Rancho Bellagio Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was informed and allowed to exercise the right to choose and attending physician for four of four residents reviewed for physician choice (Residents 1, 2, 3, and 4). This failure resulted in Residents 1, 2, 3, and 4 not being afforded the opportunity to retain a personal physician or select an attending physician of their choice upon admission.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents when the facility did not meet the required minimum of actual total Certified Nurse Assistant (CNA) Direct Care Hours Per Patient Day (DHPPD - measure the numbers of hours of direct care given to residents in skilled nursing facility) of 2.4 hours for the months of October 2025, November 2025, December 2025, and January 2026. The failure to maintain the required minimum CNA DHPPD hours had the potential to place residents at risk for unmet needs, compromised safety, and decreased quality of care.

Inspectors wroteBased on interview, and record review, the facility failed to promptly notify the physician for a change in condition, for two of eight residents reviewed for changes in condition (Resident 8 and 110) when: 1. For Resident 8, licensed nurses did not notify the physician of multiple refusals of prescribed insulin [chemical in the body that helps move sugar from the blood into the body's cells]. 2. For Resident 110, licensed nurses did not notify the physician of the repeated episodes of blood pressure readings less than 100/60 mm Hg (millimeters per mercury - unit of measurement). These failures placed the residents at increased risk to their health and well-being due to the lack of physician oversight necessary to evaluate and address changes in their medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan to address a resident's repeated refusal of prescribed insulin (a chemical in the body which helps more sugar from the blood into the body's cells) for one of ten residents for care planning (Resident 8). This failure placed Resident 8 at risk for uncontrolled blood glucose levels and potential diabetic complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 22) reviewed received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. For Resident 22, nursing staff did not follow the physician's insulin (medication to treat diabetes) sliding scale order (a chart with insulin doses to maintain blood sugar levels) to notify the physician when the blood sugar (BS) result was above 350. This failure had the potential to compromise Resident 22's health and well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure that upon written request, medical records were released within two working days, for one of two sampled residents (Resident 5). This failure had the potential to impact continuity of care, appeals, or legal matters.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure resident right to choose attending physician for two of eight sampled residents (Residents 1 and 6) in a universe of 91 residents. This failure had the potential to harm the resident's autonomy, continuity of care, which could potentially lead to unmet needs for residents in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure STAT, (done without delay) chest radiology and laboratory orders were done as ordered by the physician for one of eight residents reviewed for quality of care (Resident 1), in a universe of 91 residents. This failure had the potential to result in delayed diagnosis and treatment.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident 's call light was within reach, for one of three sampled residents out (Resident 1). This failure could have resulted in Resident 1 not receiving nursing assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to one of six sampled residents (Resident 1), who was diagnosed with dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and had history of elopement (incident when a resident leaves the facility without authorization). In addition, the facility failed to frequently monitor the whereabouts of Resident 1 in accordance with the care plan. Resident 1 exited the facility on December 20, 2024, via the BC wing (name of a facility wing) automatic sliding door. It was observed that the sliding door led directly to the facility's parking lot, which led to a two-way street. This failure exposed the resident to immediate danger, accidents, serious harm, or death. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate documentation for one of six residents reviewed, (Resident 1), as the resident's record indicated Resident 1 was last seen at 3:45 p.m. on December 20, 2024, while the video surveillance showed Resident 1 left the facility at 3:08 p.m. on December 20, 2024. This failure resulted in an inaccurate account of Resident 1's whereabouts and potentially impacting the accuracy of their care documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when three dumpsters were overflowing, the lids could not be closed, and the surrounding area was littered with debris. This failure had the potential to attract pests and cause infection control issues.

