Other·July 24, 2019

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 one facility-reported incident linked with one complaint. Facility-reported incident number CA00627286 and complaint number CA00627339. Representing the California Department of Public Health: Surveyor 39503, HFEN The inspection was limited to the specific facility-reported incident and complaint investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for facilityreported incident number CA00627286 and complaint number CA00627339.

F656 SS=G Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 07/21/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest 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: 0VSB11 Facility ID: CA250001745 If continuation sheet 1 of 17 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 06/21/2019 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 practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, for one resident reviewed (Resident A), the facility failed to develop and implement an individualized, resident-centered interventions, according to Resident A's Physical Therapy (PT) evaluation, to provide adequate supervision and assistance to prevent accidents. This failure resulted in Resident A having an accident on March 4, 2019, and to suffer a fracture on the left tibia (break in the large bone FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VSB11 Facility ID: CA250001745 If continuation sheet 2 of 17 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 06/21/2019 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 located on the front portion of the leg) and left fibula (break in the calf bone). Findings: On March 6, 2019, an unannounced visit was conducted to investigate a facility reported incident and a complaint. A review of Resident A's medical record was conducted. Resident A was a 90+ year old female admitted to the facility on February 24, 2019, with diagnoses that included congestive heart failure (CHF - a condition in which the heart does not pump blood as well as it should) and dementia (loss of cognitive functioning like thinking, remembering, and reasoning). Resident A's history and physical documented by the physician on February 25, 2019, indicated Resident A was not oriented to time, place, person and situation, with inappropriate mood and affect. Resident A's Physical Therapy (PT) evaluation and Plan of Treatment dated February 25, 2019, indicated the following: - Resident A's bilateral lower extremities were impaired; - Resident A's static standing (standing without movement) was poor; - Resident A had total dependence on transfers; and - Resident A's safety awareness was impaired. In addition, the PT evaluation indicated Resident A's short term and long term goals were for the resident to safely ambulate using her two-wheeled walker. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VSB11 Facility ID: CA250001745 If continuation sheet 3 of 17 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 06/21/2019 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 MDS (Minimum Data Set- an assessment tool), dated March 3, 2019, indicated the following: - Section G0110 (1B) ADL (Activities of Daily Living) Self-Performance on Transfer, Resident A needed extensive assistance (resident involved in activity, staff provide weight-bearing support); - Section G0110 (2B) ADL Support Provided on Transfer, Resident A needed two-person physical assist; and - Section G0400 Range of Motion, Resident A had functional limitation on both lower extremity including the hip, knee, ankle, and foot. Resident A's Fall Risk Assessment dated February 25, 2019, indicated the resident was confined to chair and not able to attempt balance without physical help. Resident A was assessed at risk for falls. The facility's Investigation Report, dated March 6, 2019, indicated, when Resident A attempted to sit down in the shower chair, the resident struck her left leg against the wall. Resident A developed a hematoma (a localized bleeding outside of blood vessels due to trauma) below the left knee. Resident A's physician's order dated March 4, 2019, indicated the following: - at 10:38 a.m., X-ray of the left leg related to hematoma (a localized bleeding outside of blood vessels due to trauma); and - at 11:07 a.m., monitor hematoma to left lower leg. Resident A was transferred to an emergency FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VSB11 Facility ID: CA250001745 If continuation sheet 4 of 17 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 06/21/2019 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 room (ER) on March 4, 2019, after the left leg x-ray result showed fracture of the tibia and fibula. On March 18, 2019, at 11:30 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated she was assigned and gave the shower to Resident A on March 4, 2019. CNA 1 stated it was the first time she was assigned to Resident A. CNA 1 stated she did not receive any instructions from the charge nurse nor did she ask the Physical Therapy (PT) staff, regarding Resident A's care and the assistance needed for her ADLs and transfer activity. CNA 1 stated she assisted Resident A for transfer by herself to the shower room, and after Resident A had a shower, she had Resident A stand up by herself while holding on to the grab bar in the shower room so she could pull up the new diaper and pants of the resident. CNA 1 stated after drying the resident's buttocks and pulled up the diaper and pants, she was about to pull the wheelchair for Resident A to sit when the resident told her "I cannot stand," and "I need to sit." CNA 1 stated she told Resident A to "hold on," but Resident A let go of the grab bar and fell back. CNA 1 pulled the wheelchair towards Resident A and was able to catch half of her buttocks in the wheelchair. CNA 1 stated after she wheeled Resident A back