Rancho Mirage Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review for one of three residents reviewed for quality of care (Resident 1), the facility failed to ensure:1. An appropriate assessment and evaluation were conducted prior to obtaining an order for Lorazepam (generic name for Ativan, a medication used to treat anxiety) as needed (PRN) for 14 days on June 21, 2026; and2. An appropriate assessment, monitoring, and evaluation were conducted prior to obtaining an order for Lorazepam 0.5 milligram (mg- unit of measurement) give one tablet by mouth every 12 hours for anxiety manifested by striking out, on July 6, 2021. This failure placed Resident 1 at high risk for unnecessary medication use without proper assessment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the licensed nurse appropriately assessed and monitored the combative behavior incident resulting in multiple areas of skin discoloration for one of three residents evaluated for quality of care (Resident 1). In addition, the licensed nurse did not promptly inform the physician or responsible party after Resident 1's combative incident identified on July 5, 2026. This failure placed Resident 1 at risk for delayed medical intervention and increased the likelihood of complications related to the combative incident. On July 16, 2026, an unannounced visit was conducted at the facility to investigate a complaint about lack of notification regarding an incident involving Resident 1. On July 16, 2026, at 9:10 a.m., an observation with a concurrent interview was conducted with Resident 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to meet professional standards when two of two toured medication rooms had expired COVID-19 (coronavirus disease 2019, contagious infection responsible for the death of over one million people in the United States) test kits. This failure had the potential for inaccurate test results which could cause missed COVID-19 infections and possible infection spread in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications according to the facility policy and procedures (P&P) and manufacturer's specifications when:1. Inhaled medications were not labeled with an open date in two of four reviewed medication carts (Medication Carts 1 and 2), and2. One inhaled medication was not stored inside the foil pouch as required by the manufacturer in one of four reviewed medication carts (Medication Cart 2). These deficient practices had the potential to expose residents to deteriorated or ineffective medications, which could lead to the use of unsafe and ineffective medications for the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was served at a palatable temperature consistent with resident preferences for five of 91 sampled residents (Residents 19, 27, 68, 75, and 79)This failure had the potential to diminish resident satisfaction with meals and adversely affect residents' enjoyment of dining and food intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for three of seven residents (Residents 4, 7, and 78) during the medication administration observation, when:1. Nursing staff failed to follow enhanced barrier precautions (EBP, infection control practice) for one resident (Resident 4),2. Nursing staff failed to properly clean and disinfect the prefilled insulin (medication for diabetes to treat high blood sugar) pen before use for one resident (Resident 7), and3. Nursing staff failed to properly clean and disinfect a shared glucometer (blood glucose [sugar] meter to measure the amount of sugar in the blood) for two residents (Residents 78 and 7). These failures had the potential to expose residents to infection and to compromise residents' health and safety in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was maintained for one of 11 residents reviewed for dignity (Resident 47) when Resident 47's meal tray was not provided at the same time as the other residents seated at her table. This failure had the potential to negatively affect Resident 47's sense of dignity, self-worth, and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received a prompt response and notification of the grievance investigation findings following submission of a grievance for one of four residents reviewed for grievances (Resident 9). This failure had the potential to leave Resident 9 unaware of whether her grievance had been investigated and addressed, which had the potential to contribute to ongoing dissatisfaction regarding her concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer one medication as ordered by the prescriber for one of seven residents (Resident 78) during the medication administration observation. This failure resulted in Resident 78 receiving a dose of metoprolol tartrate (generic for Lopressor, a medication to treat high blood pressure) without food which could cause hypotension (low blood pressure which can cause dizziness and fainting).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the personal belongings of one of three residents reviewed (Resident A) were protected when Resident A's hearing aid was not properly removed and stored. This failure resulted in damage to the device, which had the potential to cause impaired communication between Resident A, facility staff, and family.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to one of three residents reviewed for accidents (Resident 1), who was wheelchair bound and cognitively impaired. Resident 1 was left unsupervised while outside the facility. In addition, there was no interventions developed by the facility to address the resident who was at risk for injury and accidents due to impaired cognition. This failure resulted in Resident 1 being hit by a moving vehicle while out in the parking lot of the facility, which has the potential to cause pain or injury to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were treated with dignity and respect when staff awakened one resident in the middle of the night to ask if she wanted to be moved to another room, for one of three sampled residents (Resident A). This failure had the potential to cause unnecessary disruption, discomfort, and interfere with the resident's ability to attain her highest practicable physical, mental, and psychosocial well-being. On July 8, 2025 @ 11:09 a.m., an unannounced visit to the facility was conducted to investigate an allegation of resident rights issue. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a fall prevention intervention for one of three sampled residents (Resident 1), by not ensuring the tab monitor was attached while the resident was in a wheelchair, as sspecified in the resident's care plan. This failure had the potential to place Resident 1 at risk for further falls and potential injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when three dumpsters' lids were not closed, and the surrounding area was littered with trash. This failure had the potential to attract pests and rodents which could lead to contamination and food borne illness among residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure medications were properly labeled consistent with the policies and procedures and stored at appropriate temperature consistent with the drug manufacturer's instructions when: 1. Bisacodyl (medication to relieve constipation) 10 mg (milligram; unit of measurement) suppositories were stored in the medication room and the medication cart without proper pharmacy labels; 2. Multi-dose medications were not properly labeled with open dates; 3. One liquid medication bottle did not have a legible expiration date on the manufacturer's label; and 4. The room temperature in the Nursing Station 2 Medication Room was not maintained below the drug manufacturer's instruction for storage at room temperature. These failures had the potential for residents to received ineffective medication treatment.

