Health inspection·December 12, 2024

F 0578 elderly) score 8 (moderate cognitive impairment). Level of Harm - Minimal harm or potential for actual harm A review of Resident 69's, Advance Directive Acknowledgement, dated November 3, 2024, indicated, Resident 69 was not screened or provided AD education. Residents Affected - Some A review of Resident 69's, IDT Conference Summary, dated November 12, 2024, indicated Resident 69 was not screened or provided AD education. Further review of Resident 69's medical records indicated no documented evidence that education and information were provided to Resident 69. On December 10, 2024, at 11:43 a.m. during a concurrent interview and review of Resident 69's medical record with the Social Service Director (SSD), he stated Resident 69 was not screened, provided education, and reviewed for an AD during the IDT meeting. The SSD further stated he should have discussed the AD with the resident and or the resident representative. 3. Resident 19's record was reviewed. Resident 19 was admitted to the facility on [DATE]. A review of Resident 19's History and Physical dated November 8, 2024, indicated Resident 19 has fluctuating capacity to understand and make decisions. A review of Resident 19's Advance Directive Acknowledgement Form, undated, indicated Resident 19 was not screened or provided AD education. A review of Resident 19's Social History Assessment, dated November 18, 2024, indicated, .Self-responsible .Advance Directive .None of the above . A review of Resident 19's IDT Conference Summary, dated November 11, 2024, indicated the formulation of AD was not discussed with Resident 19 or the RP. Further review of Resident 19's medical record indicated no documented evidence Resident 19 was screened and the resident or the RP was provided education and information about AD. On December 10, 2024, at 11:42 a.m., during a concurrent interview and review of Resident 19's medical record with the SSD, he stated if a resident did not have an AD, he would offer resources and education to the resident or RP. The SSD further stated it was important for residents to be educated and have the opportunity to formulate an AD in the event the resident were unable to make decisions in the future. The SSD stated Resident 19 had no AD and he did not provide resources and education. The SSD further stated he should have provided AD resources and education to Resident 19 or the RP. A review of the facility policy and procedure titled, Advance Directives, dated 2021, indicated, .Prior to, upon, or immediately after admission, the social service director or designee inquires of the resident .about the existence of any written advance directive .If a resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives .Information about whether or not the resident has executed and advance directive is displaced prominently in the medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 2 of 20 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 12/12/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medication Nexium (esomeprazole-is used to treat conditions where there is too much acid in the stomach) was administered according to the physician's order for one of one resident reviewed (Resident 56). Residents Affected - Few This failure had the potential to result in the worsening of gastroesophageal reflux disease (GERD-overaccumulation of stomach acid) for Resident 56. Findings: On December 11, 2024, at 2:48 p.m., during an interview with Resident 56, she stated she had been experiencing a little bit of nausea. Resident 56 stated she takes Nexium before breakfast for GERD but further stated she had not taken her Nexium medication for two days. A review of Resident 56's admission Record, indicated Resident 56 was admitted to the facility on [DATE], with diagnoses which included gastroparesis (a condition in which the muscles in the stomach does not move food for digestion) and GERD. A review of Resident 56's Physician's Order, dated October 10, 2024, indicated, . Nexium .40 MG (milligram - unit of measurement) Give 1 capsule by mouth in the morning for GERD before breakfast . A review of Resident 56's Care Plan, dated October 11, 2024, indicated .FOCUS .gastrointestinal problem related to GERD .Intervention .Administer medication per physician's order . A review of Resident 56's eMAR (electronic Medication Administration Record) Medication Administration Note, indicated, Resident 56 did not receive Nexium on December 10, 2024 and December 11, 2024. On December 11, 2024, at 2:50 p.m., during a concurrent interview and review of Resident 56's eMAR with LVN 1, LVN 1 stated Resident 56 was not given Nexium on December 10, 2024, and December 11, 2024. LVN 1 stated, Nexium was not available. On December 11, 2024, at 2:55 p.m., during an interview with LVN 2, she stated Nexium had been delivered on December 2, 2024, and Resident 56 should have received the medication on December 10, 2024, and December 11, 2024. LVN 2 further stated Nexium should have been administered as ordered by the physician to prevent the worsening of Resident 56's GERD. A review of the facility policy and procedure titled, Administering Medications, dated April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 3 of 20 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 