Health inspection·January 11, 2024

F 0554 the medication was administered daily every six hours. Level of Harm - Minimal harm or potential for actual harm The facility's policy and procedure titled, Administering Medications, revised, April 2019, was reviewed and it indicated: Residents Affected - Few .Residents may self-administer their own medications only if the Attending Physician in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 2 of 19 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 01/11/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a care plan for one of one resident reviewed for oxygen use (Resident 16) and for one of three residents reviewed for edema [swelling] (Resident 165). This failure had the potential to negatively impact the residents' quality of care and had the potential for staff to not be aware of the residents' care needs and provide appropriate treatment. Findings: 1. On January 8, 2024, at 11:53 a.m., Resident 16 was observed in bed, with oxygen (O2) via nasal cannula (NC - a tube used to deliver oxygen through the nose). Resident 16's oxygen administration was observed at three liters per minute (LPM). In a concurrent interview, Resident 16 stated she uses O2 continuously due to shortness of breath and she takes it off at times during the day. Resident 16's record was reviewed. Resident 16 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD - a disease that causes obstructed airflow). The physician's order dated January 4, 2024, indicated, .Oxygen Therapy Continuous - 2 Liters Per/Minute Via Nasal Cannula. May Titrate Oxygen Up to 5 Liters To Maintain O2 Sats > 90% every shift for (SOB [short of breath] Related: COPD) . On January 10, 2024, at 9:03 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 16 had a physician's order for oxygen. In a concurrent review of Resident's 16's record, LVN 1 stated there was no documentation a care plan for oxygen was initiated for Resident 16. LVN 1 stated Resident 16 should have had a care plan for oxygen administration. On January 10, 2024, at 9:20 a.m., the Director of Nursing (DON) was interviewed. The DON confirmed a care plan for oxygen administration for Resident 16 was not initiated. The DON stated a care plan for O2 administration should have been developed for Resident 16. 2. During a concurrent observation and interview, on January 8, 2024, at 12:55 p.m., with Resident 165 in her room, Resident 165 was observed lying in bed awake, alert, and able to verbalize her needs. Resident 165 was observed wearing a left arm compression sleeve (a type of medical garment used to increase blood flow, reduce pain and swelling). Resident 165 was observed with some edema (swelling) of her left hand. Resident 165 stated she had a history of lymphedema (a condition caused by a blockage in the lympahatic system, part of immune and circulatory system) for five years. She stated she had a history of breast cancer, and sometimes the edema was bad. During a review of Resident 165's record, Resident 165 was admitted to the facility on [DATE], with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 3 of 19 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 01/11/2024 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 0655 diagnoses which included fracture of fourth lumbar vertebra (bones in the spine). Level of Harm - Minimal harm or potential for actual harm The nursing notes dated January 3, 2024, entered at 10:39 p.m., indicated, .Resident noted to have edema to left upper extremity. Encourage elevation. Resident stated she has edema due to (d/t) history of breast cancer to left breast . Residents Affected - Few The nursing progress notes from January 4, 2024 to January 8, 2024, did not indicate licensed nurse observation and monitoring of Resident 165's left arm edema and the presence of the left arm compression sleeve. The initial social service evaluation dated January 4, 2024, indicated Resident 165 was alert and oriented to person, place, time, and situation. The baseline care plans upon admission did not include the identified assessment of edema on Resident 165's left upper extremity. During a concurrent observation and interview, on January 9, 2024, at 9:05 a.m., with Resident 165, indicated Resident 165 was awake, alert, and able to verbalize her needs. Resident 165's left hand was observed without edema. She stated she felt better having no swelling on her left arm. She stated she wore her compression sleeve all day and all night. During a concurrent observation and interview, on January 9, 2024, at 9:45 a.m., conducted with the Director of Nursing (DON) in the resident's room, the DON acknowledge Resident 165 was wearing a left arm compression sleeve. During a concurrent interview and record review, on January 9, 2024, at 10:05 a.m., with the DON, the nurse's notes from January 3, 2024 to January 9, 2024, were reviewed. The DON confirmed on January 3, 2024, the licensed nurse documented Resident 165 had edema on her