Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bayshire Rancho Mirage during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a diagnosis of UTI received intermittent oxygen therapy without a physician order or care plan in place. Staff confirmed the resident's use of oxygen, and documentation showed the therapy was administered, but facility policy requiring a physician order specifying rate, route, and indication was not followed.
Surveyors found that the facility failed to properly label and store medications and devices, including storing discontinued and expired medications in active stock, not documenting correct beyond-use dates on IV bags, and labeling compounded IV medications and emergency kits with incorrect expiration dates. Staff and pharmacy interviews confirmed these deficiencies, which were observed across multiple medication storage areas.
Surveyors found that kitchen staff stored wet pans and pitchers, failed to date prepared foods, and kept expired or undated items in both the main and satellite kitchens, as well as in a resident's refrigerator. Staff interviews confirmed these practices were not in line with facility policy or professional standards, which require air-drying of dishes and proper labeling and disposal of food items.
A nurse administered a nebulized medication by turning on the machine before a resident had properly applied the facemask, causing medication mist to be released into the room rather than being fully inhaled. The resident, who had COPD and other respiratory conditions, may not have received the full prescribed dose due to this deviation from professional standards and facility policy.
A resident receiving tube feeding was observed with unlabeled and undated Jevity bottle, water bag, and tubing. An LVN and the DON confirmed that these items should have been labeled with the resident's name, date, and time. The resident had orders for daily tube feeding and equipment changes, and facility procedures required proper labeling of enteral feeding equipment.
A resident with hypertension and atrial fibrillation received Benazepril, Terazosin, and Amiodarone despite physician orders to hold these medications if systolic blood pressure was below 110 mmHg. The MAR showed multiple instances of administration below this threshold, and the DON confirmed the orders were not followed. The Consultant Pharmacist had not reviewed these medications since their order date, and facility policy requires medications to be administered per prescriber orders.
A resident was administered two different proton pump inhibitors (pantoprazole and omeprazole) daily for GERD without documented clinical justification, resulting in unnecessary duplicate therapy. The DON verified both medications were given, and the Consultant Pharmacist indicated he would have questioned the duplicate use had he reviewed the orders. Facility policy requires staff to address potentially excessive medication use, but there was no evidence this occurred.
A cook did not follow the standardized recipe for pureed bread for a resident on a pureed diet, resulting in a watery consistency that did not meet dietary requirements. The issue was confirmed by the RD, who found the bread did not have the required pudding-like texture, as specified in facility policy.
The facility failed to ensure the Notice of Discharge was provided to the LTC Ombudsman following residents being notified of their pending discharge dates. Five residents with varying degrees of cognitive impairment and different medical conditions were discharged without timely notification to the LTC Ombudsman, preventing them from being aware of their rights to appeal the discharge. Interviews revealed that the facility's practice was to notify the Ombudsman at the end of each month, rather than at the time of the residents' notification.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to obtain a physician order for the use of oxygen therapy for a resident who was admitted with a urinary tract infection and had moderate cognitive impairment. Despite documentation in the Minimum Data Set indicating the resident received intermittent oxygen therapy during their stay, a review of the admission physician orders revealed no order for oxygen use. Additionally, there was no care plan addressing oxygen therapy for this resident. Multiple staff members, including a CNA and an LVN, confirmed that the resident frequently used oxygen, and a physician's progress note documented the resident being on oxygen via nasal cannula. The Director of Nursing verified that oxygen use is a treatment requiring a physician order and acknowledged that the resident used oxygen without such an order during their stay. Facility policy requires that oxygen orders specify the rate of flow, route, and indication, and that a current list of orders be maintained in the clinical record. The process for obtaining oxygen orders involves the nurse contacting the physician and documenting the order, which was not followed in this case.