12/12/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 replace the oxygen humidifier bottle in accordance with the facility policy and procedure for one of one resident reviewed for respiratory (Resident 66). Residents Affected - Few This failure had the potential to result in ineffective oxygen therapy, respiratory distress, cross-contamination, and infection, which would lead to a decline in Resident 66's health condition. Findings: On December 9, 2024, at 10:27 a.m., a concurrent observation and interview were conducted in Resident 66's room with LVN 3. Resident 66 was receiving oxygen via nasal cannuala (NC-plastic tube that allows oxygen to be delivered to the nose from a machine). The nasal cannula was observed to be labeled with a date of 12/7. A humidifier bottle (plastic cannister filled with water to humidify air flow) was less than half filled and labeled with the date 11/24. LVN 3 stated, the nasal cannula and humidifier bottle should be changed every seven days. LVN 3 stated the cannula and humidifier bottle should have been changed together on December 7, 2024 but it did not appear that they were changed at the same time. LVN 3 stated if the nasal cannula and humidifier bottle were not changed according to the facility policy and procedure, there would be a potential for cross-contamination which could lead to a decline in the residents respiratory condition if the cannula and humidifier bottle are not changed according to the facility policy and procedures. On December 12, 2024, at 2:40 p.m. an interview was conducted with the infection preventionist (IP). The IP stated nasal cannulas and humidifier bottles are to be changed every seven days or as needed and if humidifiers are empty, they should be replaced. The IP stated if nasal cannulas and humidifiers should be changed every seven days to prevent the risk of cross-contamination and infection for residents receiving respiratory treatment. On December 12, 2024, Resident 66's record was reviewed. Resident 66 was admitted to the facility on [DATE], with a diagnosis which included immunodeficiency (weak ability to fight infection), and Chronic Obstructive Pulmonary Disease (COPD-lung disease making it difficult to breath). A review of the physicians order dated September 20, 2024, indicated, O2 at 2 L/min (liters per minute) via nasal cannula (a tube used to deliver oxygen through the nose) for as needed for SOB (shortness of breath). A review of the physician's order dated December 6, 2024, indicated, change O2 (oxygen) tubing every shift every Saturday. A review of the Care Plan titled Oxygen: Resident requires the use of oxygen. Indicated, .change humidification and O2 tubing as indicated .follow infection control protocol for universal/standard precautions . A review of the facility policy and procedure titled, Prevention of Infection Respiratory Equipment, Revised November 2011, indicated, .the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff .change pre-filled humidifier when the water level becomes low .change the oxygen tubing every seven (7) days, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 4 of 20 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 12/12/2024 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 0695 as needed .take care not to contaminate internal nebulizer tubes . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 5 of 20 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 12/12/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the medication error rates were not five percent or greater when: Residents Affected - Few 1. Resident 21's lidocaine (local anesthetic to relieve pain) patch was applied to the wrong body location; and 2. Resident 137's Metformin (medication to treat high blood sugar) and Carvedilol (heart medicine) were administered without food. These failures had the potential for Residents 21 and 137 to not adequately received the therapeutic effect of the medications. Findings: 1. On December 10, 2024, at 8:39 a.m., during medication administration observation inside Resident 21's room with Licensed Vocational Nurse (LVN) 3, LVN 3 applied Lidocaine Patch 5% (percent - unit of measurement) on Resident 21's back near the right shoulder blade. A review of Resident 21's Physician's Orders, dated August 18, 2024. indicated, .Lidocaine Patch 5% apply to each knee topically one time a day for pain management . On December 10, 2024, at 12:27 p.m., during a concurrent interview and review of Resident 21's Physician's Orders, with LVN 3, he stated he had applied the lidocaine patch to Resident 21's back. LVN 3 further stated he did not follow the physician's order. LVN 3 stated if the resident was complaining of pain in a different site, he should have called the physician to change the area of application. A review of the facility policy and procedure titled, .SPECIFIC MEDICATION ADMINISTRATION PROCEDURES, dated October 2012, indicated, .Apply topical treatment as per physician's order . 