Inspectors wroteBased on interview and record review, the facility failed to provide Advance Directive (AD-a written instruction related to the provision of health care when the resident is no longer able to make decisions) education, materials, and follow-up for three of five residents reviewed for AD (Residents 19, 35, and 69) and/or their resident representatives (RP). This failure had the potential for Residents 19, 35, and 69's medical preferences not being honored during critical healthcare decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the lunch menu on December 9, 2024, met residents' needs when: 1. Dietary Aide (DA 1) served pudding instead of mandarin oranges for five of five residents (Residents 19, 41, 134, 190 and 332) on a renal diet (a restricted diet that can help slow kidney damage). 2. [NAME] (CK 1) served pureed spinach instead of green beans for one of one resident (Resident 332) on a renal pureed diet (smooth, lump-free foods that require no chewing). 3. DA 1 used a #8 scoop size to serve dessert for regular diets. 4. CK 1 did not follow the recipe when preparing garlic parmesan spinach. These failures had the potential for residents to miss out on therapeutic and nutritional benefits, correct serving portion, and/or palatability (acceptable taste).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy on Meal Service to provide appetizing food at appropriate temperatures and appetizing taste according to residents' preferences for 14 of 96 sampled residents (Residents 14, 15, 19, 29, 36, 41, 43, 51, 65, 69, 73, 77, 182, and 282). This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutrition status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Food and Nutrition Service employees did not follow the facility cleaning procedure to clean food preparation surfaces and stationary equipment. 2. Four out of four green storage shelves in the walk-in refrigerator had buildup; 3. Dust was hanging on walk-in refrigerator's fan covers; and 4. One wet plastic container was stacked with other dried plastic containers. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 95 out of 95 residents who received food prepared in the kitchen. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medication Nexium (esomeprazole-is used to treat conditions where there is too much acid in the stomach) was administered according to the physician's order for one of one resident reviewed (Resident 56). This failure had the potential to result in the worsening of gastroesophageal reflux disease (GERD-overaccumulation of stomach acid) for Resident 56.

Inspectors wroteBased on observation, interview, and record review, the facility failed to replace the oxygen humidifier bottle in accordance with the facility policy and procedure for one of one resident reviewed for respiratory (Resident 66). This failure had the potential to result in ineffective oxygen therapy, respiratory distress, cross-contamination, and infection, which would lead to a decline in Resident 66's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rates were not five percent or greater when: 1. Resident 21's lidocaine (local anesthetic to relieve pain) patch was applied to the wrong body location; and 2. Resident 137's Metformin (medication to treat high blood sugar) and Carvedilol (heart medicine) were administered without food. These failures had the potential for Residents 21 and 137 to not adequately received the therapeutic effect of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement proper infection control measures when Certified Nurse Assistant (CNA) 1 did not perform hand hygiene and wear personal protective equipment (PPE - equipment use to protect against infection or illness) upon entering the room and while providing care to Resident 283, who was positive for Clostridium Difficile infection (C. diff - a bacteria that cause diarrhea and is spread through contact with contaminated surfaces or people). This failures had the potential to increase the spread of pathogens (germs) and infections from staff to residents, potentially leading to illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the dish machine's temperature within the manurfacturer's guidelines. Failure to ensure adequate water temperature in the dish machine may result in ineffective cleaning of dishes, putting 95 residents at risk for food-borne illness (stomach illness acquired from ingesting contaminated food).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven residents' (Resident 7) call light was answered timely. This failure had the potential to not meet the resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the correct size bed rails were installed on one resident's bed as indicated on the resident's bed rails admission assessment, for one of seven sampled residents (Resident 2). This failure had the potential to result in negative outcomes including accident, physical restraint, decline in mobility and function, and psychosocial outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when a Certified Nurse Assistant (CNA) did not perform handwashing after leaving the room of a resident on Enhanced Barrier Precautions (EBP - infection prevention and control practices that can help reduce the spread of infection). This failure had the potential to increase the spread of pathogens (germs) from staff to residents which could lead to infections and illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) ' s family was notified of a change in condition within 24 hours, on August 9, 2024. This failure had the potential for Resident 1's family to not know the medical condition of Resident 1, and not be able to advocate and assist with making medical decisions based on the change of condition.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse within two hours to the California Department of Public Health (CDPH) after the allegation was made for two of three sampled residents (Residents A and C). This failure had the potential to result in further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of three residents reviewed, (Resident 1), a follow up call and/or assessment was done to verify durable medical equipment (DME) was provided to Resident 1 upon discharge as ordered. This failure had the potential to complicate Resident 1's recovery and had the potential for Resident 1 to suffer undue financial expenses for needed medical equipment.

