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 was found deficient in multiple areas including failure to accurately record and update physician orders, failure to provide ordered double portions to a resident, inadequate infection control practices including improper use of gowns and gloves, failure to provide scheduled showers and maintain resident hygiene, lack of proper wheelchair maintenance, insufficient RN coverage, medication errors related to transcription and administration, and improper medication storage and labeling.

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 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 personal hygiene care and eating assistance to Resident #1, who was bed or chair bound and dependent on staff for all care needs. Observations showed the resident had not received personal hygiene care for over 8 hours and was left with food out of reach. The resident was at risk for weight loss and required staff assistance with meals and hydration.

The complaint investigation found that staff failed to promptly initiate CPR and make a code blue announcement when a full code resident was found unresponsive with no pulse or respirations. Staff were not properly trained on code blue procedures and use of the loudspeaker. The violation was initially at immediate jeopardy level but was lowered to level D after corrective actions.

The facility failed to provide basic life support in a timely manner for one of four sampled residents who was a full code and found without a pulse. Staff did not make a code blue announcement, and CPR was delayed. The resident was found unresponsive at approximately 5:00 P.M. and CPR was initiated only after delay. EMS was called and arrived, but the resident was pronounced dead at 5:22 P.M. The facility had policies on medical emergencies and CPR, but staff training and response were inadequate.

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.

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.

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 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 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.