Health inspection·December 11, 2025

F 0555 Honor the resident's right to choose his or her attending physician. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure resident right to choose attending physician for two of eight sampled residents (Residents 1 and 6) in a universe of 91 residents.This failure had the potential to harm the resident's autonomy, continuity of care, which could potentially lead to unmet needs for residents in the facility. Findings:On December 3, 2025, at 1:07 p.m., an unannounced visit to the facility was initiated to investigate a resident's right issue. 1) A review of Resident 1's Order Summary Report indicated resident was admitted on [DATE], with diagnoses of immunodeficiency (failure of the immune system to protect the body from infection), anemia (blood has a lower-than-normal amount of red blood cells), type 2 diabetes (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), primary hypertension (high blood pressure with no single, identifiable cause), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), hyperlipidemia (high cholesterol), (BPH - enlargement of the prostate gland), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement chiefly affecting middle-aged and elderly people), posttraumatic stress disorder (PTSD - is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event), gastroesophageal reflux disease (GERD- occurs when stomach acid frequently flows back into the tube connecting the mouth and stomach), atherosclerotic heart disease (develops when a sticky substance called plaque builds up inside the arteries), dysphagia (difficulty swallowing), malignant neoplasm (cancerous tumor) of left lung, pleural effusion (an abnormal collection of fluid between the thin layers of tissue lining the lung and the wall of the chest cavity), stroke (damage to tissues in the brain due to a loss of oxygen to the area), chronic kidney disease (the gradual loss of kidney's ability to filter wastes and excess fluids from the blood), and severe protein-calorie malnutrition, (the state of inadequate intake of food as a source of protein, calories, and other essential nutrients) under Physician B's care.A review of Resident 1's History and Physical dated August 1, 2025, indicated resident had the capacity to understand and make decisions.On December 3, 2025, at 253 p.m., an interview was conducted with the facility's Director of Business Development, (DOBD). The DOBD stated when a hospital sends the facility a referral for admission of a resident, if clinically appropriate, they have five physicians on the facility panel and would alternate between the seven physicians to assign the resident. The DOBD stated that if a physician were to attend to a resident in the facility, the physician would need to have credentials, license, a login for medical records, and be on the facility panel. The DOBD stated that Physician A was not on the panel. The DOBD was unaware that Resident 1's family had requested Physician A as the attending physician.On December 3, 2025, at 3:07 p.m., an interview was conducted with the facility's Medical Records Director, (MRD). The MRD stated that when the Residents Affected - Few Page 1 of 5 555921 555921 12/11/2025 Rancho Bellagio Post Acute 26940 E Hospital Road Moreno Valley, CA 92555

F 0555 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medical records department received a request to add a physician to the facility panel, the MRD would request a license number, credentials, and sets up in the electronic medical records (EMR). The MRD stated that the information would be sent to corporate for approval. The MRD stated that once an email is received from corporate the MRD would request a current email, job role, license number to the requesting physician, which the MRD would send a pin to the requester to set up external user access. The MRD stated that Physician A was last validated on August 22, 2022. The MRD stated that if the physician was not active, the facility administrator would need to inform medical records of the request. The MRD stated that if a physician was no longer on the panel of active physicians, the facility administrator would need to inform the Medical Records Department, in order to reactivate the physicians' credentials to sign into the electronic medical record remotely. The MRD confirmed that Physician A was no longer active and did not currently have access to the electronic medical records. On December 3, 2025, at 3:15 p.m., an interview was conducted with the Registered Nurse, (RN). The RN stated that if a resident requested a physician that was not on the panel, the RN would direct the resident to social services department. The RN stated that she was unaware that Resident 1 had requested for Physician A to provide care while at the facility. On December 3, 2025, at 3:23 p.m., an interview was conducted with the Social Services Director, (SSD). The SSD stated if a resident wanted to change physicians, the SSD would meet with the resident and find out which physician from the panel the resident wanted to provide care from, and have the resident write a written statement requesting the change. The SSD stated that if the resident wanted an outside physician, the physician would need to agree to take on the resident's care and would need to have credentials and would inform the medical records department to follow through. The SSD stated he was not aware that Resident 1 had requested a change in physicians.On December 3, 2025, at 3:30 p.m., an interview was conducted with the Director of Nursing, (DON). The DON stated that it would be up to the facility administrator to bring on a new physician to provide care to residents at the facility. The DON stated that if a resident requested an outside physician the resident or family would need to provide a written request to social services. On December 3, 2025, at 3:39 p.m., a telephone interview was conducted with the facility Administrator, (Admin). The Admin stated that Physician A was credentialled and provided access to the electronic medical records back in August of 2022. The Admin stated that he started at the facility in May of 2023. The Admin stated that if they no longer wanted the physician on the panel the facility would send a termination letter to the physician. The Admin was not aware that a termination letter was sent to Physician A. The Admin stated that physician credentials never expire. The Admin stated that a physician's credentials never expire. The Admin further stated that residents are not followed by hospital physicians and the resident can only choose from the list of physicians on the facility's panel. On December 4, 2025, at 11:53 a.m., a telephone interview was conducted with Physician A. Physician A stated that Resident 1 was his patient for 27 years. Physician A stated that he was on the facility's panel of physicians in August of 2022. Physician A stated that he had been credentialed at the facility and was not aware that his credentials had expired and denied that he had received a termination letter.On December 8, 2025, at 2:13 p.m., an interview and record review was conducted with the MRD. The MRD stated that the facility's Medical Professional Report dated December 2025, indicated seven physicians with active accounts. The MRD confirmed that Physician A was not one of the seven physicians that had an active account. The MRD stated that if a physician with an inactive account wanted to have their account reactivated, the facility administrator would have to notify medical records. The MRD stated the Administrator had not requested reactivation of Physician A. On December 8, 2025, at 2:30 p.m., an interview was conducted with the Licensed 555921 Page 2 of 5 555921 12/11/2025 Rancho Bellagio Post Acute 26940 E Hospital Road Moreno Valley, CA 92555

