an expired date, along with an opened box containing one combination flu and COVID-19 test kit that was not expired until February 24, 2026. The LVN stated she would give the expired test kits to the Infection Preventionist. During interviews, the Infection Preventionist confirmed the test kits found in the medication rooms were expired and stated the facility did not have a policy addressing expired supplies. The Consultant Pharmacist stated expired COVID-19 test kits were expected to be discarded in the medication waste bin and that anything expired should not be on the shelf. The Infection Preventionist also stated expired test kits were supposed to be discarded one week before the expiration date and confirmed this was not done. The Director of Nursing stated the expired COVID-19 test kits should not have been in the medication rooms and that there was concern of false readings if they were accidentally used.
Improper labeling and storage of DuoNeb in medication carts
Penalty
Summary
Drugs and biologicals were not properly labeled and stored in two medication carts. During observation and interview, Medication Cart 1 contained an opened box of generic DuoNeb for Resident 20 with an opened foil pouch inside. The pharmacy label showed a fill date, and the box was also marked with an open date written in black marker, but the open date appeared to be before the pharmacy fill date. LVN 5 stated the box was supposed to be labeled with the date opened and said she did not know why the dates did not match. She also stated the medication needed to be discarded because there were too many dates on the box and she did not know when it was opened. Medication Cart 2 contained an opened box of generic DuoNeb for Resident 101 without an open date label, and LVN 5 acknowledged the missing open date. The cart also contained a clear plastic bag with six doses of generic DuoNeb for Resident 101, labeled with a fill date and a yellow sticker stating, "Once the product is removed from the pouch, discard unused medication." The Consultant Pharmacist stated DuoNeb was supposed to remain in the foil pouch to protect from light and that once removed from the pouch, the vials should be used within 14 days. The DSD and DON both stated DuoNeb was supposed to be labeled with the open date and not stored in a clear plastic bag, and the DSD stated the facility would not know if the medication was expired without proper labeling and storage.
Food Served at Improper Temperatures
Penalty
Summary
Food and drink were not consistently served at a palatable temperature for five sampled residents, including Residents 19, 27, 68, 75, and 79. During interviews, Resident 27 stated hot foods were sometimes cold and cold foods were not cold as they should be. Resident 19 stated hot food was cold during every meal, Resident 68 stated hot foods were cold, and Resident 79 stated food temperatures were not as hot as expected. Resident 75 stated the food was cold and never served hot. During meal service observation in the kitchen, multiple meal items were removed from the steam table, plated three to four trays at a time, and held on a shelf above the steam table for approximately one to three minutes before being covered and placed into meal carts for service. Two sample meal trays tested at 12:32 p.m. measured below the department's expected serving temperature of 120 F: pureed meat sauce with noodles measured 115 F and pureed green beans measured 105 F. The Dietary Manager stated the temperatures did not meet the department's expected serving temperature and could affect meal palatability and resident satisfaction. The RD stated staff were expected to serve food directly from the steam table onto plates and cover it immediately, avoiding hold times greater than two minutes as standard practice.
Infection Control Practices Not Followed During Medication Administration
Penalty
Summary
The facility failed to ensure infection control practices were followed during medication administration for three residents. Resident 4 had physician orders for Enhanced Barrier Precautions due to a gastrotomy tube, and an orange sign at the doorway indicated STOP - ENHANCED BARRIER PRECAUTIONS. During a medication pass, an LVN entered the room wearing gloves but did not wear a gown while administering five medications through the resident’s G-tube. Facility staff stated that a gown was required for G-tube care and that the gown served as a barrier to prevent infection transmission. The facility also failed to properly prepare a prefilled insulin pen before use for Resident 7. During a medication pass, an LVN removed the cap from a Novolin R FlexPen and attached the needle without wiping the pen tip first. The LVN stated he was supposed to wipe the insulin pen tip with an alcohol swab before attaching the needle and forgot to do so. Facility staff and the medication’s prescribing information indicated the rubber stopper or pen tip was to be cleaned with an alcohol swab before needle attachment. In addition, the facility failed to properly disinfect a shared glucometer between residents 78 and 7. After checking Resident 78’s blood sugar, an LVN wiped the glucometer with an alcohol swab and returned it to the medication cart. The same glucometer was then used for Resident 7’s blood sugar check and returned without being wiped. The LVN later stated nurses were supposed to wipe the glucometer before and after checking each resident’s blood sugar, while the IP and DON stated the glucometer needed to be disinfected with approved sanitizing wipes between residents and that alcohol swabs were not sufficient.