left upper extremity. The DON stated there were no further monitoring and assessments of Resident 165's edema on every shift after January 3, 2024. The DON further stated there was no assessment of Resident 165's compression sleeve. A review of Resident 165's care plans indicated there was no documented evidence the baseline care plan for Resident 165's edema and compression sleeve was developed. The DON stated the licensed nurse who admitted Resident 165 should have initiated the baseline care plan for Resident 165's edema of her left upper extremity. He stated there was no physician's order for the compression sleeve. He stated the physician should have been contacted by the licensed staff. During a concurrent observation and interview, on January 10, 2024, at 10:30 a.m., Resident 165 was observed lying in bed, awake, alert, and able to verbalize her needs. Resident 165 stated she just returned from physical therapy. Resident 165 was observed with her left arm compression sleeve on and without edema on the left hand. The facility's policy and procedure titled, Care Plans - Baseline, dated December 2016, was reviewed. The policy indicated, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty eight (48) hours of admission .The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 4 of 19 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 01/11/2024 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 0655 person-centered care plan . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 5 of 19 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 01/11/2024 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 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 observation, interview, and record review, the facility failed to implement the care plan in using the dignity bag for resident's indwelling urinary catheter (catheter used to drain urine from the bladder into a bag outside the body) drainage bag for one of one resident reviewed (Resident 164). This failure resulted in Resident 164's indwelling urinary catheter drainage bag's urine being visibly exposed to visitors entering the room and the drainage bag did not have protection from contact with the bed and other equipment at the resident's bedside. Findings: On January 8, 2024, at 12:25 p.m., Resident 164 was in a room designated with contact isolation precautions (steps healthcare facility visitors and staff need to follow before going into a patient's room to stop germs from spreading by touching the patient or surfaces in the room). The personal protective equipment (PPE - used to minimize exposure to hazards that cause serious illnesses) cart was observed outside the room. During a concurrent observation and interview on January 8, 2024, at 12:28 p.m., with Resident 164 in his room, Resident 164 was observed lying in bed awake, alert, and able to verbalize his needs. Resident 164 stated he had infected wounds on his right foot. A wound vac (device used to remove excess fluid and promote healing of the wounds) was observed on resident's right side of his foot dressing. Resident 164 was observed with an indwelling urinary catheter attached to a drainage bag containing yellow urine. The indwelling urinary catheter drainage bag's bottom was touching the floor. The drainage bag was uncovered. During a concurrent observation and interview on January 8, 2024, at 12:30 p.m., with the Director of Nursing (DON), in Resident 164's room, the DON stated the resident's indwelling urinary catheter drainage bag was on the floor. He stated the drainage bag should not be touching the floor and should be covered with the dignity bag. During a concurrent observation and interview on January 8, 2024, at 12:40 p.m., with the Infection Preventionist (IP) in Resident 164's room, the IP stated the indwelling urinary catheter drainage bag should not be touching the floor and should be covered with the dignity bag. On January 8, 2024, Resident 164's record was reviewed. Resident 164 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD - kidney disease), and acute Osteomyelitis (bone infection)) of right ankle and foot, and recent right amputation of second and third toes with Methicillin Resistant Staphylococcus Aureus (MRSA - a serious infection that can lead to sepsis or death). During a review of Resident 164's record, indicated a care plan for indwelling urinary catheter, with goal and interventions. The care plan indicated, .Place indwelling urinary catheter bag in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 6 of 19 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 01/11/2024 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 0656 dignity/privacy bag . Level of Harm - Minimal harm or potential for actual harm On January 10, 2024, at 10:23 a.m., a concurrent interview and record review was conducted with the DON. The DON reviewed Resident 164's care plan for indwelling urinary catheter. The care plan indicated a goal and interventions which included .Place indwelling urinary catheter bag in dignity/privacy bag . Residents Affected - Few The DON acknowledged the care plan intervention of placing the indwelling urinary catheter drainage bag in dignity/privacy bag was not followed. The facility's policy and procedure titled, Care Plans, Comprehensive Person - Centered, dated December 2016, was reviewed. The policy 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 . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 7 of 19 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 01/11/2024 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the physician of resident's left upper extremity edema and the compression sleeve, for one of one resident reviewed (Resident 165). Residents Affected - Few This failure had potential to affect Resident 165's blood circulation on her left upper extremity and can lead to skin breakdown and other complications. Findings: During concurrent observation and interview, on January 8, 2024, at 12:55 p.m., with Resident 165 in her room, Resident 165 was observed lying in bed awake, alert, and able to verbalize her needs. Resident 165 was observed wearing a left arm compression sleeve (a type of medical garment used to increase blood flow, reduce pain and swelling). Resident 165 was observed with edema (swelling) of her left hand. Resident 165 stated she had a history of lymphedema (a condition caused by a blockage in the lympahatic system, part of immune and circulatory system) for five years. She stated she had a history of breast cancer. She stated sometimes the edema was bad. Resident 165's record was reviewed. The record indicated Resident 165 was admitted to the facility on [DATE], with diagnoses which included fracture of fourth lumbar vertebra (bone in the spine). The nursing notes dated January 3, 2024, entered at 10:39 p.m., indicated, .Resident noted to have edema to left upper extremity. Encourage elevation. Resident stated she has edema due to (d/t) history of breast cancer to left breast . The physician's orders dated January 3, 2024, indicated there was no specific orders for monitoring of Resident 165's edema of left upper extremity and instructions for the care of compression sleeve. The nursing progress notes from January 4, 2024 to January 8, 2024, did not indicate licensed nurse observation and monitoring of Resident 165's left arm edema and the presence of the left arm compression sleeve. During a concurrent observation and interview, on January 9, 2024, at 9:05 a.m., with Resident 165, Resident 165 was awake, alert, and able to verbalize her needs. Resident 165's left hand was observed without edema. She stated she felt better having no swelling on her left arm. She stated she wore her compression sleeve all day and all night. During a concurrent observation and interview, on January 9, 2024, at 9:45 a.m., conducted with the Director of Nursing (DON) in Resident 165's room, the DON acknowledge Resident 165 was wearing a left arm compression sleeve. During a concurrent interview and record review, on January 9, 2024, at 10:05 a.m., with the DON, the nurse's notes from January 3, 2024 to January 9, 2024, were reviewed. The DON confirmed on January 3, 2024, the licensed nurse documented Resident 165 had edema on her left upper extremity. The DON stated there were no further monitoring and assessments of resident's edema on every shift after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 8 of 19 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 01/11/2024 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 0658 January 3, 2024. The DON stated there was no assessment of Resident 165's compression sleeve. Level of Harm - Minimal harm or potential for actual harm A review of the physician's orders from January 3, 2024 to January 9, 2024, indicated there was no physician's order for monitoring of Resident 165's edema every shift and compression sleeve instructions. Residents Affected - Few The DON stated the licensed nurse who admitted Resident 165, should have informed the physician regarding Resident 165's edema of the left upper extremity and the resident's compression sleeve. He stated there was no physician's order for the compression sleeve, and the monitoring of resident's left upper extremity edema. During a concurrent observation and interview, on January 10, 2024, at 10:30 a.m., Resident 165 was observed lying in bed, awake, alert, and able to verbalize her needs. Resident 165 stated she just returned from physical therapy. Resident 165 was observed with her left arm compression sleeve on and without edema on the left hand. The facility's policy and procedure titled, admission Assessment and Follow Up: Role of the Nurse, dated September 2012, indicated, .The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident .Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 9 of 19 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 01/11/2024 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the residents when: Residents Affected - Few 1. Two medications for Resident 18 were not administered as ordered by the physician; and 2. One discontinued controlled substance (CS) medication was stored in the medication cart stored with other active medications available for use. This failure had the potential for inadequate medication treatment that could cause the resident to experience pain and constipation, in addition to the potential for ineffective medications to be administered to the resident. Findings: 1. On January 9, 2024, at 8:20 a.m., during a medication pass observation with the Licensed Vocational Nurse (LVN) 2, it was observed, LVN 2 prepared and administered, for Resident 18, her morning medications that included one potassium chloride (potassium supplement) ER (extended release) 8 MEq (milliequivalent - unit of measurement) tablet after crushing a total of eight medications. The eight medications that were administered to the resident by LVN 2 were as follows: One tablet of amiodarone (medication for irregular heart rhythm) 200 mg (milligram -- unit of measurement); One tablet of Eliquis (a blood thinner) 5 mg; One tablet of carvedilol (medication to control blood pressure) 3.125 mg; One tablet of ezetimibe (medication for high cholesterol) 10 mg; One tablet of losartan (medication to control blood pressure) 50 mg; One tablet of metformin (medication to control blood sugar) 500 mg; One tablet of potassium chloride ER 8 MEq; and One tablet of rosuvastatin (medication for high cholesterol) 10 mg. On January 9, 2024, the medical record of Resident 18 was reviewed, and the following was noted: There was a physician order on December 28, 2023, for docusate sodium (brand name: Colace medication to treat constipation) 100 mg with the direction to give the resident one capsule by mouth one time a day for bowel management; There was a physician order on December 21, 2023, for lidocaine external patch 5 % (topical patch for pain relief) to be applied to the resident's left knee one time a day and be removed per (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 10 of 19 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 01/11/2024 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 schedule; and Level of Harm - Minimal harm or potential for actual harm The electronic medication administration record (eMAR) for January 2024, indicated the morning dose of docusate sodium 100 mg and lidocaine 5 % patch were documented as administered to the resident; Residents Affected - Few The eMAR for January 2024, also indicated the lidocaine topical patch was to be applied at 9 a.m., and removed at 9 p.m., each day. On January 9, 2024, at 11 a.m., it was observed Resident 18 still had on her left knee the lidocaine patch that was applied the day before. In a concurrent interview, LVN 2 stated he did not administer the lidocaine patch for the resident because the resident's lidocaine patches ran out, and the resident was going home later that day. LVN 2 stated he did not administer the resident's morning dose of Colace because the resident was going home later that day. LVN 2 stated it was a mistake and he should not have documented as administered the lidocaine patch and the Colace dose in the resident's medical record. The facility's policy and procedure titled, Administering Medications, revised, April 2019, was reviewed, and it indicated: .Medications are administered in accordance with prescriber orders, including any required time frame . 2. On January 10, 2024, at 1:45 p.m., during an inspection of the medication cart located in [NAME] Hall with LVN 3, there was a blister pack containing alprazolam (medication to treat anxiety) 0.5 mg tablets for Resident 15 stored in the CS drawer of the cart with other active controlled substance (CS) medications. In a concurrent interview, LVN 3 was not able to find in the resident's medical record an active, ongoing order for alprazolam 0.5 mg. The resident's medical record was reviewed, and it indicated there was a physician order on November 16, 2023, for alprazolam 0.5 mg with the direction to give the resident one tablet every 23 hours as needed for anxiety for 14 days as manifested by episodes of verbalization of feeling anxious. There was no additional order to renew alprazolam 0.5 mg. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 11 of 19 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 01/11/2024 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for one resident (Resident 214), when two medications in the same therapeutic class were ordered by the physician and administered to the resident. Residents Affected - Few This failure had the potential for the resident to receive excessive dose of medications and unwanted adverse effects. Findings: On January 10, 2024, medical record of Resident 214 was reviewed, and the following was noted: The resident was admitted to the facility on [DATE], with the diagnoses that included glaucoma (increased pressure in the eyeball that causes gradual loss of sight); There was a physician order on December 28, 2023, for Travatan Z (a medication applied directly to eye to treat glaucoma) 0.004 % eye drop with the direction to instill one drop in both eyes once at bedtime for glaucoma; There was a physician order on December 28, 2023, for latanoprost (brand name: Xalatan - a medication applied directly to eye to treat glaucoma) 0.005 % eye drop with the direction to instill one drop in both eyes once at bedtime for glaucoma; and The electronic medication administration record (eMAR) of the resident for January 2024, indicated both Travatan Z and latanoprost eye drops were administered daily from January 1 to January 10, 2024. Lexicomp, a nationally recognized drug reference, indicated: .Travatan Z .Mechanism of Action . A selective FP (prostaglandin receptor F) prostanoid receptor agonist which lowers intraocular pressure by increasing trabecular meshwork and outflow . Latanoprost .Mechanism of Action . Latanoprost is a prostaglandin F2-alpha analog believed to reduce intraocular pressure by increasing the outflow of the aqueous humor . Avoid combination .Coadministration of latanoprost with additional prostaglandins or prostaglandin analogs (having similar structure) is not recommended . On January 11, 2024, at 2:25 p.m., in an interview, the Pharmacist-in-Charge (PIC) of the provider pharmacy stated the pharmacy identified the therapy duplication with having both Travatan Z and Xalatan ordered at the same time. The PIC stated the pharmacy sent a note to indicate and clarify the therapy duplication along with the delivery of the resident's medications without Travatan Z which was placed on hold. The PIC agreed there was a therapy duplication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 12 of 19 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 01/11/2024 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 0757 Level of Harm - Minimal harm or potential for actual harm On January 11, 2024, at 2:45 p.m., in an interview, the Director of Nursing (DON) was not aware there was a request from the pharmacy to clarify the therapy duplication with Travatan Z and Xalatan. The DON confirmed the resident's eMAR there was documentation both Travatan Z and Xalatan were administered daily in January 2024. Residents Affected - Few The facility's policy and procedure titled, Administering Medications, revised, April 2019, was reviewed and it indicated: .If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident .the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 13 of 19 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 01/11/2024 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed ensure residents were free from medication error rate greater than 5 % during medication pass observation when: Residents Affected - Few - Two medications for Resident 18 were not administered; - One long-acting extended-release formulation medication was crushed and administered; and - One long-acting extended-release formulation medication was administered without a full glass of water being offered. This failure had the potential for inadequate medication treatment that could cause the resident to experience pain, constipation, and stomach upset. The medication error rate was 12.9 percent. Findings: On January 9, 2024, at 8:20 a.m., during a medication pass observation with the Licensed Vocational Nurse (LVN) 2, it was observed, LVN 2 prepared and administered, for Resident 18, her morning medications that included one potassium chloride (potassium supplement) ER (extended release) 8 MEq (milliequivalent - unit of measurement) tablet after crushing a total of eight medications. The eight medications that were administered to the resident by LVN 2 were as follows: One tablet of amiodarone (medication for irregular heart rhythm) 200 mg (milligram -- unit of measurement); One tablet of Eliquis (a blood thinner) 5 mg; One tablet of carvedilol (medication to control blood pressure) 3.125 mg; One tablet of ezetimibe (medication for high cholesterol) 10 mg; One tablet of losartan (medication to control blood pressure) 50 mg; One tablet of metformin (medication to control blood sugar) 500 mg; One tablet of potassium chloride ER 8 MEq; and One tablet of rosuvastatin (medication for high cholesterol) 10 mg. On January 9, 2024, the medical record of Resident 18 was reviewed, and the following was noted: There was a physician order on November 19, 2023, for potassium chloride ER 8 MEq with the direction to give the resident one tablet by mouth two times a day for supplement; There was a physician order on December 28, 2023, for docusate sodium (brand name: Colace (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 14 of 19 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 01/11/2024 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 0759 Level of Harm - Minimal harm or potential for actual harm medication to treat constipation) 