F 0555 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Vocational Nurse (LVN). The LVN stated that if Resident 1 wanted a physician that did not have privileges at the facility, he would schedule an appointment for the resident to see in the physician's office. The LVN was unaware that Resident 1's family had requested Physician A to oversee Resident 1's care. On December 17, 2025, at 3:22 p.m., a telephone interview was conducted with Resident 1's family member, (FM). The FM stated they requested to have Physician A to be the attending physician upon admission to the facility. The FM stated the facility's business office informed them that they had to use a physician from the facility's panel and did not provide instructions on how to submit a request for an outside physician (Physician A). The FM further stated they were not involved in selecting Physician B. 2) A review of Resident 6's Order Summary Report indicated resident was admitted on [DATE], with diagnoses of muscle weakness, GERD, chronic kidney disease, primary hypertension, diabetes mellitus type 2, BPH, hyperlipidemia, hemiplegia (paralysis of one side of the body), and hemiparesis (weakness of one side of the body) following a stroke, and atherosclerotic heart disease, under the care of Physician C. A review of Resident 6's History and Physical dated November 20, 2025, indicated resident judgement and insight were intact.On December 3, 2025, at 253 p.m., an interview was conducted with the facility's Director of Business Development, (DOBD). The DOBD stated when the facility receives a hospital referral for admission, if clinically appropriate, the facility assigns an attending physician by alternating among seven physicians on the facility's panel. On December 3, 2025, at 3:15 p.m., an interview was conducted with the Registered Nurse (RN). The RN stated that if a resident requested a physician who was not on the panel, the RN would direct the resident to Social Services Department.On December 3, 2025, at 3:23 p.m., an interview was conducted with the Social Services Director, (SSD). The SSD stated if a resident wanted to change physicians, the SSD would meet with the resident and find out which physician from the panel the resident wanted to provide care from, and have the resident write a written statement requesting the change. The SSD stated that if the resident wanted an outside physician, the physician would need to agree to take on the resident's care and would need to have credentials and would inform the medical records department to follow through. The SSD stated he was not aware that Resident 1 had requested a change in physicians.On December 3, 2025, at 3:30 p.m., an interview was conducted with the Director of Nursing, (DON). The DON stated that it would be up to the facility administrator to bring on a new physician to provide care to residents at the facility. The DON stated that if a resident requested an outside physician the resident or family would need to provide a written request to social services.On December 8, 2025, at 1:14 p.m., an interview was conducted with Resident 6. Resident 6 stated that he had been admitted from the hospital for physical therapy on November 20, 2025. Resident 6 stated that he was not involved in choosing an attending physician at the facility. Resident 6 stated that he was unaware that he could choose a physician to provide care while in the facility. Resident 6 stated that he was not involved in choosing Physician C as his attending physician. On December 8, 2025, at 2:30 p.m., an interview was conducted with the Licensed Vocational Nurse, (LVN). The LVN stated that if a resident requested to have an attending physician that was not on the panel, they would schedule an appointment for the resident to see that physician in the office. A review of the facility's policy and procedure titled Resident Rights revised February 2021, indicated .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.s. choose an attending physician and participate in decision-making regarding his or her care. 555921 Page 3 of 5 555921 12/11/2025 Rancho Bellagio Post Acute 26940 E Hospital Road Moreno Valley, CA 92555

