Rancho Bellagio Post Acute

In the surveyor’s words

From the most serious findings on record at Rancho Bellagio Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 6, 2025

  Based on observation, interview, and record review, the facility failed to provide adequate supervision to one of six sampled residents (Resident 1), who was diagnosed with dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and had history of elopement (incident when a resident leaves the facility without authorization). In addition, the facility failed to frequently monitor the whereabouts of Resident 1 in accordance with the care plan. Resident 1 exited the facility on December 20, 2024, via the BC wing (name of a facility wing) automatic sliding door. It was observed that the sliding door led directly to the facility's parking lot, which led to a two-way street. […]

• Actual harm, isolatedF658Mar 7, 2022

  Based on interview and record review for one of three residents sampled (Resident 1), the facility failed to ensure professional standards of quality of care were met. This failure occurred when Resident 1 had returned to the facility from the general acute care hospital (GACH) where he resumed his previous diet and oral medication regimen, despite GACH discharge documentation that indicated the resident should follow a diet, STRICT NPO (Nothing Per Orem/nothing to be taken by mouth) and No Liquids, STRICT NPO, due to his increased risk for aspiration (inhalation of a foreign material). Findings: On December 30, 2021, an unannounced visit was conducted at the facility for the investigation of a complaint regarding quality of care and treatment. […]

• No harm, potential for more than minimal, widespreadF725Jan 29, 2026

  Based on interview and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents when the facility did not meet the required minimum of actual total Certified Nurse Assistant (CNA) Direct Care Hours Per Patient Day (DHPPD - measure the numbers of hours of direct care given to residents in skilled nursing facility) of 2.4 hours for the months of October 2025, November 2025, December 2025, and January 2026.The failure to maintain the required minimum CNA DHPPD hours had the potential to place residents at risk for unmet needs, compromised safety, and decreased quality of care. Findings:On January 28, 2026, at 1:40 p.m., the facility staffing records were reviewed. […]

• No harm, potential for more than minimal, widespreadF814Dec 12, 2024

  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. 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. […]

• No harm, potential for more than minimal, patternF555Jun 22, 2026

  Based on interview and record review, the facility failed to ensure a resident was informed and allowed to exercise the right to choose and attending physician for four of four residents reviewed for physician choice (Residents 1, 2, 3, and 4). This failure resulted in Residents 1, 2, 3, and 4 not being afforded the opportunity to retain a personal physician or select an attending physician of their choice upon admission. Findings: A review of Resident 1's admission record indicated, Resident 1 was admitted to the facility on [DATE], with diagnosis which included chronic osteomyelitis, left thigh (long term bone infection in the left upper leg) and osteonecrosis, left femur (part of the large bone in the left upper leg had died because it does not get enough blood). […]