Delayed Meal Service Affected Resident Dignity
Penalty
Summary
The facility failed to maintain dignity for one of 11 residents reviewed for dignity when Resident 47 did not receive her meal tray at the same time as the other residents seated at her table. On May 18, 2026, at 11:54 a.m., Resident 47 was observed seated in the dining room with two other residents. The other residents were served their meals and began eating, while Resident 47 did not receive her tray until 12:05 p.m., about 11 minutes later, and was observed looking around while waiting for her meal to arrive. During a concurrent observation and interview on May 18, 2026, CNA 1 stated Resident 47's meal tray had not been ready, which caused the delay in serving her with the other residents at the table. CNA 1 stated meal trays should be served to all residents at a table at the same time so residents are not left waiting and watching others eat, in order to preserve dignity. Resident 47 stated she ate lunch in the dining room almost every day and preferred to receive her meal at the same time as the other residents seated at her table. The RD stated residents seated together were expected to receive their meals at the same time and that serving meals separately could make residents feel left out and negatively affect their sense of self-worth or self-esteem.
Failure to Notify Resident of Grievance Findings
Penalty
Summary
The facility failed to ensure a resident received a prompt response and notification of the findings after filing a grievance about a physician referring to her as a troublemaker. Resident 9 stated she was upset by the comment and reported that she had filed a grievance with the Social Services Director (SSD) but had not received any follow-up. Resident 9 was admitted with diagnoses including depression, and her MDS dated April 6, 2026 showed a BIMS score of 14, indicating intact cognitive function. Record review showed the grievance was documented on March 26, 2026, but the Grievance Report Form and Follow-Up/Investigation Report had multiple incomplete sections, including the department manager follow-up report, whether the complaint was addressed, the date the resident was notified of findings, and who provided the notification. The SSD stated she informed the physician of the grievance and told him the resident expected an apology, but she did not follow up after speaking with him. The SSD and DON both stated the grievance remained unresolved, Resident 9 had not been informed of the outcome, and the facility did not follow its grievance process.
Medication Given Without Ordered Food
Penalty
Summary
The facility failed to administer one medication as ordered for one of seven residents during a medication pass observation. During the observation, an LVN administered four medications to a resident, including metoprolol tartrate 50 mg, and gave the resident a cup of water with the medications. The resident’s physician’s order directed metoprolol tartrate 50 mg by mouth twice a day for hypertension, to be taken with food. During a concurrent interview and record review, the LVN acknowledged the order indicated the medication should be given with food and stated he did not give food with the medication because it was too early for dinner. The consultant pharmacist stated metoprolol tartrate was recommended to be given with food because of concern for blood pressure dropping too low if given without food. The DSD and DON both stated the medication should have been given with food and that the physician’s orders were supposed to be followed. The prescribing information reviewed stated metoprolol tartrate tablets should be taken with or immediately following meals.
