Inspection Reports for
Rancho Mirage Health and Rehabilitation Center

The complaint investigation was related to an allegation of a resident rights issue involving a resident being awakened at night to discuss a room change. The complaint was substantiated based on interviews and record review.

The facility failed to ensure that residents were treated with dignity and respect when staff awakened a resident in the middle of the night to ask if she wanted to be moved to another room, potentially causing unnecessary disruption and discomfort.

The visit was complaint-related due to a fall incident involving Resident 1 on February 22, 2025. The complaint was substantiated as the facility failed to attach the tab monitor as required, increasing the risk of falls.

The facility failed to ensure that a tab monitor was attached to Resident 1 while in a wheelchair as required by the care plan, resulting in a fall on February 22, 2025. Interviews with staff confirmed the tab monitor was not attached, and the facility policy requires such devices to be used and checked for residents at risk of falls.

The facility was found deficient in multiple areas including failure to maintain a functioning paper towel dispenser in a resident's bathroom, delayed notification to the Long-Term Care Ombudsman of resident discharge, expired and improperly labeled medications, unsafe food preparation and storage practices, improper garbage disposal, incomplete medical records regarding oxygen orders, and inadequate COVID-19 vaccine education for staff.

The facility was found to have multiple deficiencies including a non-functioning paper towel dispenser affecting hand hygiene, delayed notification to the Long-Term Care Ombudsman of a resident discharge, expired and improperly labeled medications, unsafe food preparation and storage practices, improper garbage disposal, incomplete medical records regarding oxygen orders, and inadequate COVID-19 vaccine education for staff.

The visit was complaint-related, focusing on quality of care issues including call light accessibility, care planning for hearing impairment, fall prevention, and bed alarm use. The complaints were substantiated with observations, interviews, and record reviews confirming deficiencies.

The facility failed to ensure Resident 1's call light was within reach, failed to initiate a care plan for Resident 3's hearing impairment, and did not provide adequate fall prevention interventions for Residents 2 and 3, including improper use of bed alarms. These failures posed potential or actual minimal harm to residents.

The visit was complaint-related, focusing on a quality-of-care issue involving failure to implement dietary recommendations. The deficiency was substantiated with evidence from medical records, interviews, and medication administration records.

The facility failed to follow up with the physician regarding the Registered Dietitian's recommendation to discontinue high protein nourishment for Resident 1, which potentially contributed to a significant weight gain of 29 pounds (26.6%) over six months. The recommendation was not carried out by nursing staff, and the resident continued receiving high protein nourishment with all meals until October 9, 2024.

The visit was complaint-related, investigating an allegation of physical abuse. The complaint was substantiated as the facility failed to monitor the resident as required.

The facility failed to monitor Resident 1 for 72 hours following an allegation of physical abuse by a caregiver, which could affect the resident's emotional and psychosocial wellbeing. The Director of Nursing confirmed the lack of monitoring and stated the facility's standard practice is to monitor residents every shift for 72 hours after abuse allegations, although no specific policy exists.

The investigation was triggered by a complaint regarding quality care issues. The complaint was substantiated as the licensed nurse administered an incorrect insulin dose, which was confirmed through interviews and record reviews.

The facility failed to ensure the correct insulin dose was administered to Resident 3, resulting in the administration of 100 units of Lantus instead of the prescribed 10 units. This error led to the resident being transferred to the hospital due to potential hypoglycemia and risk of death.

The investigation was triggered by a complaint regarding an incident on February 3, 2024, where Resident 2 was observed with his hand inappropriately placed between Resident 1's legs. The facility did not report the allegation to authorities within the required two-hour timeframe. The family member of Resident 1 reported the abuse on February 13, 2024, ten days after becoming aware of the incident.

The facility failed to report allegations of sexual abuse to the California Department of Public Health within two hours after the allegation was made, which could have resulted in an unsafe living environment. Interviews and record reviews confirmed the incident and delayed reporting by facility staff and administration.

The facility was found deficient in several areas including failure to assess and document the use of physical restraints (bolster mattress), inaccurate Minimum Data Set (MDS) assessments, failure to conduct root cause analysis for falls, improper oxygen administration, medication errors exceeding 5%, illegible medication labels, and improper food labeling, storage, and transport practices.

The facility failed to ensure that two of three employees reviewed, including a Certified Nursing Assistant and a Physical Therapist, wore required eye protection when entering and providing care for a resident infected with COVID-19, potentially increasing exposure and transmission risk.

The facility failed to ensure that two of three employees reviewed, including a Certified Nursing Assistant and a Physical Therapist, wore required eye protection when entering and providing care for a resident infected with COVID-19, potentially increasing exposure and transmission risk.

The complaint was substantiated based on interviews and record review. Resident 1 reported the medication error but delayed reporting due to fear of retaliation. The nurse responsible received a written warning and was reassigned.

The facility failed to administer medications according to policy for Resident 1 when the wrong medication was left unattended, posing potential harm. Interviews and record reviews confirmed the error and subsequent disciplinary action against the nurse involved.

The facility was found deficient in multiple areas including failure to reassess resident self-administration of medication, failure to assist with advance directives, failure to notify family about bed hold rights, incomplete care plans, inadequate activity provision, inconsistent skin condition monitoring, improper discontinuation of restorative nursing services, failure to implement fall prevention care plans, unlabeled enteral feeding bags, improper nasal cannula replacement, medication administration errors, unlabeled food storage, failure to provide ordered rehabilitative services, and lapses in infection control practices.