F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings:
On September 16, 2024, at 2:30 p.m., an unannounced visit to the facility on two complaints investigation
was initiated.
A review of Resident 1's medical records indicated she was originally admitted on [DATE], with diagnoses
of aphasia, (affects the ability to express and understand written and spoken language), after a stroke,
urinary tract infection, (infection in the bladder), hydronephrosis, (caused by a blockage in the tube that
connects the kidney to the bladder), with renal and ureteral calculi, (hard deposits made of minerals and
salts that form inside the kidneys), Pressure ulcer injury, (bedsore) stage 4, (full thickness tissue loss with
exposed bone, tendon, or muscle).
A review of Resident 1's Brief Interview for Mental Status, (BIMS - an assessment tool for cognitive status)
dated August 8, 2024, indicated a score of 10, (8-12 - moderate cognitive impairment, [cannot navigate to
new places, and they have significant difficulty completing complex tasks such as managing finances. In
this stage, a person sometimes becomes confused about where they are and what is happening]).
A review of Resident 1 ' s Care Plan dated August 5, 2024, indicated .Cognitive impairment exhibits
cognitive loss related to Alzheimer ' s ability to make self-understood, decreased ability to understand
others, impaired decision making skills, long term and short term deficit .
On September 16, 2024, at 4:30 p.m., an interview was conducted with Resident 1. Resident 1 was asked if
she was capable of making decisions for her care. Resident 1 answered my daughter helps me with
decisions.
A review of Resident 1's eInteract Change in Condition Evaluation dated August 9, 2024, at 9:32 p.m.,
indicated .1. The change in condition, symptoms or signs I am calling about is/are . 9. Diarrhea . CNA
[Certified Nursing Assistant] reported stool with slimy consistency and mucus. Sample was
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
555921
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555921
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/04/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rancho Bellagio Post Acute
26940 E Hospital Road
Moreno Valley, CA 92555
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
collected . 3. Resident Representative Notification 1. Name of family/resident representative notified: self
notified .
A review of Resident 1's Progress Notes dated August 14, 2024, at 12:53 p.m., indicated .Called Family
[name of family member] regarding Resident got C-Diff, [infection in the stool] as a result .
Residents Affected - Few
Further review of Resident 1's medical records indicated that the resident representative was notified on
August 14, 2024, five days after the change in condition, and there was no documentation Resident 1's
representative was notified on August 9, 2024.
On September 16, 2024, at 5:38 p.m., a concurrent interview and record review was conducted with the
Registered Nurse, (RN). The RN stated that Resident 1's BIMS score was 10. The RN stated that Resident
1 had cognitive impairment. The RN stated that if a resident had cognitive impairment, they would notify the
resident representative listed as an emergency contact if a change in condition had occurred. The RN
stated that Resident 1's representative should have been notified on August 9, 2024, when she had a
change in condition.
A review of the facility ' s policy and procedure titled Change in a Resident ' s Condition or Status revised
May 2017, indicated .Our facility shall promptly notify the resident, his or her Attending Physician, and
representative (sponsor) of changes in the resident's medical/mental condition and/or status .2. A
significant change of condition is a major decline or improvement in the resident's status that: a. Will not
normally resolve itself without intervention by staff or by implementing standard disease - related clinical
interventions (is not self-limiting) b. Impacts more than one area of the resident's health status c. Requires
interdisciplinary review and/or revision to the care plan .3. Unless otherwise instructed by the resident, a
nurse will notify the resident's representative when . b. There is a significant change in the resident's
physical, mental, or psychosocial status .4. Except in medical emergencies, notifications will be made within
twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555921
If continuation sheet
Page 2 of 2