Failure to Safeguard Resident Hearing Aid Resulting in Device Damage
Penalty
Summary
The facility failed to protect a resident’s personal belongings, specifically hearing aids, resulting in damage to one device. The resident had metabolic encephalopathy, hearing loss, and lacked decision-making capacity, and was care planned to wear bilateral hearing aids, with staff directed to apply them each morning and remove, open the battery, and store them at bedtime. The Minimum Data Set documented that the resident was highly impaired in hearing and used hearing aids. A family member reported that another family member had visited and noticed a hearing aid was missing; staff were notified and the hearing aid was later found damaged in the laundry. At a subsequent observation, the resident was in bed wearing only the right hearing aid and did not respond to a CNA’s question until the family member repeated it at a louder volume. Interviews with staff revealed that both nursing and laundry processes failed to prevent the loss and damage of the hearing aid. The Laundry Supervisor stated that personal belongings should be checked in residents’ clothing before laundering and that any items found should be returned to the nursing station, but acknowledged that the laundry aide missed the hearing aid in the resident’s clothing. An LVN stated that the resident’s daughter had reported the hearing aid missing, and that after searching the room, staff found it damaged in the laundry area; the LVN also stated the daughter had previously instructed staff to remove the hearing aid before showers. The DON stated that the CNA who placed clothes in the hamper should have checked for personal belongings and that laundry staff should have checked clothing before washing for items such as phones, glasses, or hearing aids. A CNA stated that hearing aids should be removed before showers and stored in a designated case or secured location. The facility’s policy on hearing aid care indicated that licensed nurses are responsible for removal and storage of hearing aids and that hearing aids should not be exposed to moisture, but the resident’s hearing aid was nonetheless laundered and damaged.
Failure to Supervise Cognitively Impaired Wheelchair User in Parking Lot
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention measures for a cognitively impaired, wheelchair-bound resident who was allowed to be outside unsupervised. Surveyors observed that the facility had a large parking lot directly connected to a u‑shaped driveway and the main entrance, with no caution signage, patio seating, or safety barriers for pedestrians despite expected vehicle traffic. The entrance doors were automatic sliding doors that opened by motion sensor, and the receptionist’s view of the entrance was obstructed by a tall countertop with items on it. The facility did not have staff assigned to monitor exits or the parking lot, and exit doors were unlocked and lacked alarms. The resident involved had hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side and used a wheelchair. The resident’s MDS showed a BIMS score of 9, indicating moderate cognitive impairment. Despite this, the resident’s care plan did not include interventions addressing the risk for injury related to impaired cognition. Staff interviews, including with the DON, LVN, CNA, and COTA, confirmed that the resident had impaired judgment, was oriented only to self and place, and required increased supervision, particularly when outside. Staff also stated that residents with cognitive impairment should not be on the front patio or in the parking lot without supervision. On the day of the incident, the resident requested candy from the receptionist and then exited to the front patio unsupervised through the automatic doors. While the resident was propelling the wheelchair in the left side parking lot, a small white SUV was backing out of a parking space. The resident was behind the vehicle, and the driver did not see the resident, striking the left side of the wheelchair. Witnesses honked and alerted the driver while the resident yelled for the car to stop. The resident subsequently reported left elbow discomfort, and hospital documentation recorded a diagnosis of pain in the left elbow. The COTA stated that a resident with cognitive impairment should not be outside without supervision and that the incident could have been prevented by the facility.
