Health inspection·August 3, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a personalized comprehensive care plans for one of three sample residents (Resident 1) when the facility failed to develop care plans with interventions for Resident 1 ' s urinary catheter and infection. This failure had to potential to result in Resident 1 not receiving interventions to promote the resident ' s optimal level of function. Findings: A review of Resident 1 ' s admission record indicated the resident was admitted to the facility on [DATE] with diagnoses which included sepsis, pneumonia, urinary tract infection and benign prostatic hyperplasia with lower urinary tract symptoms. A review of Resident 1 ' s Brief Interview for Mental Status (BIMS) dated May 22, 2023, indicated the resident had a score of 15 (no cognitive impairment). A review of Resident 1 ' s MDS (Minimum Data Set- an assessment) section I dated June 12, 2023, indicated Resident 1's medical condition included septicemia, urinary tract infection, and pneumonia. A review of Resident 1 ' s MDS section H dated June 12, 2023, indicated Resident 1 had an indwelling catheter (including suprapubic and nephrostomy tube). A review of Resident 1 ' s care plan indicated no entry to address Resident 1 ' s infection nor indwelling catheter. On July 20, 2023, at 3:40 p.m., during an interview with the Director of Nursing (DON), he stated the facility develops care plans for issues like infections. He further stated care plan entries are developed for resident conditions that require interventions. The DON reviewed the care plan for Resident 1 and acknowledged the absence of care plans for Resident 1 ' s urinary tract infection and suprapubic catheter. He stated there should be care plans for Resident 1 ' s infection and urinary catheter. A review of the facility ' s policy and procedure titled, Care Plans, Comprehensive Person-Centered revised December 2016 indicated, 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 .The comprehensive, person-centered care plan will: a. (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 555775 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 08/03/2023 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)