F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to follow their policy and procedure for receipt of controlled
substances for one of three sampled residents (Resident 1).
This failure had the potential to result in Resident 1 not receiving his medication and medication diversion.
Findings:
A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], and
readmitted on [DATE], with diagnoses that included sjorgren syndrome (a condition that reduces moisture
produced by the body) , cognitive communication deficit, and narcolepsy (a disorder affecting sleep cycle).
The record further indicated the resident is his own representative.
A review of Resident 1's physician orders indicated an order for methylphenidate oral tablet extended
release 20 mg (a unit of measure) , give 1 tablet by mouth one time a day for narcolepsy dated June 22,
2023.
A review of Resident 1's prescription label by [retail pharmacy] for methylphenidate ER 20 mg tablets
indicated the prescription was filled on June 5, 2023, for 30 tablets.
A review of Resident 1's controlled substance/narcotic record indicated the facility recorded 9 tablets of
methylphenidate ER 20 mg for the resident on June 16, 2023. The record further indicated no signatures on
June 16, 2023.
A review of Controlled Substance Schedules by the U.S. Department of Justice, Drug Enforcement
Administration at https://www.deadiversion.usdoj.gov/schedules/indicated, Examples of Schedule IIN
stimulants include amphetamine .and methylphenidate (Ritalin®).
On August 7, 2023, at 2:10 p.m., during an interview with Licensed Vocational Nurse (LVN1), she stated if
there is a delivery of a controlled medication for the resident, she and another nurse will both sign the
narcotic sheet for the medication. She stated both nurses sign to confirm it is the right medication for the
right patient and it is the right dose. She stated the nurse assigned to the resident will then use the key and
locked the medication in the locked narcotics drawer.
On June 23, 2023, at 5:28 p.m., during an interview with the Director of Nursing (DON), he stated for a
medication brought from home, the facility would have the pharmacy confirm the medication. Then
(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 2
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
08/09/2023
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
there would be a determination as to whether the medication would need repackaging. He stated the
pharmacy would confirm if there was an order in place for the medication. He stated if the medication
requires repackaging, once delivered a licensed nurse would sign off on receipt of the medication with a
pharmacy rep. If the medication did not require repackaging medication is a controlled medication, two
licensed nurses would sign for the receipt of the medication and confirm the quantity. He stated, if there
was an order, the medication would populate on the resident's medication administration record. The
medication would be placed into the medication cart for administration. He reviewed the controlled
substance record for Resident 1's methylphenidate ER 20 mg indicating no signature by the receiving nurse
nor a cosignatory. The DON confirmed the record was not signed by a license nurse nor could the DON
confirm the amount of medication received. He reviewed the medication sheet and confirmed the practice
was not in accordance with the facility's practice.
A review of the facility's policy and procedure titled Controlled Substances revised April 2019 indicated,
Controlled substances are reconciled upon receipt .Upon Receipt: The nurse receiving the medication and
the individual delivering the medication verify the name, dose, and quantity of each controlled substance
being delivered. Both individuals sign the controlled substance record of receipt.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555775
If continuation sheet
Page 2 of 2