2. On December 10, 2024, at 9:30 a.m., during medication administration observation with LVN 1 inside Resident 137's room, LVN 1 administered Carvedilol and Metformin to Resident 137 without food. A review of Resident 137's Physician's Orders, indicated the following: - On November 20, 2024, indicated, .Carvedilol tablet 25 mg (milligram - unit of measurement) .Give 1 tablet by mouth two times a day .Give with food/meal . - On November 27, 2024, indicated .Metformin .oral tablet 1000 mg .Give 1 tablet by mouth two times a day .Give with food/meal . On December 10, 2024, at 3 p.m., during a concurrent interview and review of Resident 137's Physician's Orders, with LVN 1, she stated she did not administer food when she gave Carvedilol and Metformin to Resident 137. LVN 1 further stated she should have administered the medications with food as indicated by the physician's order. The facility's undated policy titled, .SPECIFIC MEDICATION ADMINISTRATION PROCEDURES .ORAL (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 6 of 20 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 12/12/2024 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 0759 MEDICATION ADMINISTRATION, dated October 2012, indicated .To administer oral medication in a safe, accurate and effective manner .if needed for medication .administered in food . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 7 of 20 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 12/12/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the lunch menu on December 9, 2024, met residents' needs when: 1. Dietary Aide (DA 1) served pudding instead of mandarin oranges for five of five residents (Residents 19, 41, 134, 190 and 332) on a renal diet (a restricted diet that can help slow kidney damage). 2. [NAME] (CK 1) served pureed spinach instead of green beans for one of one resident (Resident 332) on a renal pureed diet (smooth, lump-free foods that require no chewing). 3. DA 1 used a #8 scoop size to serve dessert for regular diets. 4. CK 1 did not follow the recipe when preparing garlic parmesan spinach. These failures had the potential for residents to miss out on therapeutic and nutritional benefits, correct serving portion, and/or palatability (acceptable taste). Findings: 1. A review of the facility's Winter menu for Week 2, dated December 9, 2024, indicated: -Southern beef patties with cream gravy, Mashed Potatoes (renal diet: wheat pasta) Garlic Parmesan Spinach (renal diet: green beans) Dessert: Ambrosia pudding (1/3 (one-third) cup (unit of measurement), pudding with coconut for regular diets No pudding for renal diets, instead 1/2 (one-half) cup mandarin oranges with coconut. A review of the physician diet orders for Residents 19, 41, 134, 190 and 332 indicated Residents 19, 41, 134, 190, and 332 were on renal diet. On December 9, 2024, at 11:30 a.m., during a concurrent observation and interview of the lunch tray line service (the serving of food onto plates) in the kitchen, DA 1 was observed preparing and scooping pudding into individual cups. DA 1 stated all residents would receive pudding for dessert. On December 9, 2024, at 12:45 p.m., during an observation of the tray line in the kitchen, the meal trays for Residents 19 and 41 contained pudding. On December 9, 2024, at 12:55 p.m., during an observation of the meal service carts, the meal trays for Residents 134 and 190 included pudding. On December 9, 2024, at 1:20 p.m., during a concurrent observation, interview, and review of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 8 of 20 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 12/12/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm spreadsheet menu with the Dietary Supervisor (DSS) in the kitchen, the DSS stated Resident 332's lunch meal tray included pudding. The DSS stated the resident was on a renal diet and should not have been served pudding. The DSS further stated Residents 19, 41, 134 and 190 were also on renal diets and should not have received pudding with their lunch meal trays. She further stated DA 1 should have followed the menu to avoid potential strain on residents with compromised kidney function. Residents Affected - Some On December 9, 2024, at 1:54 p.m., during an interview with the Registered Dietitian (RD), the RD stated dietary staff should have followed the cook's spreadsheet and prepare the meals according to the menu and physician orders to meet residents' nutritional needs. The RD further stated Residents 19, 41, 134, 190 and 332 should not have received pudding because the high phosphorus (a mineral that help keep bones and muscles healthy) content could be harmful to residents with kidney disease. A review of the facility policy and procedure titled Menu Planning, Section 3, dated 2023, indicated, .Menus and cook's spreadsheets are to be dated and posted in the kitchen .The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician orders and followed .The facility's diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility .Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation . A review of the facility policy and procedure titled Renal Diet 40-60-80 Gram Protein, Low Potassium, Low Salt Menu, dated 2023, indicated, .This diet regulates the dietary intake of sodium, potassium and protein to lighten the work of the diseased kidneys . 