Resident Awakened at Night for Non-Urgent Room Change Decision
Penalty
Summary
Staff failed to ensure that a resident was treated with dignity and respect when a Certified Nurse Assistant (CNA) awakened her late at night to ask about a potential room change. The resident, who had osteoarthritis and was recovering from joint replacement surgery, had previously requested a room move but declined an offer earlier in the day, stating she would move in the morning. Despite this, the CNA, following instructions from the outgoing Registered Nurse (RN), approached the resident between 11:00 p.m. and 11:15 p.m. to ask if she wanted to move that night or the following day, thereby disturbing her sleep. Facility policy and the resident's rights documents both indicate that residents should be treated with consideration and respect, and that room changes should be discussed when residents are awake unless medically necessary or for safety reasons. The Director of Nursing (DON) confirmed that the facility's practice is not to disturb residents during sleep for such discussions. This incident demonstrated a failure to honor the resident's right to a dignified existence and self-determination by unnecessarily disrupting her rest.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement a fall prevention intervention for a resident by not ensuring the tab monitor was attached while the resident was in a wheelchair, as specified in the resident's care plan. The resident, who was admitted with a diagnosis of a fracture to the lower back and muscle weakness, was identified as being at risk for falls due to impaired mobility and a history of falls. The care plan included an intervention to apply a tab monitor in the wheelchair to remind the resident to get assistance for ambulation and transfers. On observation, the tab monitor was found hanging from the bed rail and not attached to the resident while she was in the wheelchair. The resident reported a fall on a previous date because she did not use her call light to request assistance before getting out of the wheelchair. Interviews with staff, including a CNA and the DON, confirmed that the tab monitor was not attached as required by the care plan, and the CNA acknowledged the oversight. The facility's policy indicated that tab alarms should be used for residents at risk for falls and documented in the care plan, with checks to ensure they are functioning properly.
Improper Garbage Disposal and Open Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal of garbage, as observed on February 3, 2025, when three dumpsters had their lids open and trash was scattered around them. This was confirmed during an observation and interview with the Dietary Supervisor, who acknowledged that the dumpsters should have been closed and free of surrounding trash to prevent pest infestations. Additionally, on February 5, 2025, the Maintenance Supervisor confirmed his responsibility for keeping the dumpster lids closed and the area clean, acknowledging that the open dumpsters and surrounding trash could lead to rodent infestations and infection control issues. The facility's policy, dated October 2017, requires that garbage and refuse containing food wastes be stored in a manner inaccessible to pests, with dumpsters kept closed and free from surrounding litter.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as observed during an inspection. Bisacodyl suppositories were found in the medication room and on a medication cart without proper pharmacy labels, making it unclear to whom they belonged. Licensed Vocational Nurses (LVNs) acknowledged the lack of labeling and indicated that these medications were usually kept as house supply, but the bags did not indicate this. The facility's policy requires floor stock medications to be labeled as such and kept in the original manufacturer's container with specific information, which was not adhered to in this case. Additionally, multi-dose medications were not properly labeled with open dates. During an inspection, a latanoprost eye drop and a vial of cyanocobalamin were found without open dates, despite the facility's policy requiring multi-dose vials to be dated and discarded within 28 days unless otherwise specified by the manufacturer. The prescribing information for latanoprost indicates it can be stored at room temperature for up to six weeks once opened, but this was not followed due to the lack of an open date. Furthermore, a bottle of ferrous sulfate solution was found with a smudged expiration date, making it illegible. The facility's policy states that if medication containers have missing or incorrect labels, the dispensing pharmacy should be contacted for instructions. Lastly, the room temperature in the Nursing Station 2 Medication Room was recorded at 82 degrees Fahrenheit, exceeding the controlled room temperature range of 68-77 degrees Fahrenheit as per the United States Pharmacopeia standards. This failure to maintain appropriate storage conditions could potentially affect the efficacy of the medications stored there.
Sanitation and Hygiene Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen, as observed during a survey. A puree blender was found with white and yellow food residue, indicating it was not cleaned after use, which could lead to cross-contamination. Additionally, spilled dry oatmeal was observed on the floor inside the dry storage room, which the Dietary Supervisor acknowledged should be kept clean to prevent pest infestation. Further observations revealed that two ovens had a buildup of food crumbs, grease, yellow grime, and dark brown residue, which the Dietary Supervisor admitted should be kept clean and sanitary to prevent foodborne illness. A dietary staff's plastic cup was also found on the bottom shelf of the tray line table, which the Dietary Supervisor stated should not be stored in the kitchen area to avoid cross-contamination. Moreover, a cook was observed preparing pureed carrots without covering his beard and mustache, which the Dietary Supervisor noted should be covered to prevent hair from falling into the food. These deficiencies were identified as potential causes of foodborne illness among the facility's residents, who are a vulnerable population.
