Bayshire Rancho Mirage
Inspection Findings
F-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to receive a physician order for the use of oxygen, including
the specific indication of its use, for 1 out of 3 residents reviewed (Resident 1).This failure resulted in Resident 1 being treated with oxygen without a physician order. Findings:On November 25, 2025, at 8:43 a.m. an unannounced visit was made to the facility for a quality-of-care issue.Resident 1 was admitted to
the facility on [DATE REDACTED], with a diagnosis of a urinary tract infection (UTI). Resident 1 was discharged from the facility on November 19, 2025. Resident 1 had a Brief Interview for Mental Status (A cognitive assessment) score of 9, indicating moderate cognitive impairment.A review of Resident 1's Minimum Data Set (MDS-a comprehensive clinical and functional assessment), dated October 19, 2025, Section O, Respiratory Treatments, indicated Resident 1 received intermittent (not continuous) oxygen therapy upon admission and while a resident of the facility.A review of Resident 1's admission physician orders dated October 12, 2025, untimed, indicated there were no orders for the use of oxygen during Resident 1's stay at the facility.A review of Resident 1's care plans (Individualized plan of care specific to resident's healthcare needs), indicated no care plan for oxygen use.On November 25, 2025, at 2:21 p.m., in an interview with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 1's care, as she had been her CNA multiple times, and Resident 1 frequently used oxygen. On November 25, 2025, at 2:30 p.m., in an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she had performed skin assessments and treatments on Resident 1, and she observed Resident 1 using oxygen.A review of Resident 1's, Infectious Diseases Progress Note, dated, November 16, 2025, at 11:13 p.m., by Medical Doctor (MD) 1, indicated, . Seen (Resident 1) at bedside on O2 (oxygen) . via NC (nasal cannula-tube with prongs that delivers oxygen through the nose). On November 25, 2025, at 4:06 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, treatment orders include the indication of why the treatment is ordered. The DON verified oxygen use is a treatment that requires a physician order.
The DON verified Resident 1 did use oxygen during her stay at the facility and did not have a physician order for oxygen use.On December 2, 2025, at 9:39 a.m., a telephone interview was conducted with the DON, who stated the process to receive oxygen orders includes the nurse contacting the physician and notifying the physician of the residents need for oxygen. The physician would give the nurse an order for resident to use oxygen including the indications for use, the nurse would then transcribe (document) the order in the resident's medical record.A facility Policy & Procedure, Medication Orders, revised November 2014, indicated, .Supervision by a Physician .A current list of orders must be maintained in the clinical
record of each resident.Recording Orders.Oxygen orders - When recording orders for oxygen, specify the rate of flow, route and rational (indication) .
Residents Affected - Few
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
Event ID:
BAYSHIRE RANCHO MIRAGE in RANCHO MIRAGE, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in RANCHO MIRAGE, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BAYSHIRE RANCHO MIRAGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.