Inspection Reports for
Rancho Rehab and Healthcare Center

The facility failed to maintain a safe environment by not controlling water temperatures for resident consumption, resulting in a resident suffering a second-degree burn. The investigation revealed the coffee machine water temperature was excessively high (up to 200 degrees F), staff did not check water temperature before serving, and documentation and incident follow-up were incomplete.

The facility failed to conduct required emergency preparedness exercises and fire drills as scheduled. Deficiencies were found in emergency power system documentation, fire alarm system maintenance, sprinkler system maintenance, smoke barrier integrity, fire door functionality, and smoking area management.

The facility had multiple deficiencies including failure to perform CNA registry checks for new hires, inaccurate resident assessments especially related to dialysis treatments, incomplete and inaccurate physician orders, failure to provide ordered treatments and care such as showers and medication, inadequate wheelchair maintenance, missing dialysis communication sheets, insufficient RN coverage, medication errors including delayed PRN pain medication, failure to act on pharmacist medication review recommendations, medication storage and labeling issues, untimely lab testing, food safety violations, and lapses in infection control practices.

The complaint investigation focused on Resident #11, who had advanced metastatic cervical cancer and pressure ulcers. The facility failed to initiate pain medication orders timely and did not perform pain assessments every shift as required. Documentation was incomplete regarding pain location, interventions, and effectiveness. Staff interviews revealed communication gaps and lack of awareness of admission orders.

The facility failed to process and initiate pain medication orders for Oxycodone and acetaminophen for 23 days after admission and did not assess the resident for pain every shift as required by policy. Documentation of pain assessments and interventions was incomplete, and non-pharmacological interventions were not included in the care plan. Staff interviews confirmed lack of awareness and inconsistent pain management practices.

The complaint investigation was triggered by an incident on 9/19/24 where LPN A forcibly took Resident #2 to the floor and restrained him/her after the resident became upset about removal of his/her oxygen concentrator. The resident struck LPN A in the face twice. The facility failed to notify DHSS immediately and failed to properly document the incident and medication orders. The investigation concluded LPN A acted in self-defense but questions remain about the use of de-escalation tactics and proper reporting.

The facility failed to ensure Resident #2 was free from abuse when Licensed Practical Nurse A (LPN A) forcibly took the resident to the floor, held the resident down with a knee, and forced the resident back to his/her room after the resident became upset about removal of his/her oxygen concentrator. The facility also failed to immediately notify the Department of Health and Senior Services (DHSS) of the abuse allegation and failed to properly document the incident and medication orders. The resident was administered Haldol and Benadryl after the incident, but the orders were not documented timely.

The facility was found deficient in quality of care, including failure to ensure proper treatment and care for residents, inadequate protective oversight leading to an elopement incident, and failure to provide adequate supervision and assistance devices to prevent accidents. Deficiencies were cited related to residents missing surgeries due to facility errors, improper dressing and transfers, and lack of staff education on appointment instructions and resident care.

The complaint investigation revealed substantiated issues including failure to hold anticoagulant medication as ordered before surgery, failure to arrange transportation, improper dressing and transfer of a resident to dialysis, and inadequate supervision and documentation related to a resident elopement incident.

The facility failed to hold blood thinners as ordered for a resident prior to heart valve surgery, causing missed surgeries and transportation issues. Another resident was sent to dialysis improperly dressed and without required mechanical lift precautions. Additionally, a resident eloped from the facility without staff knowledge, and the facility lacked proper documentation and staff education on elopement prevention.

The facility failed to provide adequate activities of daily living (ADL) care, including personal hygiene and eating assistance for one resident. Observations and record reviews showed issues with nutrition management, personal hygiene, and incontinence care.

The complaint investigation found the violation to be at an imminent danger class I level initially, later lowered to class II after corrective actions. The facility implemented corrective actions including staff training on CPR policy and emergency response.

The facility failed to provide timely basic life support including CPR to a resident who was a full code. The investigation found staff did not promptly initiate CPR or call a code blue, and there were deficiencies in staff training and emergency response procedures.

The visit was complaint-related due to a fall incident involving Resident #300. The fall was witnessed by a CNA, and the resident sustained a left hip fracture confirmed by hospital admission. The resident fell when the bed moved during care due to faulty bed brakes. The complaint was substantiated with findings of bed instability and inadequate staff education.

The facility failed to ensure the resident's bed was stable and safe during care, resulting in the resident falling out of bed. The resident sustained a left hip fracture after the fall. Staff reported faulty beds with brakes that did not work properly. The facility conducted assessments and interventions following the fall, but issues with bed safety and staff education were noted.

Complaints investigated included allegations related to Resident Rights and other care issues. Some complaints were substantiated with deficiencies found, while others were unsubstantiated.

The facility was found noncompliant with multiple requirements including resident rights, reasonable accommodations, financial security, safe environment, comprehensive assessments, care planning, medication administration, food safety, pest control, and equipment maintenance. Several residents were observed with unmet needs and environmental deficiencies were noted.

The facility failed to meet several Life Safety Code requirements including grease buildup on kitchen range hood filters, inadequate fire alarm notification devices in courtyards, use of prohibited portable space heaters, failure to maintain the emergency generator, and improper use of extension cords and power strips.