2. Resident 332's record were reviewed. Resident 332 was admitted to the facility on [DATE], with diagnoses that included End-Stage Renal Disease (when the kidneys stop working) and on hemodialysis (special procedure done by a trained professional to remove wastes and excess fluids from the body). A review of Resident 332's physician's diet order, dated December 9, 2024, indicated, .Controlled Carbohydrate diet, Renal diet, and pureed texture . A review of Resident 332's Care Plans included a care plan with a .Focus .nutritional risk: Resident is at risk for nutritional imbalance related to dialysis, therapeutic diet .Interventions .Provide diet, supplements .as ordered . A review of the facility's Winter menu for week 2, dated December 9, 2024, indicated, .renal diet to be served seasoned green beans with margarine . The facility's Winter menu for Week 2 (Monday) was reviewed. The menu indicated renal diet to be served seasoned green beans with margarine. On December 9, 2024, at 11:39 a.m., during a concurrent observation and interview, CK 1 placed spinach and green beans into serving pans. CK 1 stated, spinach would be served to residents on regular diets and green beans to residents on renal diets. On December 9, 2024, at 1:20 p.m., during a concurrent interview and observation of the lunch tray line in the kitchen, CK 1 prepared pureed spinach on Resident 332's meal tray. CK 1 stated she forgot to substitute green beans for Resident 332, who was on a renal diet. CK 1 stated she did not check the meal card or followed the menu. CK 1 further stated, she should have prepared green beans as spinach was high in potassium (a mineral that help the body function) which may not be safe for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 9 of 20 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 12/12/2024 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 0803 residents with kidney disease. Level of Harm - Minimal harm or potential for actual harm On December 9, 2024, at 1:20 p.m., during a concurrent observation and interview with the DSS in the kitchen, the DSS verified Resident 332's meal tray included spinach. The DSS stated, Resident 332 was on a renal diet and should not have been served spinach because of the high potassium content, which could further damage the resident's kidneys. Residents Affected - Some On December 9, 2024, at 1:54 p.m., during an interview with the RD, the RD stated CK 1 should have followed the cook's spreadsheet and recipes, preparing meals according to the menu to meet Resident 332 nutritional needs according to physician orders. The RD further stated Resident 332 should not have been served spinach because high levels of potassium could accumulate in the body and further damage the kidneys. A a review of the facility policy and procedure titled Menu Planning, Section 3, dated 2023, indicated, .Menus and cook's spreadsheets are to be dated and posted in the kitchen .The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician orders and followed .The facility's diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility .Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation . A review of the facility policy and procedure titled Renal Diet 40-60-80 Gram Protein, Low Potassium, Low Salt Menu, dated 2023, indicated, .Description .This diet regulates the dietary intake of sodium, potassium and protein to lighten the work of the diseased kidneys . A review of the facility policy and procedure titled Therapeutic Diets, dated October 2017, indicated, .Policy Interpretation and Implementation .A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet . 3. On December 9, 2024, at 11:30 a.m., during a concurrent observation and interview with DA 1 in the kitchen, DA 1 used a #8 gray colored scoop to serve pudding and stated it was the correct scoop. During a review of the Winter Menus Spreadsheet, the menu indicated the Ambrosia pudding for regular diet portions was to use the #12 scoop size, equivalent to 1/3 (one-third) cup (unit of measure) or 5 tablespoons (unit of measure). On December 9, 2024, at 4:33 p.m., during a concurrent observation, interview, and review of the menu spreadsheet with the DSS, the DSS stated, DA 1 had used a #8 scoop and should have used a #12 scoop to serve the pudding. The DSS further stated a #8 scoop was almost doubled the portions of the pudding and could result residents to receive too many calories and affect their health. On December 12, 2024, at 3:25 p.m., a telephone phone interview was conducted with the RD. The RD stated the dietary staff should have used the correct serving scoop when preparing pudding. She stated using the wrong scoop could result in residents receiving incorrect calorie amounts and could affect their health. The RD further stated all dietary staff were expected to follow the menu, recipes and serving portions accurately. A review of the facility policy and procedure titled Portion Control, dated 2023, indicated, .To provide specific portion control information .To be sure portions served equal portion sizes listed on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 10 of 20 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 12/12/2024 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the menu, the portion control equipment must be used .Scoop numbers and amounts are listed within the Healthcare Menus Direct, LLC. Recipe books . 