to her room, the resident complained of pain on her left foot. CNA 1 noticed the resident's left leg felt odd, it was loose when moved. CNA 1 further stated Resident A had a bump on the left lower knee and it was getting bigger, so she immediately called her charge FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VSB11 Facility ID: CA250001745 If continuation sheet 5 of 17 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 06/21/2019 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 nurse to assess the resident's left leg. CNA 1 stated "it happen so fast," she may have pushed the wheel chair too hard and too fast to catch Resident A, "made the resident push her knee to the wall." On March 18, 2019, at 9:20 a.m., a concurrent interview and record review was conducted with the Physical Therapy (PT). The PT stated she evaluated Resident A on February 25, 2019. The PT verified Resident A's performance on static (no movement) standing was "Poor" (maximum assistance with upper extremities support to stand, 75% support assistance should be coming from the caregiver). The PT stated standing while holding on to the grab bar was an example of static standing. The PT stated based on Resident A's evaluation, the resident could not stand on her own and hold on to the grab bar. The PT further stated the resident needed assistance from the caregiver for static standing. The PT added that Resident A had behavior changes. There were days she will cooperate with the therapy and all of a sudden she will refuse and not cooperate, or there were times the resident would get tired and become weak. The PT stated considering Resident A's response to the therapy and her changing behavior and condition, it is not safe for Resident A to stand by herself and just hold on to the grab bar. On March 18, 2019, at 10:40 a.m., a record review and interview was conducted with LVN 2. Resident A's care plans dated February 25, 2019, indicated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VSB11 Facility ID: CA250001745 If continuation sheet 6 of 17 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 06/21/2019 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 - "...Focus...The resident has an ADL Self Care Performance Deficit... Interventions/Task...PT/OT evaluation and treatment as per MD (physician) orders...The resident requires assistance for ADLs...The resident requires assistance to dress...The Resident requires staff assistance with bathing/showering..."; and - "...Focus...The resident is at risk for falls... Goal...The resident will not sustain injury... Interventions/Tasks...OT eval (evaluation) and treat (treatment) as ordered...PT evaluate and treat as ordered..." LVN 2 stated Resident A's care plan did not specify what level of assistance was needed while providing ADL's to Resident A, nor specific interventions were developed to prevent the resident from having a fall. LVN 2 stated there should be input from different department as applicable in developing the care plans for the residents. On March 18, 2019, at 10:15 a.m., the Rehabilitation Director (RD) was interviewed. The RD stated his department does not communicate to the nurses the result of evaluations conducted by the PT/OT. The RD stated it is not being done in this facility. The RD stated the nurses could read the PT/OT evaluation and notes after it is filed in the medical records. The RD further stated some licensed nurses and CNAs would ask the PT/OT regarding their residents but it is not consistent. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VSB11 Facility ID: CA250001745 If continuation sheet 7 of 17 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 06/21/2019 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 RD stated it is important to have communication between the two departments so everyone would be in the same page to provide safe care to the residents. On March 21, 2019 at 9:22 a.m., the Regional Director of Clinical Operations (RDCO) was interviewed. The RDCO stated she was a Registered Nurse and was the interim Director of Nursing for the facility. The RDCO stated in developing the care plan for the residents, there should be involvement of different department as applicable. The RDCO further stated for Resident A's care plan on ADLs and fall risk, there should be an input from the rehab department. In a concurrent record review of Resident A's care plan, The RDCO stated the care plan for ADL was not clear. The RDCO stated the care plan did not specify the extent of assistance needed by the resident like one-person or twoperson assist. The RDCO stated the care plan should have indicated the level of assistance needed for Resident A. The RDCO stated the care plan for fall risk was not clear. The RDCO stated the care plan did not specify what fall risk interventions were in placed to prevent Resident A from having a fall. The RDCO stated the care plan should have the fall risk interventions developed for Resident A. The facility's policy and procedure titled, "Comprehensive Care Plan," dated November 2017, indicated, "...A comprehensive, personcentered Care Plan will be developed for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that have been identified through a comprehensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VSB11 Facility ID: CA250001745 If continuation sheet 8 of 17 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 06/21/2019 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 assessment... The comprehensive care plan is based on a comprehensive assessment which includes, but is not limited to, the MDS, Care Area Assessments, clinical assessments and data collection forms, Therapy Evaluations, psychosocial and cognitive evaluations, physician assessments/consults... Each resident's comprehensive care plan will describe... Identified resident issues, conditions, risk