Rancho Mirage Health: Resident Woken at 11 PM - CA
The resident, identified in inspection records only as Resident A, was recovering from joint replacement surgery and also living with osteoarthritis, a condition that causes the cartilage cushioning the ends of bones to break down. She had asked earlier that day about switching rooms. Staff offered her a room on another station. She declined. They offered again that evening. She said she would move in the morning.
That should have been the end of it until daylight.
It wasn't.
A certified nursing assistant working the 10:30 p.m. to 6:30 a.m. shift told inspectors he had been instructed by the outgoing registered nurse to check in with Resident A and find out whether she wanted the move to happen that night or the next day. He followed the instruction. He went to her room. He woke her up.
When inspectors interviewed the Director of Nursing on July 8, 2025, she said the facility's practice is to discuss room changes with residents when they are awake, and not to disturb them during sleep to ask such questions. The facility's own written policy on room transfers states that unless a move is medically necessary or required for safety, residents are to receive advance notice before any transfer occurs.
Neither condition applied here. The resident had already been asked twice. She had already answered twice. She wanted to move in the morning.
The inspection was triggered by a complaint and conducted as an unannounced visit on July 8, 2025, nearly three weeks after the incident. Inspectors reviewed Resident A's admission records, the facility's room change notification form dated June 18, 2025, and the facility's own rights documentation, which states that residents are to be treated with consideration, respect, and full recognition of dignity and individuality.
The violation was cited under the federal standard requiring facilities to ensure residents are treated with dignity and respect. Inspectors classified the harm level as minimal, with potential for actual harm, and noted the failure affected a small number of residents.
The classification reflects the regulatory floor, not the human reality of what it means to be woken after 11 p.m. when you are recovering from surgery, have already answered the question twice, and are trying to sleep.
The CNA was following an instruction. The registered nurse gave the instruction. The facility's written policy said not to do it. Somewhere between the policy on paper and the order passed at shift change, a woman recovering from joint surgery was pulled out of sleep to answer a question she had already answered.
The nursing assistant confirmed the timeline. The Director of Nursing confirmed the policy. The room change form confirmed that Resident A had said, clearly, that she would move in the morning.
She had already said it twice.
Nobody waited until morning to ask again.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 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.
She had asked earlier that day about switching rooms.
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.