F 0777 Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure STAT, (done without delay) chest radiology and laboratory orders were done as ordered by the physician for one of eight residents reviewed for quality of care (Resident 1), in a universe of 91 residents. This failure had the potential to result in delayed diagnosis and treatment. Findings:On December 3, 2025, at 1:07 p.m., an unannounced visit to the facility on two complaints and a Facility Reported Incident were initiated.A review of Resident 1's Order Summary Report indicated resident was admitted on [DATE], with diagnoses of immunodeficiency, (failure of the immune system to protect the body from infection), anemia, (blood has a lower-than-normal amount of red blood cells), type 2 diabetes, (a chronic condition that affects the way the body uses sugar. The body either resists the effects of insulin - a hormone that regulates the movement of sugar into the cells - or doesn't produce enough insulin to maintain normal sugar levels), primary hypertension, (high blood pressure with no single, identifiable cause), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), hyperlipidemia, (high cholesterol), benign prostatic hypertrophy (BPH - enlargement of the prostate gland), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), chiefly affecting middle-aged and elderly people), posttraumatic stress disorder, (PTSD - is a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event), gastroesophageal reflux disease (GERD- occurs when stomach acid frequently flows back into the tube connecting the mouth and stomach), atherosclerotic heart disease (develops when a sticky substance called plaque builds up inside the arteries), dysphagia (difficulty swallowing), malignant neoplasm (cancerous tumor) of left lung, pleural effusion (an abnormal collection of fluid between the thin layers of tissue lining the lung and the wall of the chest cavity), stroke (damage to tissues in the brain due to a loss of oxygen to the area), chronic kidney disease (the gradual loss of kidney's ability to filter wastes and excess fluids from the blood), and severe protein-calorie malnutrition (the state of inadequate intake of food as a source of protein, calories, and other essential nutrients).A review of Resident 1's History and Physical dated August 1, 2025, indicated resident had the capacity to understand and make decisions.A review of Resident 1's Progress Notes dated August 31, 2025, at 11:01 p.m., indicated Resident reported that his (sic) having a (sic) Shortness of Breath. (sic) And family requested to have labs and Chest STAT XRAY informed MD [medical doctor] MD wants resident to be sent out. RN [Registered Nurse] informed Family is at his bedside and family refused to be sent out and instead family wants resident to have labs first and have STAT Chest X ray as per Family(sic) resident just came here 2 days ago and hospital is too much (sic) At this time family wants its (sic) to have LABS here first and STAT XRAY before deciding to be sent out again. MD aware and to carry out all the labs and X-ray as requested.A review of Resident 1's Radiology Order dated August 31, 2025, at 8:53 p.m., indicated .Priority: STAT.Exam - XRAY CHEST 3 VIEW.Symptom - SHORTNESS OF BREATH. A review of Resident 1's Order Requisition dated September 1, 2025, at 12:44 a.m., indicated .Service Required: Laboratory.Test CBC [complete blood count] w Diff, Platelets Comprehensive Metabolic Panel.There was no documented evidence Resident 1's orders for STAT X-ray and labs were done as ordered by the physician.On December 11, 2025, at 1:10 p.m., an interview with concurrent record review was conducted with the Director of Nursing (DON). The DON stated that STAT radiology and laboratory orders should be completed within the first couple of hours, while routine orders are to be completed the following day. Upon review of Resident 1's Progress Notes, dated August 31, 2025, at 11:01 p.m., the DON confirmed that the laboratory tests Residents Affected - Few 555921 Page 4 of 5 555921 12/11/2025 Rancho Bellagio Post Acute 26940 E Hospital Road Moreno Valley, CA 92555

F 0777 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and chest X-ray should have been completed as ordered by the physician, and it was not done. A review of Resident 1's Progress Notes dated September 1, 2025, at 7:55 p.m., indicated .Resident noted desaturated, [a drop in blood oxygen levels below normal 95-100%], o2 sat [oxygen saturation], 89% on nasal canula, wife at bed side stated to monitor to see if he gets better, a while after resident became alter metal (sic) status, afebrile, no facial expression of pain, wife remains at bed side, [name of physician] was notifiedwith (sic) new order to transfer to ER [emergency room] of further evaluation. 911 was call (sic) and took over on arrival, resident was transfer to [name of hospital] ED [emergency department].A review of the facility's policy and procedure titled Request for Diagnostic Services revised April 2007, indicated .3. Orders for diagnostic services will be promptly carried out as instructed by the physician's order. 4. Emergency requests must be labeled stat to assure that prompt action is taken. 555921 Page 5 of 5