Non-Functioning Paper Towel Dispenser in Resident's Bathroom
Penalty
Summary
The facility failed to ensure that a resident's bathroom had a functioning paper towel dispenser, which is essential for proper hand hygiene and infection prevention. On February 6, 2025, during an observation and interview, the Maintenance Supervisor (MS) confirmed that the paper towel dispenser in the resident's bathroom was not dispensing paper towels. The resident had previously reported the issue to both the Case Manager (CM) and the Infection Preventionist (IP) nurse. However, the IP nurse, despite being informed of the issue on February 4, 2025, did not follow up to ensure it was resolved. Further interviews revealed that the CM had notified the front desk to inform Maintenance, but the front desk staff did not relay this information to the MS. The MS stated that the facility's process requires a maintenance request form to be filled out, which he never received regarding the paper towel dispenser issue. The Director of Nursing (DON) emphasized the importance of a functioning towel dispenser for hand hygiene to prevent infection spread. The facility's policy on maintaining a homelike environment includes ensuring a clean, sanitary, and orderly setting.
Failure to Timely Notify LTC Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman at the same time the notice was given to a resident, impacting the resident's rights and continuity of care. The resident, who was cognitively intact, was admitted with a diagnosis that included fatty liver and was discharged to a hospital due to jaundice. The discharge notice was given to the resident upon discharge, but the facility did not send the notice to the LTC Ombudsman until 27 days later. Interviews with the Social Service Director and Case Manager revealed that the facility's policy required the LTC Ombudsman to be notified at the same time as the resident. However, the Case Manager admitted to not sending the notification letter, which was her responsibility. This oversight had the potential to delay advocacy and oversight of the resident's discharge plan.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to ensure that expired medications were not available for use by residents, as observed during an inspection of medication carts. On the 8400 Floor Medication Cart, a discontinued bubble pack of hydroxyzine for a resident was found alongside active medications. LVN 5 confirmed that the medication had been discontinued and should have been removed from the cart. Similarly, on Medication Cart 3A, a used Humalog Qwikpen with an open date of December 1, 2024, was found, which exceeded the 28-day usage period as per the facility's policy. LVN 3 acknowledged that the insulin pen should have been discarded according to the policy. These findings indicate that the facility did not adhere to its own policy and procedure titled 'Medication Labeling and Storage,' which requires multi-dose vials to be dated and discarded within 28 days unless otherwise specified by the manufacturer. This oversight had the potential to result in residents receiving ineffective medication therapy.
Failure to Transcribe Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a physician's order for oxygen therapy was transcribed into the electronic medical record for a resident. This oversight was identified during an observation on February 3, 2025, when the resident was seen receiving oxygen at 2 liters per minute via nasal cannula. The resident, who was admitted with diagnoses of pneumonia and dementia and was under hospice care, did not have a corresponding physician order for the oxygen therapy documented in the electronic medical record. Interviews with facility staff revealed that the order was initially placed in the resident's physical chart by a hospice nurse upon admission on January 21, 2025, but was not transcribed into the electronic system. The Licensed Vocational Nurse (LVN) acknowledged that all physician orders should be transcribed at the time of admission. The Medical Records Director confirmed that the responsibility for transcribing the order lay with the licensed nurse who received it. The Director of Nursing (DON) stated that the order should have been transcribed immediately to ensure all staff were aware of the prescribed treatment, but the facility's licensed nurse forgot to do so.