Improper Medication Labeling and Storage
Penalty
Summary
Surveyors identified multiple failures in the facility's medication management practices, specifically regarding the labeling and storage of drugs and biologicals. During inspections of various medication storage areas, including medication carts, IV carts, treatment carts, and the medication room, surveyors observed that discontinued and expired medications were not removed from active stock. For example, a discontinued blister card of calcium acetate capsules prescribed for a resident was found stored with active medications, despite the order having been changed weeks prior. The responsible nurse confirmed the medication should have been removed and disposed of according to facility policy. Further observations revealed expired medications and devices stored in several locations. An insulin pen for a resident was found in the medication cart beyond its 28-day in-use period, and multiple expired heparin lock flush syringes and a bottle of Adapt Stoma Powder were found in the IV cart, treatment cart, and medication room. Staff interviews confirmed awareness that these items were expired and should have been disposed of in the pharmaceutical waste bin, as outlined in facility policies and manufacturer instructions. Additionally, surveyors found issues with the labeling of expiration dates and beyond-use dates (BUD) on IV diluent bags and compounded IV medications. IV bags stored outside of their protective overwrap lacked appropriate BUD documentation, and compounded ceftriaxone IV bags were labeled with incorrect expiration dates, exceeding the maximum storage time allowed by USP <797> standards. The emergency medication kit also had an incorrect expiration date on its exterior label, not reflecting the earliest expiration date of its contents. These findings were confirmed through interviews with pharmacy staff and review of facility policies.
Deficient Food Storage and Preparation Practices
Penalty
Summary
Surveyors observed multiple failures in food preparation and storage practices within the facility. In the main kitchen, four metal pans and three large pitchers were found stored while still wet, contrary to professional standards and facility policy, which require all dishes and utensils to be air-dried after washing. Both the Dietary Manager and Registered Dietician confirmed that storing wet dishes is not acceptable, as moisture can harbor bacteria. The facility's dishwashing procedure and the FDA Food Code both mandate air-drying of equipment and utensils after sanitization. Further deficiencies were identified in the satellite kitchen, where an undated cup of cut fruit and a tub of low-fat cottage cheese past its expiration date were found in the refrigerator. Staff interviews confirmed that all prepared foods should be dated and expired items discarded promptly. Additionally, in the resident dining area, an open bottle of reduced fat ultra filtered milk without a date was found in a resident's refrigerator. Staff acknowledged that all resident food items should be labeled with the resident's name, room number, and the date of opening or receipt. Facility policy requires all food products to be dated upon receipt, opening, and preparation, and for expired or outdated items to be discarded.
Improper Nebulizer Administration Procedure
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to administer a nebulized medication in accordance with professional standards of practice. During a medication pass, the LVN added sodium chloride 3% inhalation solution to the nebulizer cup and turned on the nebulizer machine before ensuring the resident had properly placed the facemask over their nose and mouth. Mist began to be released from the nebulizer before the resident applied the mask, resulting in the potential for medication to disperse into the room rather than being fully inhaled by the resident. The LVN later acknowledged that the mask was not in place before the machine was activated and that some medication might not have been delivered to the resident as prescribed. The resident involved had a medical history including chronic obstructive pulmonary disease (COPD) with acute exacerbation, pneumonia, and chronic respiratory failure with hypoxia. The resident had a physician's order for sodium chloride inhalation solution via nebulizer twice daily for COPD management. Both the LVN and the Director of Nursing (DON) confirmed that the correct procedure was not followed, as the mask should have been properly applied before the nebulizer was turned on, in accordance with facility policy and national guidelines.
Failure to Label and Date Enteral Feeding Equipment
Penalty
Summary
The facility failed to ensure that the tubing, feeding bottle, and water bag used for enteral feeding were properly labeled and dated for a resident receiving tube feeding. During an observation, a resident was seen receiving Jevity 1.2 CAL tube feeding and water through an electronic pump system, but the Jevity bottle, water bag, and tubing were not labeled or dated. This was confirmed by an LVN, who acknowledged that these items should have been labeled with the date, time, and the resident's name. The Director of Nursing also confirmed that the facility's practice is to label these items with the resident's name, orders, date, and time they were opened. The resident involved had a medical history including dysphasia, encephalopathy, and a cervical spine fracture, and had physician orders for daily Jevity 1.2 tube feeding and daily changes of the enteral feeding bag and tubing. Product information for Jevity 1.2 CAL indicated it should be consumed within 24 hours, and facility procedures required labeling the container and administration set with the date and time it was first hung. The failure to label and date the feeding equipment was identified through observation, interview, and record review.
Failure to Follow Medication Holding Parameters for Blood Pressure
Penalty
Summary
The facility failed to ensure that pharmacy services were provided in accordance with physician orders for a resident with hypertension and atrial fibrillation. Specifically, three medications—Benazepril, Terazosin, and Amiodarone—were administered to the resident despite physician orders to hold these medications if the systolic blood pressure (SBP) was below 110 mmHg. Medication Administration Records (MAR) for March and April 2025 showed multiple instances where these medications were given when the resident's SBP was below the specified threshold. The Director of Nursing confirmed that the medications were administered contrary to the holding parameters outlined in the physician's orders. The Consultant Pharmacist stated that he had not reviewed these medications since they were ordered after his most recent medication regimen review. He indicated that, had he identified the issue, he would have recommended a physician review of the blood pressure readings and possible adjustment of the medication regimen. The facility's policy on administering medications requires that medications be given in accordance with prescriber orders, which was not followed in this case.
