Health inspection·April 17, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the Notice of Discharge (a notice informing the resident of their pending discharge date , and their rights to appeal the discharge) was provided to the Long Term Care (LTC) Ombudsman, following resident being notified of their pending discharge date for 5 out of 5 residents' (Residents 1, 2, 3, 4 & 5). This failures could have resulted in Residents 1, 2, 3, 4 & 5 not to be aware of their rights to appeal the discharge and the Ombudsman to not to be able to inform the residents of their rights and options to appeal prior to the resident being discharged . Findings: On March 15, 2024, at 10:00 a.m., an unannounced visit was made to the facility to investigate a Quality-of-Care issue. 1. A review of Resident 1's face sheet, indicated the resident was admitted to the facility on [DATE], with a diagnosis of a cerebral infarction (Brain tissue death due to blood vessel blockage), with a BIMS (Brief Interview for Mental Status- an interview used to assess cognitive intactness) score of 0 (severe cognitive impairment). A review of Resident 1's Doctor's (Drs) orders, dated, March 19, 2024, untimed, indicated, . LCD (Last Cover Date for insurance) DC (Discharge) (March 19, 2024) . A review of Resident 1's Notice of Transfer/Discharge, dated, March 11, 2024, untimed, indicated the resident was notified of his discharge date , and signed the notice of discharge on the same date, March 11, 2024, with a pending date of discharge March 13, 2024. A review of Resident 1's, Discharge Summary, dated, March 19, 2024, at 8:53 a.m., indicated the resident discharged from the facility on March 18, 2024, at 10:00 a.m. 2. A review of Resident 2's face sheet, indicated the resident was admitted to the facility on [DATE], with a diagnosis of a fractured left femur (upper leg bone), and a BIMS score of 12 (cognitively intact). A review or Resident 2's Drs orders, dated, March 15, 2024, untimed, indicated, . LCD (March 18, 2024) DC (Discharge) to . (Assisted living facility) . (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 3 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 04/17/2024 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)