100 mg (milligram - unit of measurement) with the direction to give the resident one capsule by mouth one time a day for bowel management; There was a physician order on December 21, 2023, for lidocaine external patch 5 % (topical patch for pain relief) to be applied to the resident's left knee one time a day and be removed per schedule; and Residents Affected - Few The electronic medication administration record (eMAR) for January 2024 indicated the morning dose of potassium chloride 8 MEq, docusate sodium 100 mg, and lidocaine 5 % patch were documented as administered to the resident. On January 9, 2024, at 11 a.m., in an interview, LVN 26 stated he did not administer lidocaine patch for the resident because it was not available to administer, and the resident was going home later that day. LVN 2 stated he did not administer the resident's morning dose of Colace because the resident was going home later that day. LVN 2 stated it was a mistake and he should not have documented as administered the lidocaine patch and the Colace dose in the resident's medical record. LVN 2 stated the resident preferred the medications to be crushed and they had been crushed and administered ever since. LVN 2 did not indicate there was a physician order to crush long-acting formulation of potassium chloride and administer to the resident. LVN 2 stated he did not offer fluid after administration of crushed medications that included potassium chloride. The facility's policy and procedure titled, Administering Medications, revised, April 2019, was reviewed, and it indicated: .Medications are administered in accordance with prescriber orders, including any required time frame . According to the manufacturer's prescribing information for potassium chloride ER tablet: . Take potassium chloride extended-release tablets with meals and with a glass of water or other liquid. Do not take on an empty stomach because of its potential for gastric irritation . Swallow tablets whole without crushing, chewing, or sucking . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 15 of 19 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 01/11/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure: Residents Affected - Few 1. One medication stored at bedside for self-administration was properly labeled for Resident 49; and 2. Opened insulin lispro KwikPen (an injectable pen containing insulin, a hormone that regulates blood sugar) dated with 28-day expiration date was not available for use past the expiration date. This had the potential for wrong, and ineffective medications to be administered to residents. Findings: 1. On January 10, 2024, at 2:10 p.m., during inspection of the medication cart located in Red Hall, there was a manufacturer box for albuterol (medication to treat difficulty breathing) aerosol inhaler, which had a pharmacy label to indicate it belonged to Resident 49, without the inhaler inside, stored in the bottom drawer of the cart. In a concurrent interview, the Licensed Vocational Nurse (LVN) 1 stated the albuterol inhaler was kept at the resident's bedside inside the resident's room for resident to self-administer the medication. On January 10, 2024, at 2:35 p.m., it was noted the inhaler was stored in the drawer of the side table next to the resident's bed. The inhaler was not labeled to indicate it belonged to Resident 49. In a concurrent interview, the Infection Preventionist (IP) stated the resident's inhaler would be secured in a locked box. The IP also confirmed there was no label on the resident's albuterol inhaler to indicate it belonged to the resident. The facility's policy and procedure titled, Labeling of Medication Containers, revised, April 2019, was reviewed, and indicated: .All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations . Labels for individual resident medications include all necessary information, such as: a. the resident's name; b. the prescribing physician's names; c. the name, address, and telephone number of the issuing pharmacy; d. the name, strength, and quantity of the drug; e. the prescription number (if applicable); (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 16 of 19 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 01/11/2024 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 0761 f. the date that the medication was dispensed; Level of Harm - Minimal harm or potential for actual harm g. appropriate accessory and cautionary statements; h. the expiration date when applicable; and Residents Affected - Few i. directions for use . 