factors and safety issues... Interventions that will be implemented to enable each resident to meet his/her objectives..." The facility's policy and procedure titled, "Fall Prevention," dated October 2018, indicated, "...Resident's Care Plan shall reflect that he/she is at a higher risk for falls and identifies approaches that are to be taken..." On March 13, 2019, at 3:45 p.m., Resident A's family member stated the orthopedic surgeon told him Resident A "is not a candidate for surgery" because of "her age and medical condition." Resident A suffered physical harm, pain, and loss of function as a result of having an accident on March 4, 2019, due to the facility's failure to develop and implement a comprehensive person-centered care plan that includes specific interventions to address and meet Resident A's needs for adequate supervision and assitance to prevent accidents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VSB11 Facility ID: CA250001745 If continuation sheet 9 of 17 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 06/21/2019 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)

F689 Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) SS=G ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 07/21/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to develop and implement an individualized, resident-centered interventions, according to Resident A's Physical Therapy (PT) evaluation, to provide adequate supervision and assistance to prevent accidents. Additionally, the PT evaluation of Resident A's needs for level of supervision and assistance was not communicated to the Certified Nursing Assistant (CNA) 1. These failure resulted in Resident A having an accident on March 4, 2019, and to suffer a fracture on the left tibia (break in the large bone FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VSB11 Facility ID: CA250001745 If continuation sheet 10 of 17 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 06/21/2019 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 located on the front portion of the leg) and left fibula (break in the calf bone). Findings: On March 6, 2019, an unannounced visit was conducted to investigate a facility reported incident and a complaint. A review of Resident A's medical record was conducted. Resident A was a 90+ year old female admitted to the facility on February 24, 2019, with diagnoses that included congestive heart failure (CHF - a condition in which the heart does not pump blood as well as it should) and dementia (loss of cognitive functioning like thinking, remembering, and reasoning). Resident A's history and physical documented by the physician on February 25, 2019, indicated Resident A was not oriented to time, place, person and situation, with inappropriate mood and affect. Resident A's Physical Therapy (PT) evaluation and Plan of Treatment dated February 25, 2019, indicated the following: - Resident A's bilateral lower extremities were impaired; - Resident A's static standing (standing without movement) was poor; - Resident A had total dependence on transfers; and - Resident A's safety awareness was impaired. In addition, the PT evaluation indicated Resident A's short term and long term goals were for the resident to safely ambulate using her two-wheeled walker. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VSB11 Facility ID: CA250001745 If continuation sheet 11 of 17 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 06/21/2019 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 MDS (Minimum Data Set- an assessment tool), dated March 3, 2019, indicated the following: - Section G0110 (1B) ADL (Activities of Daily Living) Self-Performance on Transfer, Resident A needed extensive assistance (resident involved in activity, staff provide weight-bearing support); - Section G0110 (2B) ADL Support Provided on Transfer, Resident A needed two-person physical assist; and - Section G0400 Range of Motion, Resident A had functional limitation on both lower extremity including the hip, knee, ankle, and foot. Resident A's Fall Risk Assessment dated February 25, 2019, indicated the resident was confined to chair and not able to attempt balance without physical help. Resident A was assessed at risk for falls. The facility's Investigation Report, dated March 6, 2019, indicated, when Resident A attempted to sit down in the shower chair, the resident struck her left leg against the wall. Resident A developed a hematoma (a localized bleeding outside of blood vessels due to trauma) below the left knee. Resident A's physician's order dated March 4, 2019, indicated the following: - at 10:38 a.m., X-ray of the left leg related to hematoma (a localized bleeding outside of blood vessels due to trauma); and - at 11:07 a.m., monitor hematoma to left lower leg. Resident A was transferred to emergency room FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VSB11 Facility ID: CA250001745 If continuation sheet 12 of 17 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 06/21/2019 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 (ER) on March 4, 2019, after the left leg x-ray result showed fracture of the tibia and fibula. On March 18, 2019, at 11:30 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated she was assigned and gave the shower to Resident A on March 4, 2019. CNA 1 stated it was the first time she was assigned to Resident A. CNA 1 stated she did not receive any instructions from the charge nurse nor did she ask the Physical Therapy (PT) staff, regarding Resident A's care and the assistance needed for her ADLs and transfer activity. CNA 1 stated she assisted Resident A for transfer by herself to the shower room, and after Resident A had a shower, she had Resident A stand up by herself while holding on to the grab bar in the shower room so she could pull up the new diaper and pants of the resident. CNA 1 stated after drying the resident's buttocks and pulled up the diaper and pants, she was about to pull the wheelchair for Resident A to sit when the resident told her "I cannot stand," and "I need to sit." CNA 1 stated she told Resident A to "hold on," but Resident A let go of the grab bar and fell back. CNA 1 pulled the wheelchair towards Resident A and was able to catch half of her buttocks in the wheelchair. CNA 1 stated after she wheeled Resident A back to her room, the resident complained of pain on her left foot. CNA 1 noticed the resident's left leg felt odd, it was loose when moved. CNA 1 further stated Resident A had a bump on the left lower knee and it was getting bigger, so she immediately called her charge nurse to assess the resident's left leg. