Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure one of seven residents' (Resident 7)
call light was answered timely.
Residents Affected - Few
This failure had the potential to not meet the resident's needs.
Findings:
On October 31, 2024, at 8:44 a.m., an unannounced visit was conducted to the facility for a quality of care
issue.
On October 31, 2024, at 12:02 p.m., during a concurrent observation and interview with Certified Nursing
Assistant (CNA) 2, CNA 2 was observed to not answer Resident 7's call light after walking past the
resident's room twice. CNA 2 stated he had just finished taking his morning break and did not have any
residents to assist at the time. CNA 2 stated he saw the call light on and thought the nurse assigned to that
room would answer it. CNA 2 stated he should have answered the call right away, even if the room was not
on his assignment list. CNA 2 further stated he should have checked on the resident and communicated the
resident's needs to the other CNA or licensed nurse. CNA 2 stated, had the resident needed immediate
help, it would not have been known, which placed the resident at risk for harm or injury.
On October 31, 2024, at 12:17 p.m., an interview was conducted with Resident 7 in her room. Resident 7
was alert and oriented and stated she had pressed her call light more than 20 minutes ago. Resident
stated, sometimes it took a while for staff to respond. She stated a nurse eventually came in to help
reposition her in bed because she was not comfortable. Resident 7 stated, she was weak and needed
assistance with repositioning.
On October 31, 2024, at 12:27 p.m., during a concurrent observation and interview with a Licensed
Vocational Nurse (LVN) 1, LVN 1 stated he was the charge nurse on that wing that day. LVN 1 further stated
one way staff were alerted when a call light was activated was through a wall board system mounted on the
wall in the nursing station. LVN 1 stated, when the call light was activated, the resident ' s room would light
up, accompanied by an alarm sound, to alert staff that resident needed assistance. LVN 1 stated all staff
were expected to respond to a call light whether the room was not assigned to them. LVN 1 further stated, if
the call light was not answered immediately, it could delay meeting the resident ' s needs.
On October 31, 2024, at 3:28 p.m., the Director of Staff Development (DSD) was interviewed. The DSD
stated staff members were expected to answer the call light as soon as possible and should never
(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 5
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
10/31/2024
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 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
ignore it. She stated CNA 2 should have answered the call light to avoid delays in providing care to
residents.
On October 31, 2024, at 4:15 p.m., the Director of Nursing (DON) was interviewed. The DON stated, staff
members were expected to answer the call light immediately to ensure the needs of residents were met.
The DON further stated, CNA 2 should have answered the call light even if the room was not assigned to
him, and communicated the resident's needs to the appropriate staff.
On October 31, 2024, Resident 7's record was reviewed. Resident 7 was admitted to the facility on [DATE],
with diagnoses which included bilateral osteoarthritis of knee, muscle weakness, and asthma (a type of
lung disease).
A review of Resident 7's Brief Interview for Mental Status (BIMS -a tool used to screen and identify
cognitive condition of residents), dated September 23, 2024, indicated a score of 13 (cognitively intact).
A review of Resident 7's care plan, dated June 17, 2024, indicated, .ADL (activities of daily living)/Mobility:
Resident has actual risk for ADL/mobility decline and requires assistance .Will have needs anticipated and
met by staff .
A review of facility policy and procedure titled, Answering the Call Light, dated October 2010, indicated,
.Answer the resident's call as soon as possible .If you are uncertain as to whether or not a request can be
fulfilled or if you cannot fulfill the resident' s request, ask the nurse supervisor for assistance .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555921
If continuation sheet
Page 2 of 5
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
10/31/2024
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 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a
resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed
consent; and (4) Correctly install and maintain the bed rail.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure the correct size bed rails were
installed on one resident's bed as indicated on the resident's bed rails admission assessment, for one of
seven sampled residents (Resident 2).
This failure had the potential to result in negative outcomes including accident, physical restraint, decline in
mobility and function, and psychosocial outcome.
Findings:
On October 31, 2024, at 12:02 p.m., a concurrent observation and interview were conducted with Resident
2. Resident 2 stated her bed was comfortable, but she did not like her side rails. Resident 2 stated she
initially had short side rails but after she returned from the hospital, they changed her bed to one with
longer side rails. She further stated that she felt closed in and she could not transfer easily to her
wheelchair.
A review of Resident 2's medical records indicated she was originally admitted on [DATE], with diagnoses
of left knee and hip effusion (when fluids collect around a joint and cause swelling), muscle weakness, and
was readmitted on [DATE].
A review of Resident 2's History and Physical,dated September 18, 2024, indicated .patient has intermittent
capacity to make decisions .
A review of Resident 2's Bed Rail and Entrapment Risk Observation/Assessment dated September 16,
2024, and October 26, 2024, both indicated .quarter (1/4 - unit of measurement) bed rail type .left and
upper locations .for mobility .