4. On December 9, 2024, at 11:39 a.m., during a concurrent interview and observation with CK 1, CK 1 prepared the garlic parmesan spinach. CK 1 stated she had steamed seven large bags of spinach to make about 100 servings. The recipe sheet titled, Recipe: Garlic Parmesan Spinach, was reviewed. The recipe for the garlic parmesan spinach indicated the addition of 11/2 (one and one-half) cup margarine, 12 chopped cloves, 1 tablespoon of salt, and 3 cups of Parmesan cheese to boiled or steamed spinach and may substitute 1/8 teaspoon garlic powder for 1 clove garlic. On December 9, 2024, at 11:45 a.m., during a concurrent interview and observation with CK 1 in the kitchen, CK 1 added an unmeasured amount of butter to the spinach. CK 3 stated the recipe called for one stick of butter and parmesan cheese to be sprinkled on top of the spinach when plating. CK 1 stated she should have followed the recipe as listed to ensure the flavor of the spinach would be palatable and the residents would be served good quality food. On December 9, 2024, at 1:20 p.m., during a concurrent observation and interview with the DSS in the kitchen, the DSS stated CK 1 had not used all the ingredients in the recipe for the garlic parmesan spinach. The DSS stated it was important to follow the recipe because it was designed to meet the nutritional needs and flavor for each serving of food. The DSS further stated, not following the recipe could result in the food being under-flavored and the residents may not want to eat it, which could lead to weight loss. On December 9, 2024, at 1:54 p.m., a test tray sample was conducted with the RD in the DSD's office. The RD stated she did not taste salt or garlic in the spinach. She stated cooks should follow recipes when preparing meals to ensure the food were appealing and the residents met the nutritional value of the meals. The RD further stated not following the recipe could result in residents not wanting to eat the food which could lead to low calorie intake or malnutrition (a condition when the body doesn't get the right amount of nutrients). A review of the facility policy and procedure titled Food Preparation, dated 2023, indicated, .Food shall be prepared by methods that conserve nutritive value, flavor .The facility will use approve recipes, standardized to meet the resident census .Recipes are specific as to portion, yield, method of preparation, quantities of ingredients, and time and temperature guidelines . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 11 of 20 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 12/12/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow its policy on Meal Service to provide appetizing food at appropriate temperatures and appetizing taste according to residents' preferences for 14 of 96 sampled residents (Residents 14, 15, 19, 29, 36, 41, 43, 51, 65, 69, 73, 77, 182, and 282). Residents Affected - Some This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutrition status. Findings: On December 8, 2024, at 8:47 a.m., during an interview with Resident 73, she stated, the served food does not taste very good, not good quality. On December 8, 2024, at 9:30 a.m., during an interview with Resident 282, he stated, food tasted bad and is cold for breakfast, lunch and dinner every day. On December 8, 2024, at 9:55 a.m., during an interview with Resident 182, he stated, food tasted bland. On December 8, 2024, at 9:55 a.m., during an interview with Resident 14, she stated, the served food taste bad. On December 8, 2024, at 10:12 a.m., during an interview with Resident 41, she stated, the served food not appetizing, sometimes tasted salty and sometimes tasted bland. On December 8, 2024, at 10:20 a.m., during an interview with Resident 65, he 65 stated, served food is cold and they don't serve what's listed on the menu. On December 8, 2024, at 11:17 a.m., during an interview with Resident 36, he stated, the food is unbearable and is cold. On December 8, 2024, at 11:18 a.m., during an interview with Resident 15, she stated, food tasted, bland, cold and sometimes tasted salty. On December 8, 2024, at 12:16 p.m., during an interview with Resident 19, he stated, food is served cold on 3 meals mostly on breakfast. On December 8, 2024, at 12:54 p.m., during an interview with Resident 43, she stated, food is too salty, not cooked well, sausage has pink and turkey is dry and hard. On December 8, 2024, at 12:58 p.m., during an interview with Resident 69, he stated, food is cold especially during dinner. On December 9, 2024, at 11:00 a.m., Residents 51 and Resident 77 stated, cold food service. On December 9, 2024, at 11:00 a.m., Resident 29 stated, food is cold. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 12 of 20 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 12/12/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On December 9, 2024, at 1:54 p.m., a concurrent observation of test tray (to evaluate the quality of a meal during a meal service and identify any areas for improvement) for regular diet and pureed diet and interview with the Registered Dietitian (RD) were conducted. The RD acknowledged she could not taste garlic or parmesan cheese on the served Garlic Parmesan Cheese Spinach. The RD stated served spinach (regular and pureed) required more seasoning. The RD stated cooks should follow recipes when preparing meals to ensure the food is appealing and palatable (refers to the taste and/or flavor of the food). She further stated serving unseasoned foods could result in residents not wanting to eat, which could lead to malnutrition (a condition when the body doesn't get the right amount of nutrients). A review of the facility policy and procedure titled, Meal Service, dated 2023, indicated, .Meals that meet the nutritional needs of the residents will be served in an accurate and efficient manner, and served at the appropriate temperatures .Temperature of the food when the resident receives it is based on palatability . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 13 of 20 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 12/12/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: Residents Affected - Some 1. Food and Nutrition Service employees did not follow the facility cleaning procedure to clean food preparation surfaces and stationary equipment. 2. Four out of four green storage shelves in the walk-in refrigerator had buildup; 3. Dust was hanging on walk-in refrigerator's fan covers; and 4. One wet plastic container was stacked with other dried plastic containers. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 95 out of 95 residents who received food prepared in the kitchen. 1. During a review of the facility provided procedure title, SHELVES, COUNTERS, AND OTHER SURFACES INCLUDING SINKS (HANDWASHING, FOOD PREPARATION, ETC.), the procedure indicated, CLEANING PROCEDURE: 1. Remove any large debris and wash surface with a warm detergent solution . 2. Rinse with clear water using a clean sponge or cloth. Wipe dry with a clean cloth. 3. Spray with a sanitizer . On December 8, 2024, at 10:29 a.m., an interview was conducted with the Dietary Supervisor (DSS). The DSS stated Food and Nutrition service employees only used sanitizer to clean used prep table surfaces and stationary equipment. On December 8, 2024, at 10:47 a.m., an interview was conducted with [NAME] (Ck) 2. Ck 2 stated he only used sanitizer to clean used prep table surface and stationary equipment. On December 8, 2024, at 10:56 a.m., an interview was conducted with Ck 4. Ck 4 stated she used detergent to wash the stationary equipment and then sanitized it with sanitizer. Ck 4 stated, for used Prep table surface, she only used sanitizer to sanitize. On December 9, 2024, at 8:30 a.m., an observation was conducted with [NAME] (Ck) 1. Ck 1 cleaned stationary mixer base with sanitizer after preparing pudding. On December 9, 2024, at 11:44 a.m., a concurrent observation and interview were conducted with Ck 3. Ck 3 cleaned stationary blender base with sanitizer after preparing mechanical soft meat. Ck 3 confirmed she cleaned the blender base twice with sanitizer. On December 11, 2024, at 3:45 p.m., a phone interview was conducted with the RD. The RD stated Food and Nutrition service employees should follow the facility cleaning procedure to wash, rinse, and sanitize used stationary equipment and food preparation surface. The RD further stated if the cleaning procedure was not followed, used equipment and food preparation surface would not be properly cleaned, which could result in cross-contamination and lead to food borne illness in the residents. 2. On December 8, 2024, at 10:29 a.m., a concurrent observation and interview were conducted with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 14 of 20 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 12/12/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the DSS in the walk-in refrigerator. Four out of four green storage shelves were observed to have whitish, grayish, blackish particles, and grime buildup. Milk, egg, and produce were observed stored on the green storage shelves. The DSS verified the buildup and stated, Food and Nutrition Service employees had missed cleaning the green storage shelves. The DSS stated unsanitary storage shelves could potentially cause cross-contamination when Food and Nutrition Service employees touched the unsanitary shelves while removing food items from the refrigerator. On December 8, 2024, at 3:46 p.m., an interview was conducted with the RD. The RD stated storage shelves in walk-in refrigerator should be kept clean. The RD stated the potential concern for unsanitary storage shelves in walk-in refrigerator was cross-contamination and mold growth. During a review of the facility's Policy and Procedure (P&P) titled, SANITATION, dated 2023, the P&P indicated, .11. All .shelves . shall be kept clean . 3. On December 8, 2024, at 11:37 a.m., a concurrent observation and interview with the DSS were conducted, in the walk-in refrigerator. The DSS confirmed black debris was dust hanging on the refrigerator's fan covers. On December 8, 2024, at 3:46 p.m., an interview was conducted with the RD. The RD stated the walk-in refrigerator's fan covers should not have dust. The RD explained dust could potentially fall into food items stored in the refrigerator. During a review of the facility's Policy and Procedure (P&P) titled, SANITATION, dated 2023, the P&P indicated, .11. All .equipment shall be kept clean . 4. On December 8, 2024, at 12:06 p.m., a concurrent observation and interview with the DSS were conducted in the coffee room. A wet clear plastic container was stacked together with four dried plastic containers on the rack. The DSS stated the wet clear plastic container should not have been stacked with the dried plastic containers. On December 8, 2024, at 3:46 p.m., a concurrent observation and interview with the RD. The RD stated wet container should be air dried before being stacked and stored with other dried containers on the rack. The RD explained that the moisture from the wet container could create an environment for bacteria to grow, which could lead to cross-contamination and food borne illness. During a review of the facility's Policy and Procedure (P&P) titled, DISHWASHING, dated 2023, the P&P indicated, .PROCEDURE: .5. Dishes are to be air dried in racks before stacking and storing . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 15 of 20 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 12/12/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when three dumpsters were overflowing, the lids could not be closed, and the surrounding area was littered with debris. Residents Affected - Many This failure had the potential to attract pests and cause infection control issues. Findings: On December 8, 2024, at 8:15 a.m., during an observation of the dumpster storage area outside of the facility near the corner entrance, three out of three dumpsters were overflowing with garbage and cardboard boxes. The dumpster lids were not closed, and debris was scattered around the dumpsters. On December 8, 2024, at 10:17 a.m., during a concurrent observation and interview with the Dietary Supervisor (DSS), in front of the dumpsters, the DSS stated the dumpsters should be closed and not overflowing with garbage or boxes. The DSS further stated there should not be any debris surroundnig the dumpster area to prevent pest infestations, which could lead to infection control issues. On December 8, 2024, at 10:22 a.m., during a concurrent observation and interview with the Maintenance Supervisor (MTD), in front of the dumpsters, the MTD stated all dumpsters should be closed and not overflowing to prevent rodent infestation which could result in infection control problems. The MTD further stated, the dumpsters should be inspected daily to ensure no garbage is left around the outside perimeter of the dumpsters. On December 8, 2024, at 3:13 p.m., during an interview with the Registered Dietitian (RD), the RD stated the dumpsters should not be overflowing and should always remain closed to avoid attracting flies, insects, rodents, and other pests. The RD stated, there should not be no garbage in the surrounding area. The RD further stated, not adhering to the policy could result in pest infestation and infection control issues. A review of the facility policy and procedure titled Miscellaneous Areas: Garbage and Trash Procedure, dated 2023, indicated, .Garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed .The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 16 of 20 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 12/12/2024 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 implement proper infection control measures when Certified Nurse Assistant (CNA) 1 did not perform hand hygiene and wear personal protective equipment (PPE - equipment use to protect against infection or illness) upon entering the room and while providing care to Resident 283, who was positive for Clostridium Difficile infection (C. diff - a bacteria that cause diarrhea and is spread through contact with contaminated surfaces or people). Residents Affected - Few This failures had the potential to increase the spread of pathogens (germs) and infections from staff to residents, potentially leading to illness. Findings: On December 10, 2024, at 8:25 a.m., during a concurrent observation and interview in the hallway outside Resident 283's room, a contact precaution (a set of precautions to prevent the spread of germs that are transmitted through direct or indirect contact) sign was observed on the wall. CNA 1 entered and exited the room, provided care to Resident 283, and did not perform hand hygiene or don (put on) PPE. CNA 1 stated Resident 283 was on contact precautions for C. diff. CNA 1 stated, facility staff and visitors must wash hands, wear a gown and gloves before room entry and upon room exit. CNA 1 further stated she entered and exited Resident 283's room, provided care and she did not wash her hands and wear PPE. CNA 1 stated she should have washed her hands and worn gloves and a gown (PPE) to prevent the spread of pathogens and infection to facility resaidents. On December 10, 2024, Resident 283's record was reviewed. Resident 283 was admitted to the facility on [DATE], with diagnosis which included Enterocolitis (inflammation of intestines) due to Cdiff. A review of Resident 283's Minimum Data Set (MDS - an assessment tool), dated September 12, 2024, indicated Resident 283 had a Brief Interview for Mental Status (use to assess cognition) score of 3 (severe cognitive impairment). A review of Resident 283's Lab Results, dated December 7, 2024, indicated, .Critical result .December 8, 2024 .Cdiff: Positive . A review of Resident 283's Care Plan, dated December 8, 2024, indicated, .Stool culture positive for c-diff .Interventions: isolation with contact precautions . A review of the facility document titled, Contact Precaution Sinage, undated, indicated, .Everyone Must: Clean their hands, including before entering and when leaving the room .Providers and Staff must also: Put on gloves before room entry .Put on gown before room entry . On December 11, 2024, at 9:05 a.m., during an interview with the Infection Preventionist (IP), he stated it was the facility practice for staff to perform hand hygiene upon entering