Failure to Educate Staff on COVID-19 Vaccine Risks and Benefits
Penalty
Summary
The facility failed to provide education regarding the risks and benefits of the COVID-19 vaccine to one of the three staff members reviewed for immunization, specifically a Certified Nurse Assistant (CNA). This deficiency was identified through interviews and record reviews, which revealed that there was no documented evidence that the CNA received the necessary education about COVID-19 immunization. The CNA's last COVID-19 vaccination was recorded as being administered approximately three years prior, and the Director of Staff Development (DSD) confirmed the lack of documentation for the required education. During interviews, the Infection Preventionist (IP) acknowledged the responsibility for ensuring all facility staff received education on COVID-19 during their scheduled vaccinations. However, the IP admitted to not providing the CNA with the necessary education on the risks and benefits of the COVID-19 vaccine. The facility's policy, dated June 2023, mandates that staff are educated about the benefits and risks of the COVID-19 vaccine, and this education should be provided again if the vaccination requires multiple doses. The failure to adhere to this policy potentially left staff without proper guidance and information, which could affect their decision-making and increase the risk of infection transmission within the facility.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a critical aspect of accommodating the needs and preferences of residents. During an unannounced visit, it was observed that the call light for a resident with a contracted right hand and limited mobility due to a stroke and multiple sclerosis was tied around the bed rail and hanging towards the floor, making it inaccessible. The resident, who was moderately cognitively impaired, reported that she often could not reach her call light and had to rely on her roommate to call for assistance. Interviews with facility staff, including a CNA and an LVN, confirmed that the call light should have been clipped to the resident's clothing at chest level to ensure accessibility. However, during the observation, the call light was not clipped as required, and both staff members acknowledged that it was out of reach. The Director of Nursing also stated that call lights should always be within reach to allow residents to call for assistance. The facility's policy on answering call lights, revised in September 2022, also emphasized the importance of ensuring call lights are accessible to residents when in bed.
Failure to Initiate Care Plan for Hearing Impairment
Penalty
Summary
The facility failed to initiate a care plan for a resident who was hard of hearing, which was identified during an observation and interview. The resident, who was wearing hearing aids, reported difficulty hearing even with the aids. The resident's medical records indicated a diagnosis of a brain hemorrhage and a mild cognitive impairment. Despite these indicators, the baseline care plan did not include an assessment for hearing, and the comprehensive care plan did not address the resident's hearing issues. The Minimum Data Set (MDS) also inaccurately reflected the resident's hearing status, stating that the resident had adequate hearing and did not wear hearing aids. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Minimum Data Set Nurse (MDSN), revealed that the resident's hearing issues were known but not communicated to relevant parties or included in the care plan. The Director of Nursing (DON) confirmed that a care plan should have been initiated to address the resident's hearing difficulties, including interventions for the use of hearing aids and actions to take if the aids were not functioning. The facility's policy on care plans emphasized the need for comprehensive, person-centered plans developed from thorough assessments, which was not adhered to in this case.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide fall prevention interventions for a resident assessed as a fall risk, leading to the resident falling and sustaining a scalp hematoma. The resident, who was admitted with a neck fracture and muscle weakness, was assessed as a fall risk upon admission. However, a fall risk care plan with safety interventions was not initiated. The Director of Nursing (DON) acknowledged that fall precaution interventions should have been individualized and implemented, but they were not. The resident's representative had requested a bed alarm due to increased activity, but the Licensed Vocational Nurse (LVN) did not inform the physician or place the alarm, which could have prevented the fall. Another deficiency involved the improper attachment of a bed alarm for a resident with severe cognitive impairment and a high risk for falls. The resident's care plan indicated the use of a bed alarm as a fall risk intervention. However, during an observation, the bed alarm was found not attached to the resident, rendering it ineffective. The LVN responsible for checking the alarm admitted that sometimes the Certified Nursing Assistant (CNA) forgets to reattach it. The DON confirmed that the alarm should have been attached to the resident, and the CNA admitted to not verifying the alarm's attachment after changing the resident's shirt. The facility lacked a specific policy and procedure for the use of bed alarms, which contributed to the oversight in ensuring the alarms were properly attached and functional. The DON expressed disappointment in the staff's failure to adhere to expectations for checking and ensuring bed alarms were attached and turned on when entering and exiting resident rooms. The Administrator confirmed the absence of a policy for bed alarm use, highlighting a gap in the facility's fall prevention measures.
