Health inspection·July 20, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete conditions, as they provide nursing staff with consistent nursing interventions, which the staff implemented during provision of resident care. A review of the facility Policy titled, Care Plans, Comprehensive Person-Centered, revised, December 2016, indicated, . Policy Statement: A comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Policy Interpretation and Implementation . 8. The comprehensive, person-centered care plan will: g. Incorporate identified problem areas; 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . Event ID: Facility ID: 555775 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Rancho Mirage 72-201 Country Club Drive Rancho Mirage, CA 92270 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical records were complete and accurately documented, when residents had a fall, for three of four residents (Residents 1, 2 and 3). This failure had the potential for the records not to fully reflect accurate status of the residents after a fall incident which could result in inappropriate interventions or treatments. Findings: On June 1, 2023, at 9:00 a.m., an unannounced visit was made to the facility to investigate a quality care issue. 1. A review of Resident 1's medical record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included abnormalities in gait, lack of coordination, and chronic fatigue. Further review of records indicated Resident 1 has a Brief Interview for Mental Status (BIMS) score of 14 (meant cognitively intake). A review of Resident 1's Interdisciplinary Team (IDT) Meeting Note dated 5/26/2023, at 10:55 a.m., indicated, . IDT Meeting Notes: Met to discuss fall on 05/25/2023. After investigation it appears that (Resident 1) sustained fall when (Resident 1) attempted to take self to restroom lost his (sic) balance causing (Resident 1) to fall onto buttocks on the floor . A review of Resident 1's record on the resident's fall incident on May 25, 2023, indicated incomplete documentation on the fall incident for Resident 1. On June 1, 2023, at 2:35 p.m., a concurrent record review and interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 1's medical record was missing a post fall nursing note and Change of Condition (COC- A clinical deviation from a mental, physical, or psychological baseline) note on fall incident which occurred on May 25, 2023. 2. A review of Resident 2's medical record, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included fracture of right femur (Long leg bone), multiple fractures of right side of ribs, muscle weakness, history of falls, and Parkinson's disease (A brain disorder which causes unintended muscle tremors, lack of coordination, and imbalance). Further review of record indicated the resident has a BIMS score of 14 (cognition intact). A review of Resident 2's nursing progress note, dated May 30, 2023, at 3:35 p.m., indicated Resident 2, . Sustained fall when attempting to close privacy curtain in room. Lost balance and fell onto floor . A review of Resident 2's Interdisciplinary Team (IDT) Meeting Note, dated, June 1, 2023, at 1:37 p.m., indicated, . After investigation it appears that (Resident 2) sustained (a) fall when (Resident 2) attempted to close . privacy [NAME] (sic) without assistance lost . balance causing (Resident 2) to fall onto (sic) floor . On June 1, 2023, at 2:47 p.m., a concurrent record review and interview was conducted with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Rancho Mirage 72-201 Country Club Drive Rancho Mirage, CA 92270 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ADON. The ADON stated Resident 2's record was missing a change of condition documentation and a post fall nursing note on May 30, 2023. 3. A review of Resident 3's medical record, indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included lack of coordination, muscle weakness, unsteadiness on feet, and spinal stenosis (Pressure on the spinal cord, which can result in pain and muscle weakness). A review of Resident 3's nursing note, dated, March 19, 2023, at 1:03 a.m., indicated, . (Resident 3) Fell at 0100 a.m. coming from restroom, sustained injury to right shoulder, fell on (right) shoulder(complaints of) severe pain . Further review of records indicated a Post fall COC was missing from Resident 3's medical records. On June 1, 2023, at 3:04 p.m., a concurrent record review and interview was conducted with the ADON. She verified Resident 3's medical record was Missing a COC, post fall assessment on March 19, 2023. On July 19, 2023, at 11:40 a.m., an interview was conducted with the Director of Nursing (DON), who stated nursing documentation post resident fall should include, at least physician and responsible party, what happened, a COC, and vital signs. At the very least a brief assessment of the resident's condition, including vital signs. A review of the facility's Policy and Procedure, titled, Charting and Documentation, revised May 2017, indicated, Policy Statement . All services provided to the resident . any changes in the resident's medical, physical, or psychosocial condition, shall be documented in the resident's medical record . 2. The following information is to be documented in the resident medical record: d. Changes in the resident's condition; e. Events, incidents, or accidents involving the resident . A review of the facility's Policy and Procedure, titled, Change in Resident's Condition or Status, revised, May 2017, indicated, . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555775 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Rancho Mirage 72-201 Country Club Drive Rancho Mirage, CA 92270 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the call light system was always functioning properly, when the call light system was observed to be inaudible. Residents Affected - Few This failure has the potential to result in delayed notification of the nurses of the residents' needs which could negatively impact the residents' health condition. Findings: On June 1, 2023, at 9:00 a.m., an unannounced visit was made to the facility for a quality care issue. On June 1, 2023, at 12:35 p.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was observed resting in bed, with the call light by his side. Resident 1 pulled the call light, and a light in the hallway was triggered. Further observation of the call light system, indicated no alarm was triggered at the nursing station. On June 1, 2023, at 12:40 p.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 1 and LVN 2. LVNs 1 and 2 were observed sitting at the nurse's station. The call light in Resident 1's room could not be heard at the nurse's station. During interview, LVNs 1 and 2 stated, they were unaware Resident 1's call light was pulled, as no alarm was activated at the nurse's station. LVN 2 stated Resident 1's call light has been triggered, as the room number was lit up on the phone system, however; she stated the alarm was muted. LVN 2 was observed deactivating the call light mute buttton and the call light alarm could then be immediately heard at the nurse's station. LVNs 1 and 2 stated they did not know that the call light was muted, and it should not be muted. On June 1, 2023, at 12:43, during an interview, the ADON stated she was unaware the call light system was muted at the nursing station. The ADON stated the call light system should never be muted. A review of the facility's Policy, titled, Answering the Call Light, revised September 2022, indicated, . Purpose: The purpose of the procedure is to ensure timely responses to the resident's request and needs . General Guidelines: 4. Be sure that the call light is .functioning at all times . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 5 of 5