Bayshire Rancho Mirage

Inspectors wroteBased on interview and record review the facility failed to receive a physician order for the use of oxygen, including the specific indication of its use, for 1 out of 3 residents reviewed (Resident 1). This failure resulted in Resident 1 being treated with oxygen without a physician order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications and devices in accordance with the facility's policies and procedures and/or manufacturer's instructions when: 1. One discontinued medication was stored in the Red Medication Cart with other active medications available for use; 2. A total of three expired medications and devices were stored in the Red Medication Cart, IV Cart (a cart used to store medications and supplies needed for intravenous medications given through a vein), Treatment Cart (a cart used to store medication and supplies needed for wounds treatment), and Medication Room; and 3. A total of three medications with incorrect expiration dates were stored in the IV Cart and refrigerator in the Medication Room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were followed in accordance with professional standards of practice when: 1. Four half (1/2) size sheet steam drip metal pans and three eight quarts (8-qts - a unit of measurement) pitchers were stored wet; 2. One cup of undated cut fruits and one five pound (5-lb) tub low fat cottage cheese with an expiration date of April 11, 2025, were found stored in the satellite kitchen refrigerator; and 3. One undated open bottle of reduced fat ultra filtered milk was found stored in the resident's refrigerator. These failures had the potential to cause food-borne illnesses (stomach illness resulting from ingestion of contaminated food) in a medically vulnerable population who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with professional standards of practice for one of five residents observed for medication administration (Resident 17) when the staff turned on the nebulizer machine (a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) before the resident placed the facemask over nose and mouth. This failure had the potential to result in the resident receiving less than the prescribed amount of medication, leading to ineffective drug therapy and a medication error due to inadequate medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the tubing, feeding bottle, and water bag were labeled and dated for one of two residents (Resident 238) who receive enteral feeding (nutrition provided through a tube inserted into the stomach). This failure had the potential to cause food borne illness to Resident 238.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the residents when three medications with holding parameters were not administered in accordance with the physician's orders for one resident (Resident 14). This failure had the potential to significantly lower the blood pressure to cause dizziness, confusion, fainting and a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for one of five residents (Resident 14) when two medications from the same therapeutic (drug) class, proton pump inhibitors (PPI - a class of drug that reduce the amount of acid made by the stomach), were ordered and administered for the same indication. This deficient practice had the potential for unnecessary duplicate therapy or additive medication adverse effects including bone fractures and gastrointestinal (stomach and intestines) infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the [NAME] followed the recipe for preparing pureed bread for dinner on April 21, 2025. This failure had the potential to compromise the nutritional needs for one resident (Resident 138) reviewed for pureed diet.

Inspectors wroteBased on interview and record review the facility failed to ensure the Notice of Discharge (a notice informing the resident of their pending discharge date , and their rights to appeal the discharge) was provided to the Long Term Care (LTC) Ombudsman, following resident being notified of their pending discharge date for 5 out of 5 residents' (Residents 1, 2, 3, 4 & 5). This failures could have resulted in Residents 1, 2, 3, 4 & 5 not to be aware of their rights to appeal the discharge and the Ombudsman to not to be able to inform the residents of their rights and options to appeal prior to the resident being discharged .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the interdisciplinary team (IDT) assessed and documented for Resident 49 being capable of self-administering medications, prior to having the medication stored at the resident's bedside for administering it himself. This had the potential for inadequate drug therapy by allowing the resident to administer doses below or above the prescribed dose by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan for one of one resident reviewed for oxygen use (Resident 16) and for one of three residents reviewed for edema [swelling] (Resident 165). This failure had the potential to negatively impact the residents' quality of care and had the potential for staff to not be aware of the residents' care needs and provide appropriate treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan in using the dignity bag for resident's indwelling urinary catheter (catheter used to drain urine from the bladder into a bag outside the body) drainage bag for one of one resident reviewed (Resident 164). This failure resulted in Resident 164's indwelling urinary catheter drainage bag's urine being visibly exposed to visitors entering the room and the drainage bag did not have protection from contact with the bed and other equipment at the resident's bedside.