2. On January 10, 2024, at 2:10 p.m., during inspection of the medication cart located in Red Hall, there was a 3-ml insulin lispro (a fast-acting insulin used to prevent high blood sugar) 100 Unit/ml (unit of measurement) KwikPen for injection with the open date, 12/11/23, that belonged to Resident 49. The pen also had the following instruction on the label: Discard 1/8/24. Discard unused portion after 28 days. On January 11, 2024, at 9:30 a.m., the IP agreed the multidose insulin pen was only good for 28 days after opening. The facility's policy and procedure titled, Injectable Medications, revised, October 2018, was reviewed, and it indicated: .Multiple use vials (MDV) will expire according to the manufacturer's expiration date printed on the vial except when special considerations are specified by the manufacturer .All other MDV medications will expire 28 days after opening per USP Guidelines unless otherwise specified . According to the manufacturer's prescribing information for insulin lispro 100 units/ml KwikPen: .Storage and Handling .In-Use (Opened) .28 days Room temperature only (Do not refrigerate) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 17 of 19 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 01/11/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and implement infection prevention and control practices when the resident's indwelling urinary catheter (catheter used to drain urine from the bladder into a bag outside the body) drainage bag was touching the floor for one of one resident reviewed (Resident 164). Residents Affected - Few This failure increased the potential to expose Resident 164 for further development of infection and transmission of communicable diseases. Findings: On January 8, 2024, at 12:25 p.m., Resident 164 was observed in a room designated with contact isolation precautions (steps healthcare facility visitors and staff need to follow before going into a patient's room to stop germs from spreading by touching the patient or surfaces in the room). The personal protective equipment (PPE - used to minimize exposure to hazards that cause serious illnesses) cart was observed outside the room. During a concurrent observation and interview on January 8, 2024, at 12:28 a.m., with Resident 164 in his room, Resident 164 was observed lying in bed awake, alert, and able to verbalize his needs. Resident 164 stated he had infected wounds on his right foot. A wound vac (device used to remove excess fluid and promote healing of the wounds) was observed on resident's right side of his foot dressing. Resident 164 was observed with indwelling urinary catheter attached to a drainage bag containing yellow urine. The bottom of the indwelling urinary catheter drainage was touching the floor. The drainage bag was uncovered. During a concurrent observation and interview on January 8, 2024, at 12:30 p.m., with the Director of Nursing (DON), in Resident 164's room, the DON stated the resident's indwelling urinary catheter drainage bag was on the floor. He stated the indwelling urinary drainage bag should not be touching the floor and should be covered with the dignity bag. During a concurrent observation and interview on January 8, 2024, at 12:40 p.m., with the Infection Preventionist (IP), in Resident 164's room, the IP stated the indwelling urinary catheter drainage bag should not be touching the floor and should be covered with the dignity bag. On January 8, 2024, Resident 164's record was reviewed. Resident 164 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD - kidney disease), and acute osteomyelitis (bone infection) of right ankle and foot, and recent right amputation of second and third toes with Methicillin Resistant Staphylococcus Aureus (MRSA - a serious infection that can lead to sepsis or death) During a review of the facility's policy and procedure titled, Catheter Care, Urinary, dated September 2014, indicated, .The purpose of this procedure is to prevent catheter-associated urinary tract infections .Be sure the catheter tubing and drainage bag are kept off the floor . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 18 of 19 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 01/11/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain the kitchen grill in sanitary and safe operating condition, when the equipment was covered with blackish materials. Residents Affected - Few This failure had the potential to cause cross contamination and unsanitary condition in the kitchen. Findings: During the initial tour of the kitchen, conducted on January 8, 2024, beggining at 9:30 a.m., with the Culinary Director (CD), the kitchen equipment was observed. During a concurrent observation and inteview on January 8, 2024, at 10:49 a.m., with the CD, the kitchen grill was observed with blackish materials on the surface and at the sides of the grill. The kitchen grill was situated next to the kitchen griddle being used by the cook for food preparation. The CD stated the kitchen grill had not been used for a long time. He further stated the grill should have been cleaned even if not in use. During a review of the facility's policy and procedure titled, GRILL - GAS, dated August 31, 2018, indicated, .SANITATION OF EQUIPMENT .frequency: After each use .Scrape grill to loosen burned-on-particles .clean grill surface . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555775 If continuation sheet Page 19 of 19