Other·September 20, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of a linked facility-reported incident and complaint. Complaint number CA00597336 and facilityreported incident number CA00596939. Representing the California Department of Public Health: Surveyor Federal ID number 38478, HFEN; and Surveyor Federal ID number 40227, HFEN. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for complaint number CA00597336 and facility-reported incident number CA00596939.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 09/03/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L65V11 Facility ID: CA250001745 If continuation sheet 1 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555775 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE RANCHO MIRAGE 72201 Country Club Dr Rancho Mirage, CA 92270 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L65V11 Facility ID: CA250001745 If continuation sheet 2 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555775 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE RANCHO MIRAGE 72201 Country Club Dr Rancho Mirage, CA 92270 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L65V11 Facility ID: CA250001745 If continuation sheet 3 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555775 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE RANCHO MIRAGE 72201 Country Club Dr Rancho Mirage, CA 92270 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on interview and record review, the facility failed to ensure notification of transfer/discharge was provided to the office of the state long-term care ombudsman for one of three sampled residents (Resident A). This failure increased the potential for the ombudsman to not be aware or involved of facility practices and activities related to the resident's transfer and discharge. Findings: On August 2, 2018, at 9:45 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding admission, transfer and discharge. Resident A's record was reviewed on August 2, 2018. Resident A was admitted to the facility on March 8, 2018, with diagnoses which included diabetes mellitus (disease associated with high blood sugar levels), cerebrovascular disease (stroke), and heart failure. The facility's document titled, "Transition of Care and Discharge Summary," dated April 20, 2018, indicated, "...(Resident A) discharge to residence...on 04/20/2018 01:00 (April 20, 2018 at 1 p.m.)..." There was no documented evidence the longterm care ombudsman was notified of Resident A's discharge. On August 2, 2018, at 11:32 a.m., Resident A's record was reviewed with the Social Services Director (SSD). The SSD confirmed there was no ombudsman notification for Resident A's transfer and discharge. The SSD stated she started providing notice to the ombudsman for resident discharges on July 19, 2018. The SSD FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L65V11 Facility ID: CA250001745 If continuation sheet 4 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555775 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE RANCHO MIRAGE 72201 Country Club Dr Rancho Mirage, CA 92270 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated she did not recall when she found out about the regulations regarding ombudsman notification. When asked about the facility's policy, the SSD stated the facility followed the federal regulations on ombudsman notification for transfers and discharges. On August 14, 2018, at 2:46 p.m., the Director of Nursing (DON) was interviewed regarding ombudsman notification. The DON stated the social services was responsible for providing notice of transfer/discharge to the ombudsman which started in July 2018. The DON stated the facility provides notification of residents' transfer and discharges to the ombudsman at the end of each month.

F745 SS=D Provision of Medically Related Social Service CFR(s): 483.40(d)

F745 09/06/2018 §483.40(d) The facility must provide medicallyrelated social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the social services designee provided a follow-up for the ordered necessary appointments and consults for one of three sampled residents (Resident A). This failure had the potential to result in delayed treatments and unmet care needs. Findings: On August 1, 2018, at 4:20 p.m., Resident A's durable power of attorney (DPOA) was interviewed. The DPOA stated Resident A "missed his appointments" with the doctors and specialists. The DPOA further stated "nobody FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L65V11 Facility ID: CA250001745 If continuation sheet 5 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555775 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE RANCHO MIRAGE 72201 Country Club Dr Rancho Mirage, CA 92270 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE followed through." On August 2, 2018, at 9:45 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care concerns. Resident A's record was reviewed on August 2, 2018. Resident A was admitted to the facility on March 8, 2018, with diagnoses which included diabetes mellitus ((disease associated with high blood sugar levels), cerebrovascular disease (stroke), and heart failure. The acute hospital's "Neurology (branch of medicine that deals with the study of the nerves and the nervous system) Report," dated March 5, 2018, indicated, "...Impression: This is an abnormal electroencephalogram (test for brain activity)...suggestive of encephalopathy (disease that affects the function or structure of the brain). Resident A's hospital transfer orders, dated March 8, 2018, indicated the following: - "...Neurology..follow up within 2 weeks..." - "Discharge instructions...follow up with (name of urologist) (urologist- doctor who specializes in the study or treatment of the function and disorders of the urinary system) within 2 weeks for cystoscopy (procedure that allows your doctor to examine the lining of your bladder) planning..." There was no documented evidence in Resident A's clinical record that a follow up was completed during Resident A's first admission (March 8, 2018 to April 20, 2018). There was no documentation of any follow-through communication regarding scheduling of the ordered appointments with the doctor's clinic or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L65V11 Facility ID: CA250001745 If continuation sheet 6 of 7 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555775 (X3) DATE SURVEY COMPLETED 08/22/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE RANCHO MIRAGE 72201 Country Club Dr Rancho Mirage, CA 92270 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the insurance group. On August 2, 2018, at 11:32 a.m., the Social Services Director (SSD) was interviewed regarding Resident A's doctors' appointments. The SSD stated that if there was an order for appointment, the receptionist would schedule those appointments. The SSD stated, "I don't schedule appointments...(name of receptionist) is usually good...I don't have to..." When asked about her involvement and follow up with resident appointments, the SSD stated, "I don't do appointments for the most part..." On August 2, 2018, at 12:38 p.m., the Receptionist was interviewed. The Receptionist stated she called and scheduled appointments for the residents. On review with Resident A's record, the receptionist confirmed there was no documentation of any neurology or urology follow-up on Resident A's first admission. The Receptionist stated, "I don't know what happened." On August 14, 2018, at 2:46 p.m., the Director of Nursing (DON) was interviewed regarding the process of follow up and scheduling appointments. The DON stated if a resident had an ordered appointment on admission, the receptionist would call the doctor or the clinic. The DON further stated, if the appointment was not scheduled or was not available, the receptionist was supposed to inform the charge nurses assigned with the involved residents. The facility was unable to provide a policy and procedure regarding resident appointments and consults. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: L65V11 Facility ID: CA250001745 If continuation sheet 7 of 7