Inspection Reports for Bayshire Rancho Mirage

The inspection was an unannounced annual required visit conducted to evaluate the facility's compliance with licensing requirements.

The facility was found to be clean, well-maintained, and in compliance with infection control, physical plant, food service, care and supervision, record keeping, medication management, and disaster preparedness requirements. No deficiencies were cited during the visit.

The inspection visit was an unannounced complaint investigation conducted in response to allegations received on 2022-03-15 regarding staff failing to meet residents' medical needs, neglect, delayed response to call assistance buttons, and failure to meet resident needs.

The investigation included interviews, observations, and record reviews. Interviews with residents and staff generally denied the allegations. Records showed changes in resident care levels, and no conclusive evidence was found to substantiate the complaints. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included staff failing to meet resident's medical needs, neglect, failure to respond timely to call buttons, and failure to meet resident needs. Interviews and record reviews did not provide sufficient evidence to prove the allegations.

An unannounced annual required visit was conducted to evaluate the facility's compliance with licensing regulations.

The facility was found to be clean, well-maintained, and in compliance with safety and health requirements. Staff files, resident records, medication management, emergency plans, and safety equipment were all in order. No deficiencies were cited during the inspection.

The inspection was an unannounced Case Management visit triggered by a self-report made on 2024-04-25 regarding verbal abuse of a resident by care staff.

The Licensing Program Analyst found one deficiency related to verbal abuse by a staff member towards a resident, posing a potential health and safety risk. No immediate health and safety concerns were observed during the visit.

The visit was complaint-related due to a self-report of verbal abuse by care staff. An internal investigation was completed, care staff was disciplined, and law enforcement was involved. The deficiency was substantiated.

An unannounced complaint investigation was conducted in response to allegations that facility staff do not assist residents with transfers and are not meeting residents' care needs.

The investigation found that the complaint was unfounded because the resident involved was admitted only to the Skilled Nursing Facility, which is outside the jurisdiction of the Community Care Licensing. Therefore, the allegations were determined to be false or without reasonable basis.

The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 12/09/2022 regarding staff handling and speaking inappropriately to a resident.

Two allegations were investigated: one regarding rough handling of a resident, which was deemed unsubstantiated due to lack of sufficient evidence; and another regarding inappropriate speech by staff to a resident, which was substantiated and resulted in a citation for violation of resident personal rights.

The complaint investigation involved allegations that Staff One (S1) handled Resident One (R1) roughly and spoke inappropriately to R1. The rough handling allegation was unsubstantiated due to insufficient evidence, while the inappropriate speech allegation was substantiated based on staff interviews and evidence, leading to a citation.

The inspection was an unannounced visit conducted to address a violation observed during the investigation of complaint #18-AS-20221209144911 involving alleged physical and verbal assault.

The investigation revealed that a suspected abuse incident involving a resident and staff was not reported to the appropriate agencies as required, due to an internal investigation that could not corroborate the incident. A citation will be issued for failure to report.

The visit was complaint-related, investigating complaint #18-AS-20221209144911. The complaint involved an alleged physical and verbal assault on Resident One by Staff One. The incident was not reported to appropriate agencies as mandated, despite initial suspicion of abuse.

An unannounced annual required visit was conducted to evaluate the facility's compliance with licensing requirements.

The facility generally met infection control, physical plant, food service, medication management, and disaster preparedness requirements. However, deficiencies were found related to inadequate care and supervision of a resident and an unassociated staff member working at the facility.

The visit was an unannounced follow-up to an incident report regarding a resident having suicidal ideation.

No immediate health and safety concerns were found. The resident's care plan was updated and the facility has oversight of the incident. No deficiencies were noted at the time of the visit.

The visit was triggered by a complaint related to a resident's suicidal ideation. No deficiencies or substantiated issues were found.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-08-31 regarding multiple allegations about resident care and facility operations at Bayshire Rancho Mirage.

The investigation substantiated allegations that staff did not respond timely to a resident's requests for assistance and failed to develop a care plan for the resident's oxygen needs. Other allegations including unclean rooms, mail delivery issues, inadequate staff training, medication mismanagement, overcharging, and safeguarding personal items were found to be unsubstantiated.