Failure to Implement Dietitian's Recommendation Leads to Resident's Weight Gain
Penalty
Summary
The facility failed to follow up with the physician regarding the Registered Dietitian's (RD) recommendation to discontinue a resident's high protein nourishment (HPN) for one of the sampled residents. This oversight potentially contributed to the resident's significant weight gain of 29 pounds, or 26.6%, over a six-month period. The resident, who was cognitively intact, expressed that they had gained enough weight and did not need to gain more. The RD had recommended reducing the HPN to breakfast only, but this recommendation was not communicated to the physician, and the resident continued to receive HPN with all meals. The RD stated that she monitored and managed weight variance by conducting weekly interdisciplinary team (IDT) meetings and made dietary recommendations to the Director of Nursing (DON), Director of Staff Services (DSS), and licensed nurses. However, the nursing staff did not follow up with the physician to obtain an order to change the HPN as recommended. The DON confirmed that the RD's recommendations were not carried out by the licensed nurses, as no physician order was written to decrease the HPN to breakfast only. The facility's policy and procedure required verbal orders to be recorded immediately, but this was not adhered to in this case.
Failure to Monitor Resident After Abuse Allegation
Penalty
Summary
The facility failed to monitor a resident following an allegation of physical abuse, which was reported on August 26, 2024. The resident, who was cognitively intact and had mental capacity, was admitted with a diagnosis of left shoulder osteoarthritis. The allegation involved a certified nursing assistant (CNA) who reportedly handled the resident roughly during a transfer, causing moderate to severe pain in the resident's left shoulder. Despite the facility's standard practice to monitor residents for 72 hours after any abuse allegations, there was no documented evidence that the resident was monitored for emotional distress, behavioral changes, or delayed physical injuries from August 26 to August 29, 2024. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the resident was not monitored as required. Both the LVN and the DON acknowledged the importance of monitoring residents involved in abuse allegations to detect any negative effects, including emotional or psychosocial impacts and latent physical injuries. The DON stated that it is the facility's standard practice to conduct 72-hour monitoring and documentation after an abuse incident or allegation, although there was no specific policy in place. The lack of monitoring was a deviation from the facility's standard practice and expectations.
Incorrect Insulin Dose Administration
Penalty
Summary
The facility failed to ensure the correct insulin dose was administered as prescribed by the physician for one resident. The resident, who had diabetes mellitus, was supposed to receive 10 units of Lantus insulin subcutaneously at bedtime. However, on the evening of February 26, 2024, a Licensed Vocational Nurse (LVN) administered 100 units of Lantus instead of the prescribed 10 units. This error was documented in the Medication Administration Note and led to the resident being transferred to the hospital for blood sugar monitoring. The Interdisciplinary Team reviewed the incident and confirmed that the LVN had inadvertently administered the incorrect dose. During interviews, both the LVN and the Director of Nursing (DON) acknowledged that 100 units of Lantus is an unusually high dose and should have been questioned. The DON emphasized that the licensed nurse should have double-checked the physician's order and the Medication Administration Record (MAR) before administering the insulin. The facility's policies on administering medications and subcutaneous injections were reviewed, which indicated that medications must be administered as prescribed and that the correct dose should be verified before administration. The failure to follow these procedures resulted in the resident being at risk of hypoglycemia and necessitated hospital transfer.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 175 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rancho Mirage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bayshire Rancho Mirage | 2.3 mi | ★★★★★ | 1 | 0 |
| Monterey Palms Health Care Center | 2.4 mi | ★★★★★ | 25 | 0 |
| The Springs Healthcare Center At The Carlotta | 3.5 mi | ★★★★★ | 2 | 0 |
| Desert Springs Post Acute | 5 mi | ★★★★★ | 40 | 0 |
| Premier Care Center For Palm Springs | 7.5 mi | ★★★★★ | 33 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Rancho Mirage Health And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.