Inspection Reports for
Bayshire Rancho Mirage

The visit was complaint-related and substantiated based on the failure to obtain a physician order for oxygen use for Resident 1.

The facility failed to obtain a physician order for oxygen use for one resident, resulting in treatment without proper authorization. Interviews and record reviews confirmed oxygen was used without a physician's order during the resident's stay.

The complaint was substantiated. Resident #1 had 6 elopements in 2022, with at least two confirmed during the investigation. The resident was admitted on 2022-08-19 and was unable to leave unassisted. The facility failed to prevent elopement despite alarms and supervision efforts.

The investigation substantiated the allegation that Resident #1 eloped from the facility at least twice in 2022 due to lack of supervision. Interviews with staff and residents, document reviews, and incident reports confirmed the elopements and identified a failure to maintain sufficient supervision in the memory care unit.

The facility failed to ensure proper medication administration, labeling and storage of medications, avoidance of unnecessary duplicate medications, proper feeding tube care, and safe food preparation and storage. Multiple deficiencies were identified including medication errors, expired and mislabeled medications, improper food consistency, and unsanitary food storage.

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.

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 investigation was triggered by a Quality-of-Care complaint regarding failure to notify the LTC Ombudsman timely about resident discharges. The complaint was substantiated based on interviews and record reviews.

The facility failed to ensure timely notification to the Long Term Care Ombudsman of resident discharges following resident notification of their pending discharge date for 5 residents. The facility notified the Ombudsman monthly rather than at the time of each resident's discharge notification.

The facility had multiple deficiencies including failure to ensure proper medication self-administration assessment, incomplete care plans for oxygen use and edema, improper medication administration, medication storage issues, infection control lapses, and unsanitary kitchen equipment.

The investigation was triggered by abuse allegations from Resident 1 against the COTA and from Resident 2 against the CNA. The allegations were substantiated by interviews and record reviews. The facility did not remove the accused staff from work schedules during the investigation.

The facility failed to protect residents from potential abuse by allowing the Certified Occupational Therapy Assistant (COTA) and Certified Nurse Assistant (CNA) to continue working while abuse investigations were ongoing. This failure placed other residents at risk of abuse.

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.

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 complaint investigation found that the facility did not follow its policy for controlled substance receipt, with missing signatures on the narcotic record for Resident 1's medication. The deficiency was substantiated with evidence from record reviews and staff interviews.

The facility failed to ensure that controlled substances were properly signed for upon receipt, as required by policy. Specifically, the controlled substance record for Resident 1's methylphenidate ER 20 mg showed no signatures by the receiving nurse or cosignatory, indicating noncompliance with the facility's controlled substances policy.

The facility failed to develop comprehensive care plans for a resident's urinary catheter and infection, did not implement effective pain management interventions resulting in prolonged pain, and failed to notify the physician of abnormal laboratory results for another resident.

The investigation was complaint-driven, focusing on Resident 1. The findings indicated failures in personal belongings verification and medication administration. The complaint was substantiated with minimal harm identified.

The facility failed to verify and return Resident 1's personal belongings upon discharge, potentially causing loss of possessions. Additionally, the facility did not administer Resident 1's medication as ordered and failed to perform an assessment prior to transferring the resident to immediate care, potentially jeopardizing the resident's health and safety.

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 complaint-related, triggered by quality of care concerns including failure to develop care plans, incomplete medical records after falls, and malfunctioning call light system. Substantiation status is not explicitly stated.

The facility failed to develop and monitor a care plan for edema in Resident 3, had incomplete and inaccurate medical records post-fall for Residents 1, 2, and 3, and the call light system was found muted and inaudible at the nurse's station, risking delayed nurse notification.

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.

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 visit was complaint-related, investigating quality-of-care issues regarding skin condition assessments and wound care documentation. The complaint was substantiated with findings of inadequate monitoring and documentation.

The facility failed to consistently assess and monitor changes in skin condition and wounds for multiple residents, resulting in delayed treatment and the development of pressure injuries. Documentation of wound assessments and change of condition reports were incomplete or missing.

The investigation was triggered by an allegation of abuse. The deficiency involved failure to complete an itemized inventory list on admission as required.

The facility failed to ensure an itemized inventory list of personal belongings was completed on admission for one out of five residents reviewed, increasing the risk for misappropriation of property. The inventory list for Resident 1 was completed two days after admission instead of on the day of admission as required by facility policy.

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.

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 facility was found deficient in multiple areas including failure to provide oxygen therapy with a physician's order, insufficient nursing staff leading to delayed call light responses, incomplete medication administration logs for emergency kits, improper use of psychotropic medications, inadequate labeling and storage of medications, unsanitary kitchen equipment, and failure to properly change PICC line dressings.