Duplicate Proton Pump Inhibitor Therapy Administered Without Clinical Justification
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications when two proton pump inhibitors (PPIs), pantoprazole 40 mg in the morning and omeprazole 20 mg at bedtime, were ordered and administered daily for the same indication of gastroesophageal reflux disease (GERD). Review of the resident’s medical record and Medication Administration Record (MAR) showed both medications were given concurrently from March 22 through April 23, with no documented clinical rationale for the duplicate therapy. The orders for both PPIs were initiated on the same date, and the administration was verified by the Director of Nursing (DON), who acknowledged that both drugs are from the same therapeutic class and have similar mechanisms of action. The facility’s Consultant Pharmacist (CP) confirmed that he had not reviewed these medications since they were ordered after his last medication regimen review. The CP stated he would have questioned the duplicate use and recommended discontinuing one of the PPIs if there was no clinical justification. Facility policy requires staff to contact the prescriber if a medication is believed to be inappropriate or excessive, but there was no evidence this was done. Prescribing information and national guidelines indicate that the two PPIs are considered equivalent for GERD treatment and that there is no benefit to administering both simultaneously.
Failure to Follow Standardized Recipe for Pureed Bread
Penalty
Summary
The facility failed to ensure that the cook followed the standardized recipe for preparing pureed bread for a resident on a pureed diet. During observation, the cook was seen adding significantly more milk than the recipe required and using a disposable spoon instead of a proper measuring spoon to add thickener. The resulting pureed bread was runny and watery, rather than the required pudding-like consistency. Both the cook and the Dietary Manager initially stated that the consistency was correct, but upon review, the Registered Dietician determined that the pureed bread did not meet the necessary standards for a pureed diet. A review of the facility's recipe and policies confirmed that the pureed bread should have a smooth, lump-free, and extremely thick consistency, similar to mashed potatoes or pudding. The Registered Dietician stated that the cook did not follow the recipe, which led to the improper consistency of the pureed bread. This deficiency was identified for one resident who required a pureed diet, and the failure to follow the recipe had the potential to compromise the nutritional needs of the resident.
Failure to Timely Notify LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure the Notice of Discharge was provided to the Long Term Care (LTC) Ombudsman following residents being notified of their pending discharge dates. This deficiency was identified for five residents, each of whom had varying degrees of cognitive impairment and different medical conditions. The residents were notified of their discharge dates and signed the notices, but the facility did not promptly inform the LTC Ombudsman, which could have prevented the residents from being aware of their rights to appeal the discharge and the Ombudsman from informing them of their rights and options to appeal prior to discharge. For instance, Resident 1, with severe cognitive impairment due to a cerebral infarction, was notified of his discharge date on March 11, 2024, and discharged on March 18, 2024. Similarly, Resident 2, who had a fractured left femur and was cognitively intact, was notified on March 13, 2024, and discharged on March 18, 2024. Other residents, including those with severe cognitive impairments and various medical conditions, were also discharged without timely notification to the LTC Ombudsman. Interviews with the Social Services Director (SSD) and other staff revealed that the facility's practice was to notify the LTC Ombudsman of all discharges at the end of each month, rather than at the time of the residents' notification. This practice was confirmed by the Administrator and the SSD, who admitted to faxing the notifications in bulk at the end of the month. The facility's policy and procedure documents indicated that notifications should be sent monthly, which contributed to the delay in informing the LTC Ombudsman.
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What surveyors actually found near you
We read the 161 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rancho Mirage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rancho Mirage Health And Rehabilitation Center | 2.3 mi | ★★★★★ | 2 | 0 |
| Monterey Palms Health Care Center | 3.7 mi | ★★★★★ | 1 | 0 |
| Desert Springs Post Acute | 5.2 mi | ★★★★★ | 39 | 0 |
| Premier Care Center For Palm Springs | 5.7 mi | ★★★★★ | 32 | 1 |
| The Springs Healthcare Center At The Carlotta | 5.8 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.