and exiting a resident's room and to wear personal protective equipment when caring for residents on contact preacutions. The IP stated, all staff were expected to follow the facility infection control practices to prevent cross contamination and infection to facility residents. A review of the facility Policy and Procedure titled, Isolation - Transmission-Based Precautions & Enhanced Barrier Precautions, dated September 2022, indicated, .Contact Precautions .Staff and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 17 of 20 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 12/12/2024 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 visitors wear gloves when entering the room .Wear disposable gown upon entering the room . Level of Harm - Minimal harm or potential for actual harm A review of the facility Policy and Procedure titled, Handwashing/Hand Hygiene, dated 2021, indicated, .This facility considers hand hygiene as the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to to help prevent the spread of infection to .residents . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 18 of 20 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 12/12/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain the dish machine's temperature within the manurfacturer's guidelines. Failure to ensure adequate water temperature in the dish machine may result in ineffective cleaning of dishes, putting 95 residents at risk for food-borne illness (stomach illness acquired from ingesting contaminated food). Residents Affected - Few Findings: According to the United States FDA (Food and Drug Administration) Food Code 2022, Section 4-204.115 Warewashing Machines, Temperature Measuring Devices, the Food Code indicated, The requirement for the presence of a temperature measuring device in each tank of the warewashing machine is based on the importance of temperature in the sanitization step. In hot water machines, it is critical that minimum temperatures be met at the various cycles so that the cumulative effect of successively rising temperatures causes the surface of the item being washed to reach the required temperature for sanitization. When chemical sanitizers are used, specific minimum temperatures must be met because the effectiveness of chemical sanitizers is directly affected by the temperature of the solution. On December 8, 2024, at 9:14 a.m., a concurrent observation and interview with [NAME] (Ck) 2, with a review of the manufacturer's guidelines for the dish machine, were conducted. The Manufacturer's guideline indicated, Wash tank temperature: minimum 150 degrees Fahrenheit (°F - a unit of measurement) and Final Rinse temperature minimum: 180 °F. During the observation of the dish machine in operation, the wash temperature was recorded at 143°F and the rinse temperature at 175 °F. In a follow-up interview with Ck 2 at 9:15 a.m., Ck 2 confirmed that the dish machine's wash temeprature was at 142 °F and the rinse temperature was 178 °F, not within manufacturer's guideline. Ck 2 stated the dish machine wash temperature should be 150 °F and rinse temperature should be 180 °F. On December 8, 2024, at 9:25 a.m., a concurrent reobservation of the dish machine in operation and an interview with Ck 2 were conducted. Ck 2 confirmed the dish machine's temperatures were not within manufacturer's guidelines, with the wash temperature at 145 °F and rinse temperature at 172 °F. On December 8, 2024, at 9:41 a.m., a concurrent observation and interview were conducted with the Maintenance Supervisor (MTD) while the dish machine was operating. The MTD verified that the wash temperature indicated 149 °F and the rinse temperature was 174°F. The MTD stated the dish machine water temperature should be between 150°F and 180°F. The MTD acknowledged sometimes dish machine water temperature could change during cleaning process and he could set the machine to maintain temperature range of 150°F to 180°F. On December 8, 2024, at 2:58 p.m., an interview was conducted with the Infection Preventionist (IP). The IP stated not maintaining the dish machine's temperature within the manufacturer's guidelines could result in improperly cleaned and sanitized dishes, which could lead to cross-contamination and the risk of food borne illness. On December 8, 2024, at 3:46 p.m., an interview was conducted with the Registered Dietitian (RD). The RD stated the dish machine must maintain the manufacturer's guidelines temperatures, otherwise (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555921 If continuation sheet Page 19 of 20 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 12/12/2024 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the dishes would not be cleaned and sanitized properly, which could lead to cross contamination, infection control issue, and risk of food borne illness. During a review of the facility's Policy and Procedure (P&P) titled, DISHWASHING, dated 2023, the P&P indicated, POLICY: All dishes will be properly sanitized through the dishwasher.PROCEDURE: .9. The dishwasher will run the dish machine until the temperature is within the manufacturer's recommendations.High-temperature machine: .use the machine at a temperature of 150 °F to 165 °F or higher for the wash and 180 °F or above for the rinse. Event ID: Facility ID: 555921 If continuation sheet Page 20 of 20