On October 31, 2024, at 1:09 p.m., a concurrent observation, interview and record review were conducted
with the Minimum Data Set (MDS) coordinator (a person who coordinates assessments in long-term care
facilities). The MDS stated the admitting nurse would complete a bed rails assessment for each resident
upon admission. The MDS stated, if the resident or family wished to make a change, a re-assessment of
the resident would be done, and the physician would be informed. The MDS verified that Resident 2 had
half side rails installed on her bed, instead of the quarter side rails as indicated on her bed rails
assessment. The MDS stated Resident 2 should not have had half side rails installed on her bed because
they could potentially make the resident feel entrapped and may have limited her mobility on the bed.
On October 31, 2024, at 1:37 p.m., a concurrent observation and interview were conducted with the
Maintenance Director (MTD). The MTD stated most of the facility beds came with the quarter side rails,
which measured at 10 inches (a unit of measurement) long and half side rails, which measured at 32
inches long. The MTD verified that Resident 2 had half side rails installed on her bed.
On October 31, 2024, at 4:15 p.m., an interview was conducted with the Director of Nursing (DON). The
DON stated upon admission, all residents were assessed for side rail use. The DON stated in the facility,
quarter side rails were standard but if a resident or family requested a change, the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555921
If continuation sheet
Page 3 of 5
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
10/31/2024
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 0700
Level of Harm - Minimal harm
or potential for actual harm
licensed nurse would re-assess the resident and inform the physician. The DON stated according to
Resident 2's re-admission assessment, Resident 2 should have had quarter side rails, not the half side
rails, on her bed. The DON stated Resident 2's bed rails assessment was not accurate and should have
been followed up. The DON further stated the resident could potentially have felt uncomfortable and
entrapped in her bed, which could have limited her mobility.
Residents Affected - Few
A review of facility policy and procedure titled, Bed Safety and Bed Rails, dated August 2022, indicated,
.The use of bed rails or side rails is prohibited unless the criteria for use of bed rails have been met
.including resident assessments .The resident assessments to determine risk of entrapment includes
.mobilit .accident hazards .barrier to perform routine activities .contributes to feelings of isolation .or anxiety
.The staff shall report to the director or nursing and administrator any incidents associated with side or bed
rails .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555921
If continuation sheet
Page 4 of 5
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
10/31/2024
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure infection control practices were
implemented when a Certified Nurse Assistant (CNA) did not perform handwashing after leaving the room
of a resident on Enhanced Barrier Precautions (EBP - infection prevention and control practices that can
help reduce the spread of infection).
Residents Affected - Few
This failure had the potential to increase the spread of pathogens (germs) from staff to residents which
could lead to infections and illness.
Findings:
On October 31, 2024, at 9:29 a.m., a Certified Nursing Assistant (CNA) 1 was observed providing care to a
resident on EBP. CNA 1 removed her gown and gloves and did not perform hand hygiene after exiting the
resident's room. CNA 1 was observed grabbing a meal tray cart from outside and pushing the cart down the
hallway.
On October 31, 2024, at 9:31 a.m., CNA 1 was interviewed. CNA 1 stated she had forgotten to wash her
hands and that she should have used the gel sanitizer outside in the hallway after leaving the resident's
room. She further stated, not washing her hands could spread germs through cross contamination and
potentially cause infections in the residents.
On October 31, 2024, at 3:15 p.m., the Infection Preventionist (IP) was interviewed. The IP stated that all
staff should wash their hands before and after any patient care or procedures. The IP further stated that
CNA 1 should have washed her hands to prevent the spread of infection to the residents.
On October 31, 2024, at 4:15 p.m., the Director of Nursing (DON) was interviewed. The DON stated all staff
members were expected to perform hand washing before and after patient care. The DON stated that CNA
1 should have washed her hands or used the gel sanitizers available in the hallway. The DON further stated
unwashed hands could transmit and spread infection to other residents.
On October 31, 2024, Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE],
with diagnoses which included left hip replacement surgery and right breast cancer with mastectomy
(surgery to remove a breast).
A review of Resident 6's care plan, dated August 2, 2024, indicated, .Vascular Access: Resident is at risk
for complications due to presence of a peripherally inserted central catheter (PICC - a long, thin tube that's
inserted through a vein in your arm and passed through to the larger veins near your heart and used to
deliver fluids and medications) .Utilize Enhanced Barrier Precautions (EBP) during high-contact resident
care activities .
A review of facility policy and procedure titled, Handwashing/Hand Hygiene, dated August 2019, indicated,
.All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of
infections to other personnel, residents, and visitors .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555921
If continuation sheet
Page 5 of 5
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the October 31, 2024 survey of RANCHO BELLAGIO POST ACUTE?
This was a inspection survey of RANCHO BELLAGIO POST ACUTE on October 31, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at RANCHO BELLAGIO POST ACUTE on October 31, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.