Inspectors wroteBased on interview and record review the facility failed to notify the representative for one of three sampled residents (Resident 1) when the facility applied a knee immobilizer to Resident 1. This failure had the potential to violate the rights Resident 1's representatives.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain medication was offered or provided for one of four residents reviewed (Resident 1). This failure had the potential for Resident 1 to have increased pain which could impair mobility and function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of a resident when the physician ordered medications were not acquired by the facility timely and available for use, for one of four residents reviewed (Resident 1). This failure had the potential to result in the delay of treatment and care for Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed, for one of four residents reviewed (Resident 1), to maintain accurate medical records in accordance with accepted professional standards and practice when the staff failed to accurately document medication given to Resident 1 on the medication administration record (eMAR). This failure could increase the potential for confusion to occur in the provision of care for Resident 1 and for Resident 1 to receive unnecessary duplicated medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received colostomy care as ordered by the physician. This deficient practice had the potential for Resident 1 to suffer from infection, skin breakdown, and pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of three sampled residents, Resident 1, bedframe was properly maintained in safe operating condition. The brake on Resident 1's bed was malfunctioning, causing the bed to move from left to right while in the locked position. This failure had the potential to place the resident at risk for entrapment, accident, and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (a device to alert nursing staff when a resident is in need) was within reach of one resident (Resident 1) out of a sample of three residents. This failure prevented Resident 1 from communicating his care needs and had the potential to increase his anxiety (a feeling of fear, and uneasiness).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented when: 1. One facility staff did not perform hand hygiene during, donning (putting on gloves and gown) and doffing (removing gloves and gown) of PPE (Personal Protective Equipment - mask, gown, gloves, face shield or goggles) inside the PUI Unit (Person Under Investigation - a resident suspected of having or exposed to COVID-19 [coronavirus-an illness caused by a virus that can spread from person to person]) upon meal pass; 2. A resident's urinal was placed on a bedside table beside a lunch tray; 3. A licensed nurse did not disinfect a medication tray during med pass; 4. One facility staff touched resident's meal with dirty gloves; 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of four residents (Resident 15) dignity when the resident was observed with long, dirty fingernails and with an unshaven face. This failure had the potential to affect resident's self-esteem and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to keep Resident 11 free from verbal abuse when the staff, while exiting the room used foul language which was perceived by Resident 11 as being directed to her. This failure had the potential for Resident 11 to experience psychological harm.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse involving a Certified Nurse Assistant (CNA) and a resident, no later than 2 hours to the State Survey Agency, after the allegation was made. This failure had the potential to result in a delay of investigation which placed resident at risk for further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed to address resident's dental problem, for one of 19 residents reviewed (Resident 37). This failure had the potential for staff not to be aware of the resident's dental needs and provide the necessary care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards during medication administration for one of three residents (Resident 54), when the Diclofenac Gel (medication used to treat pain) was not administered in accordance with the physician's order. This failure had the potential to result in not having the effective amount of medication at all times and prolonging the amount of time for the resident to feel relief.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities that met the interest for one of one residents reviewed (Resident 44). This failure had the potential to result in a decline in the physical, and emotional well-being of Resident 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received treatment and care for one of 19 residents reviewed (Resident 25), when he was not re-evaluated for persistent swelling (edema) of bilateral lower extremities. This failure had the potential to result in the delay in treatment and further decline in resident's medical condition, affecting, psychosocial, mental, and physical well-being of Resident 25

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% when: 1. For Resident 54, the medications Q-var inhaler (used to treat lung problem) and Diclofenac Sodium topical Gel 1% (used to treat pain) were not administered in accordance with the physician order. 2. For Resident 52, the medication [NAME] C tablet (B complex) was not available for administration. This failure resulted in a medication error rate of 6.12% which had the potential to which cause complications to an already compromised residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the appropriate diet texture was provided for one of one resident (Resident 37), when Resident 37 was having difficulty chewing food due to dental problem. This failure had the potential to negatively affect the resident's food intake which could cause a decline in nutritional health status of Resident 37.