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VSB11 Facility ID: CA250001745 If continuation sheet 13 of 17 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 06/21/2019 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 CNA 1 stated "it happen so fast," she may have pushed the wheel chair too hard and too fast to catch Resident A, "made the resident push her knee to the wall." On March 18, 2019, at 9:20 a.m., a concurrent interview and record review was conducted with the Physical Therapy (PT). The PT stated she evaluated Resident A on February 25, 2019. The PT verified Resident A's performance on static (no movement) standing was "Poor" (maximum assistance with upper extremities support to stand, 75% support assistance should be coming from the caregiver). The PT stated standing while holding on to the grab bar was an example of static standing. The PT stated based on Resident A's evaluation, the resident could not stand on her own and hold on to the grab bar. The PT further stated the resident needed assistance from the caregiver for static standing. The PT added that Resident A had behavior changes. There were days she will cooperate with the therapy and all of a sudden she will refuse and not cooperate, or there were times the resident would get tired and become weak. The PT stated considering Resident A's response to the therapy and her changing behavior and condition, it is not safe for Resident A to stand by herself and just hold on to the grab bar. On March 13, 2019, at 2:13 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated he worked on evening shift (3 p.m. to 11 p.m.). LVN 1 stated he was familiar with Resident A's care and he was assigned to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VSB11 Facility ID: CA250001745 If continuation sheet 14 of 17 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 06/21/2019 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 resident several times. LVN 1 verified he worked on March 3, 2019, and was assigned to Resident A. LVN 1 stated Resident A was unstable and could not stand on her own, even if she was holding on to something. On March 18, 2019, at 10:40 a.m., a record review and interview was conducted with LVN 2. Resident A's care plans dated February 25, 2019, indicated, - "...Focus...The resident has an ADL Self Care Performance Deficit... Interventions/Task...PT/OT evaluation and treatment as per MD (physician) orders...The resident requires assistance for ADLs...The resident requires assistance to dress...The Resident requires staff assistance with bathing/showering..."; and - "...Focus...The resident is at risk for falls... Goal...The resident will not sustain injury... Interventions/Tasks...OT eval (evaluation) and treat (treatment) as ordered...PT evaluate and treat as ordered..." LVN 2 stated Resident A's care plan did not specify what level of assistance was needed while providing ADL's to Resident A, nor specific interventions were developed to prevent the resident from having a fall. LVN 2 stated there should be input from different department as applicable in developing the care plans for the residents. On March 18, 2019, at 10:15 a.m., the Rehabilitation Director (RD) was interviewed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VSB11 Facility ID: CA250001745 If continuation sheet 15 of 17 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 06/21/2019 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 RD stated his department does not communicate to the nurses the result of evaluations conducted by the PT/OT. The RD stated it is not being done in this facility. The RD stated the nurses could read the PT/OT evaluation and notes after it is filed in the medical records. The RD further stated some licensed nurses and CNAs would ask the PT/OT regarding their residents but it was not consistent. The RD stated it is important to have communication between the two departments so everyone would be in the same page to provide safe care to the residents. After the fall on March 4, 2019, Resident A was admitted to an acute hospital emergency room (ER). The ER notes indicated Resident A's left lower leg was swollen and the resident "...hold (sic) the left lower extremity slightly flexed at the hip and knee, refuses to range (to move) at all secondary to pain..." On March 13, 2019, at 3:45 p.m., Resident A's family member stated the orthopedic surgeon told him Resident A "is not a candidate for surgery" because of "her age and medical condition." Resident A suffered physical harm, pain, and loss of function as a result of having an accident on March 4, 2019, due to the facility's failure to provide adequate supervision and assistance. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0VSB11 Facility ID: CA250001745 If continuation sheet 16 of 17 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 06/21/2019 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) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: 0VSB11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA250001745 (X5) COMPLETE DATE If continuation sheet 17 of 17