The facility failed to maintain an adequate surety bond for resident trust funds as required by regulation. The bond amount was insufficient compared to the required amount based on the average monthly balance of resident funds.

The facility was found deficient in multiple areas including resident dignity and care, call light accessibility, resident funds security, environmental cleanliness, assessment and care planning, medication administration, food service quality and safety, equipment maintenance, pest control, and proper disposal of garbage.

The facility failed to ensure call light cords were accessible to residents on two halls, limiting their ability to summon assistance. Additionally, the facility failed to administer medications as ordered to one resident, with multiple missed doses documented over a two-month period.

The complaint investigation substantiated issues with missed treatments and insufficient nursing staff coverage on 6/3/23, impacting resident care and safety.

The facility failed to ensure treatments were performed for sampled residents, resulting in missed medication and wound care treatments. Staffing shortages were noted, including absence of a nurse for several hours, impacting resident care.

Staff failed to ensure treatments and wound care were performed as ordered for multiple residents, and the facility was without a nurse for approximately three and a half hours on 6/3/23, potentially affecting all residents. Missed treatments and inadequate staffing were documented with minimal harm identified.

The facility failed to provide written notice and explanation to residents and their families regarding room changes. Residents were not given the opportunity to see new rooms or meet new roommates prior to moves, violating resident rights.

The complaint investigation found that the facility did not provide written notice or explanation for room changes to residents or their families, and residents were not given the opportunity to see new rooms or meet new roommates prior to the move. The Social Worker did not provide written notification as required, and family members reported missing belongings and dissatisfaction with the moves.

The facility failed to provide two sampled residents and/or their families with written explanations for room changes and did not allow the residents to see the new rooms or meet new roommates prior to the move. The facility's policy on room changes was reviewed, and interviews confirmed that residents and families were not given timely written notice or opportunity to meet roommates before moves.

The complaint investigation found that the facility failed to notify the resident and/or the resident's representative in writing of an immediate discharge notice, including the reasons for discharge for one sampled resident. The resident was transferred to the hospital and was not allowed to return. The facility did not provide a 30-day discharge notice or emergency discharge paperwork. The resident's daughter was involved in discharge planning and was upset about the discharge process.

The facility failed to notify the resident and/or the resident's representative in writing of an immediate discharge notice, including the reasons for discharge for one sampled resident. The facility census was 91 at the time of the survey.

The facility was found in compliance with COVID-19 emergency preparedness and infection control requirements. However, deficiencies were cited related to pressure ulcer prevention and treatment, and nutrition/hydration status maintenance, including failure to document administration of enteral feedings and assistance to residents requiring help with meals and fluids.

The investigation was complaint-driven, focusing on allegations of inadequate pressure ulcer care and poor hygiene practices by staff. The complaint was substantiated as evidenced by observations and interviews.

The facility failed to ensure that residents with pressure ulcers received care consistent with professional standards to promote healing and prevent infection. Observations and interviews revealed inadequate treatment and poor hygiene practices related to pressure ulcers in sampled residents.

The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness but failed to maintain an infection control program during the COVID-19 pandemic. Specific failures included improper use of PPE, inadequate hand hygiene, and failure to clean and disinfect equipment between residents.

The facility was found deficient in multiple areas including failure to deliver mail on Saturdays, failure to provide ordered nutritional supplements to residents, lack of documentation of physician visits as required by CMS, failure to prepare and serve super cereal as ordered, improper labeling and storage of food items in the kitchen, and inadequate infection prevention signage and supplies for visitors.

The facility was found deficient in multiple areas including residents' right to receive mail on Saturdays, nutritional and hydration status maintenance, physician visit documentation, menu and nutritional adequacy, food procurement and storage, and infection prevention and control. Plans of correction were submitted to address these deficiencies.

The facility failed to meet several Life Safety Code requirements including missing 'no exit' signs on doors leading outside, lack of semi-annual fire alarm inspections, incomplete fire drills, and improper disposal of ashtray contents in designated smoking areas. These deficiencies had the potential to affect all occupants of the facility.

The facility was found to have multiple deficiencies related to care plan timing and revision, quality of care, pain management, safe and effective medication system, bedrails, and pharmacy services. Several residents' care plans and medication administration records were not properly updated or documented.

The facility failed to maintain walls and doors that resist the passage of smoke, had gaps around doors and drains, and did not ensure proper fire barriers and smoke barriers. Extension cords were improperly used, and some doors lacked self-closing devices or proper fire resistance ratings.

The facility was found to have multiple deficiencies including issues with resident care, abuse prevention, food safety, environment safety, and documentation. The facility failed to maintain a safe, clean, and homelike environment and did not fully comply with resident rights and care plan requirements.

The facility failed to maintain an adequate emergency preparedness plan and did not meet several fire safety requirements including maintaining fire barriers, self-closing doors, hydrostatic testing of fire extinguishers, fire drills, smoking regulations, and proper storage of hazardous materials and oxygen tanks. These deficiencies potentially affected all residents and staff.