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 resident was found on the puree blender. 2. Spilled dry oatmeal was observed on the floor inside the dry storage room. 3. Two ovens had grime buildup and food residue. 4. A dietary staff's plastic cup was found on the bottom shelf of the tray line table. 5. The cook's beard and mustache were not covered with a beard net. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) among a vulnerable population of 86 out of 92 residents who received food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of one resident reviewed (Resident 71), the resident's bathroom had a functioning paper towel dispenser. This failure had the potential to prevent Resident 71 from performing proper hand hygiene, increasing the risk of infection.

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman (LTC Ombudsman - an advocate for residents of nursing homes to protect residents' rights and ensure quality care) at the same time the discharge notice was given to the resident, for one of three residents reviewed for closed records (Resident 88). This failure had the potential to delay advocacy and oversight of Resident 88's discharge plan, impacting continuity of care and resident rights.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure expired medications were not available for use by residents. This failure had the potential for residents to received ineffective medication therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician's order for oxygen was transcribed into the electronic medical record after the order was received. This failure resulted in an incomplete and inaccurate medical record, which could have led to miscommunication among staff regarding Resident 189's prescribed oxygen therapy, potentially affecting the resident's respiratory care.

Inspectors wroteBased on interview, and record review the facility failed to ensure one of three staff reviewed for immunization (process of developing immunity [the ability to resist diseases]) (Certified Nurse Assistant [CNA] 1) was provided education regarding the risk and benefits of the COVID-19 vaccine (a medication that helps the body fight diseases caused by COVID-19 [a respiratory illness caused by a virus ). This failure had the potential to leave staff without proper guidance and information regarding the COVID-19 vaccine, potentially affecting their decision-making and increasing the risk of infection transmission within the facility.

Inspectors wroteBased on observation & interviews, the facility failed to ensure resident's call light was within reach for one out of three residents (Resident 1). This failure had the potential to result in Resident 1 unable to call nursing staff for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate a care plan (an individualized, plan of care, specific to resident's healthcare needs) for hard of hearing for one of three residents (Resident 3). This failure had the potential to negatively impact the resident's quality of life, as well as the quality of care and services received for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Provide fall prevention interventions for a resident assessed as a fall risk, for one out of three residents (Resident 3). This failure resulted for Resident 3 falling and sustaining a scalp hematoma (localized collection of blood that forms beneath the skin of the scalp due to trauma). 2. Ensure that the bed alarm (a device used as a fall precaution intervention to alert staff when a resident attempts to get out of bed) was properly attached to the resident, for one out of two residents (Resident 2). This failure had the potential to result in injury to Resident 2 if the resident attempted to get out of bed without staff knowledge.

Inspectors wroteBased on interview and record review, the facility failed to follow up with the physician regarding the Registered Dietitian's (RD) recommendation to discontinue the resident 's high protein nourishment (HPN) for one of three sampled residents (Resident 1). This failure had the potential to contribute to the resident's significant weight gain of 29 pound (lbs) (26.6 percent) over 6 months.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three residents (Resident 1) was monitored following an allegation of physical abuse. This failure had the potential to affect Resident 1 ' s emotional and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure the correct insulin (medication use to lower blood sugar levels) dose was administered as prescribed by the physician, for one of three residents (Resident 3). This failure has the potential risk of dangerously low blood sugar level for Resident 3, leading to harm and or death.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of sexual abuse to the California Department of Public Health (CDPH) within two hours after the allegation was made for one of three sampled residents (Residents 1). This failure could have resulted in an unsafe living environment for Res 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed, for two of three employees reviewed, to ensure the infection control policy and procedures were followed when Certified Nursing Assistant (CNA) 1 and Physical Therapist (PT) failed to wear an eye protection (goggles or a face shield that covers the front and sides of the face) as required while entering and providing care for a resident who was infected with the Covid-19 virus (a highly infectious respiratory virus). This failure had the potential to increase staff and resident exposure and transmission of Covid-19 virus resulting in illness. Findings 1. On October 31, 2023, at 12:50 p.m., an observation with a concurrent interview was conducted with CNA 1. CNA 1 was observed exiting the room of a Covid (+ positive Covid test) resident without an eye protection. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure food was labeled, dated, and stored properly for 75 of 77 residents who received food from the kitchen. The facility further failed to ensure all food transported from the kitchen to residents' rooms was covered the entire time for residents who resided on two (200 Hall and 300 Hall) of 3 halls in the facility.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure an assessment was conducted prior to bolster mattress use for 1 (Resident #15) of 1 sampled resident reviewed for physical restraints.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 3 (Residents #53, #63, and #88) of 19 sampled residents.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to refer 1 (Resident #26) of 6 sampled residents to the appropriate state-designated authority for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination after the resident received a new mental illness diagnosis.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to include a resident's ability to perform their activity of daily living (ADL) and the assistance required on the comprehensive care plan for 1 (Resident #39) of 24 sampled residents.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a root cause analysis of a fall was conducted for 1 (Resident #15) of 5 sampled residents reviewed for accidents.

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, the facility failed to ensure oxygen was administered as ordered by the physician for 2 (Resident #63 and Resident #243) of 2 sampled residents reviewed for respiratory care.

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, the facility failed to ensure their medication error rate less was than 5%. The facility had two medication errors out of 28 opportunities, which yielded a medication error rate of 7.14% for 2 (Resident #10 and Resident #16) of 4 residents observed for medication administration.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure medication labels on 1 (3A medication cart) of 4 medication carts were legible.

Inspectors wroteBased on interview and record review the facility failed to administer medications according to the facility's policy and procedure for one of three sampled residents (Resident 1) when the facility left the wrong medication unattended for Resident 1. This failure had the potential cause Resident 1 to consume the wrong medication and experiencing an adverse effect.