The complaint investigation was substantiated for allegations that staff did not respond timely to Resident 1's requests for assistance and failed to develop a care plan for Resident 1's oxygen needs. Other allegations were unsubstantiated.

An unannounced visit was made to collect documentation and interview residents in relation to complaint number 18-AS-20210831170004.

The Licensing Program Analyst met with the Executive Director, toured the facility, and interviewed three residents. An exit interview was conducted and a copy of the report was provided.

Visit was related to complaint number 18-AS-20210831170004; no substantiation status stated.

The visit was an unannounced complaint investigation initiated due to a complaint received on 2022-12-29 alleging that staff do not assist a resident with getting out of bed.

The investigation found the allegation to be unfounded after interviews with staff, the resident, and the Executive Director. The resident denied the allegation and staff reported the resident has remained in bed due to directions from family and specialized care providers, with the resident coming out for meals.

The complaint alleged that staff do not assist Resident One with getting out of bed. The allegation was investigated and deemed unfounded based on interviews and evidence.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 09/09/2021 alleging that staff did not inform a resident's authorized representative of issues concerning the resident.

The complaint was substantiated as the facility failed to notify both of the resident's Powers of Attorney about the resident's falls, which is a violation of Title 22. The facility was cited for not meeting reporting requirements.

The complaint was substantiated. It was found that the facility notified only one of the two Powers of Attorney listed for resident R1 about the falls, failing to notify both as required.

An unannounced complaint investigation visit was conducted following allegations that staff did not safeguard a resident's personal belongings and that the facility did not have adequate staff to meet residents' needs.

The investigation found that the facility provided necessary tools to safeguard the resident's belongings and that staffing levels were adequate to meet residents' needs. Both allegations were found to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included missing personal belongings (a wedding ring) and inadequate staffing. Interviews, record reviews, and resident statements did not support the allegations.

An unannounced annual inspection was conducted with an emphasis on infection control.

The inspection found sufficient hand hygiene supplies, cleaning and disinfecting provisions, proper use of face coverings, sufficient PPE supplies, and staff training on COVID-19. No deficiencies were cited during the visit.

An unannounced complaint investigation was conducted in response to an allegation that residents were being physically abused by staff.

The investigation found no evidence to support the allegation. Interviews and resident roster review indicated the named resident was not at the facility, and the complaint was deemed unfounded.

The allegation was that residents, including Resident One (R1), were being physically abused by staff. The complaint was investigated and found to be unfounded based on interviews and record review.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-08-31 regarding staff not following CDC guidelines for COVID-19 prevention and administering COVID vaccine without resident's authorized representative consent.

The investigation found both allegations to be unsubstantiated after interviews and observations. Staff were observed following COVID-19 protocols including mask wearing and visitor screening, and consent for vaccination was confirmed.

The complaint included two allegations: 1) Staff did not follow CDC guidelines for preventing the spread of COVID-19, specifically not wearing masks when entering a resident's room; 2) Staff administered COVID vaccine without resident's authorized representative consent. Both allegations were determined to be unsubstantiated.

The inspection was a post licensing visit to confirm the facility name and address, and to verify compliance following the initial licensing of the facility on 06/01/2021.

The facility was found to be licensed for 135 non-ambulatory residents with a hospice waiver for 20. There was a confirmed COVID-19 positive resident, but the facility completed a second round of COVID testing on 08/26/2021 and is following approved COVID-19 mitigation procedures. Communal activities are temporarily suspended pending negative test results.

The visit was conducted as an announced pre-licensing inspection for a Residential Care Facility for the Elderly (RCFE) to evaluate readiness for licensure.

The facility was found to be in good condition with no obstructions, operable safety detectors, sufficient and secure storage, adequate food service equipment, and proper posting of required signs. The fire clearance was granted for 135 non-ambulatory residents, including 15 bedridden.

The visit was conducted as a change of ownership application evaluation for the facility, including verification of the applicant/administrator's identity and understanding of California Code Title 22 regulations.

The applicant/administrator demonstrated understanding of facility operation, admission policies, staffing requirements, restricted health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness during a telephone interview.

The visit was conducted as part of a Change of Ownership application process for the facility, including verification of applicant and administrator identification and confirmation of understanding of California Code Title 22 regulations.

The applicant and administrator participated in a telephone interview confirming understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. Signed documentation and photo ID were obtained.