Rancho Mirage Health: Staff Woke Resident at 11pm - CA
The incident occurred on June 18, 2025, at Rancho Mirage Health and Rehabilitation Center, where the resident had been recovering from joint replacement surgery. Federal inspectors found the nighttime disruption violated the resident's right to dignity and respect.
The resident, identified as Resident A in the inspection report, had requested a room move earlier that day. According to facility records, she was offered a room on station 2 but declined at that time. She was offered the room again that evening and said she would move in the morning.
But around 11 p.m., the night shift nursing assistant went to her room anyway.
During a July interview with inspectors, the nursing assistant said he worked the 10:30 p.m. to 6:30 a.m. shift. He explained that earlier in his shift, the outgoing registered nurse had instructed him to ask Resident A if she wanted the room change to occur that night or the following day.
So between 11 p.m. and 11:15 p.m., he went to her room and woke her to ask the question.
The facility's Director of Nursing told inspectors this violated standard practice. The DON stated the facility's policy is to discuss room changes with residents when they are awake and not to disturb them during sleep to ask such questions.
Resident A was admitted to the facility for care following joint replacement surgery. Her medical diagnoses included osteoarthritis, a chronic joint disease characterized by the breakdown of cartilage that cushions the ends of bones in joints.
The facility's own policies supported the Director of Nursing's statement about proper procedures. An undated policy titled "Transfer, Room To Room" states that unless medically necessary or for the safety and wellbeing of residents, a resident will be provided with advance notice of room transfers.
The facility's resident rights document also specifies that residents have the right "to be treated with consideration, respect and full recognition of dignity and individuality."
Federal inspectors determined the nighttime wake-up call had the potential to cause unnecessary disruption and discomfort. More significantly, they found it could interfere with the resident's ability to attain her highest practicable physical, mental, and psychosocial well-being.
The violation was classified as causing minimal harm or potential for actual harm, affecting few residents. The inspection was conducted July 8, 2025, following a complaint about resident rights issues.
The case illustrates how seemingly minor policy violations can undermine resident dignity. Sleep disruption is particularly problematic for elderly residents recovering from surgery, who need adequate rest for healing.
The nursing assistant's actions directly contradicted both facility policy and basic standards of respectful care. The resident had already indicated her preference to move in the morning, making the midnight inquiry unnecessary.
Resident A remains at the facility, where staff continue to provide care for her post-surgical recovery.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rancho Mirage Health and Rehabilitation Center from 2025-08-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
RANCHO MIRAGE HEALTH AND REHABILITATION CENTER in RANCHO MIRAGE, CA was cited for violations during a health inspection on August 11, 2025.
Federal inspectors found the nighttime disruption violated the resident's right to dignity and respect.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.