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of resident's left upper extremity edema and the compression sleeve, for one of one resident reviewed (Resident 165). This failure had potential to affect Resident 165's blood circulation on her left upper extremity and can lead to skin breakdown and other complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the residents when: 1. Two medications for Resident 18 were not administered as ordered by the physician; and 2. One discontinued controlled substance (CS) medication was stored in the medication cart stored with other active medications available for use. This failure had the potential for inadequate medication treatment that could cause the resident to experience pain and constipation, in addition to the potential for ineffective medications to be administered to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for one resident (Resident 214), when two medications in the same therapeutic class were ordered by the physician and administered to the resident. This failure had the potential for the resident to receive excessive dose of medications and unwanted adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure residents were free from medication error rate greater than 5 % during medication pass observation when: - Two medications for Resident 18 were not administered; - One long-acting extended-release formulation medication was crushed and administered; and - One long-acting extended-release formulation medication was administered without a full glass of water being offered. This failure had the potential for inadequate medication treatment that could cause the resident to experience pain, constipation, and stomach upset. The medication error rate was 12.9 percent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. One medication stored at bedside for self-administration was properly labeled for Resident 49; and 2. Opened insulin lispro KwikPen (an injectable pen containing insulin, a hormone that regulates blood sugar) dated with 28-day expiration date was not available for use past the expiration date. This had the potential for wrong, and ineffective medications to be administered to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and implement infection prevention and control practices when the resident's indwelling urinary catheter (catheter used to drain urine from the bladder into a bag outside the body) drainage bag was touching the floor for one of one resident reviewed (Resident 164). This failure increased the potential to expose Resident 164 for further development of infection and transmission of communicable diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen grill in sanitary and safe operating condition, when the equipment was covered with blackish materials. This failure had the potential to cause cross contamination and unsanitary condition in the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to protect other residents from potential abuse while the investigation was in progress, for two of seven residents reviewed (Resident 1 and Resident 2), when: 1. The Certified Occupational Therapy Assistant (COTA); and 2. Certified Nurse Assistant (CNA) were allowed to continue to work pending the results of the alleged abuse. These failures had the potential to place the other residents in the facility at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff for four out of four residents reviewed for sufficient staffing, when staff did not respond timely to the call lights of Residents 9, 186, 286, and 334. This failure increased the potential for the residents to not receive timely and necessary care and services to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on the observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and preparation were followed when the inside and outside, including the racks, of the double oven were observed to have dry, sticky, brown residue. This failure had the potential to result in foodborne illnesses to the vulnerable resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one resident reviewed for oxygen administration (Resident 184), when the resident received oxygen therapy without a physician's order. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and a decline in the resident's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a medication administration log for emergency medication kits. This failure prevented the emergency medication kits from being tracked to prevent potential theft and diversion of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess for the need of an antipsychotic medication, have medication evaluated by the physician, and failed to provide adequate indications for an antipsychotic medication for one of six residents reviewed for antipsychotic medication use. (Resident 335). This failure had the potential to jeopardize the health and safety of Resident 335.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1) properly label a prescribed medication needed for safe administration, when one insulin injectable pen and one glucagon injectable pen were found in medication cart 2 without a pharmacy label; and 2) ensure proper organization and storage of Cefazolin (antibiotic) IV (intravenous) bags, risking administration of an antibiotic beyond its use-by-date. In addition, the facility was unable to differentiate between the IV solution that were different in color. These failures had the potential for residents to receive the improper amount of insulin and for residents to receive expired IV medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the PICC (Peripherally Inserted Central Catheter - an IV [intravenous], longer than a regular IV) line dressing was changed according to the standard of practice for one of one resident reviewed (Resident 287). This failure had the potential to place Resident 287 at risk for infection and other complications.