Cycle 1
Health 2025-04-24 · Fire 2025-04-24
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Rancho Mirage, CA
Bayshire Rancho Mirage
4-star overall rating with 4-star inspections with $15,524 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
72-201 Country Club Drive, Rancho Mirage, CA
(760) 340-5999
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
40
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bayshire Senior Communities
Operator or chain grouping
Approved since
2001-07-19
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.46
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.74
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.61
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.20
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.18
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.28
CMS adjusted total nurse staffing hours
Case-mix index
1.92
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,366
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 23.63% · Performance 24.82% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 9.68% · Performance 9.77% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.05
Baseline 69.33% · Performance 44.64% · Measure score 5.05 · Achievement 4.66 · Improvement 5.05
Adjusted total nurse staffing
0
Baseline 3.06 hours · Performance 3.19 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.72% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 554 · Observed rate 11.19% · Lower 95% interval 9.11% |
| Discharge to community | 65.53% |
50.57%
15 pts better
|
Better than the National Rate · Eligible stays 540 · Observed rate 61.85% · Lower 95% interval 60.56% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 366 · Denominator 366 |
| Falls with major injury | 1.09% |
0.77%
0.3 pts worse
|
Numerator 4 · Denominator 366 |
| Discharge self-care score | 61.07% |
53.69%
7.4 pts better
|
Numerator 149 · Denominator 244 |
| Discharge mobility score | 49.59% |
50.94%
1.3 pts worse
|
Numerator 121 · Denominator 244 |
| Pressure ulcers or injuries, new or worsened | 3.83% |
2.29%
1.5 pts worse
|
Numerator 14 · Denominator 366 · Adjusted rate 3.74% |
| Healthcare-associated infections requiring hospitalization | 9.77% |
7.12%
2.6 pts worse
|
Worse than the National Rate · Eligible stays 333 · Observed rate 10.21% · Lower 95% interval 7.47% |
| Staff COVID-19 vaccination coverage | 6% |
8.2%
2.2 pts worse
|
Numerator 6 · Denominator 100 |
| Staff flu vaccination coverage | 81.67% |
42%
39.7 pts better
|
Numerator 196 · Denominator 240 |
| Discharge function score | 62.7% |
56.45%
6.2 pts better
|
Numerator 153 · Denominator 244 |
| Transfer of health information to provider | 87.01% |
95.95%
8.9 pts worse
|
Numerator 288 · Denominator 331 |
| Transfer of health information to patient | 95% |
96.28%
1.3 pts worse
|
Numerator 19 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 28.26% |
25.2%
3.1 pts better
|
Numerator 52 · Denominator 184 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
94.0%
5.3 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 99.7% · Q3 99.7% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.8% |
11.2%
3.6 pts worse
|
12.0%
2.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.8% · Observed 13.0% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.7% |
93.2%
6.5 pts better
|
79.7%
20 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.9% |
23.2%
5.7 pts worse
|
23.9%
5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.9% · Observed 26.2% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
11 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-12-09 · Fire 2022-12-09
20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-04-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-27
C · Minimal harm
2025-04-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-27
C · Minimal harm
2025-04-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-27
D · Potential for more than minimal harm
2024-01-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-02-06
D · Potential for more than minimal harm
2024-01-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-06
F · Potential for more than minimal harm
2022-12-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-12-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-12-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-12-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-23
C · Minimal harm
2022-12-09
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-01-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-15
E · Potential for more than minimal harm
2025-04-24
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-05-18
E · Potential for more than minimal harm
2025-04-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-18
D · Potential for more than minimal harm
2025-04-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-18
D · Potential for more than minimal harm
2025-04-24
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-05-18
D · Potential for more than minimal harm
2025-04-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-18
D · Potential for more than minimal harm
2025-04-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-18
D · Potential for more than minimal harm
2025-04-24
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-05-18
E · Potential for more than minimal harm
2024-04-17
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-01-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-11
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-11
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-11
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-02-16
D · Potential for more than minimal harm
2023-11-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-08-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-09
D · Potential for more than minimal harm
2023-08-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-03
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-03
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-09-07
E · Potential for more than minimal harm
2023-07-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-20
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-17
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-06-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-08
D · Potential for more than minimal harm
2023-06-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-08
D · Potential for more than minimal harm
2023-05-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-06-14
E · Potential for more than minimal harm
2022-12-09
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-01-22
E · Potential for more than minimal harm
2022-12-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-22
D · Potential for more than minimal harm
2022-12-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-22
D · Potential for more than minimal harm
2022-12-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-01-22
D · Potential for more than minimal harm
2022-12-09
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-01-22
D · Potential for more than minimal harm
2022-12-09
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-01-22
D · Potential for more than minimal harm
2022-12-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-22
Penalties and ownership
What sits behind the stars
$3,176
2023-08-14
Fine
Fine · fine $3,176
Fine
$2,823
2023-08-07
Fine
Fine · fine $2,823
Fine
$6,351
2023-07-17
Fine
Fine · fine $6,351
Fine
$3,174
2023-05-30
Fine
Fine · fine $3,174
Fine
$0
2023-05-15
Payment Denial
Payment Denial · denial start 2023-08-15 · 26 days
26 day denial
Ownership
Kirby, Scott
Operational/Managerial Control · Individual
Skilled Mirage LLC
Operational/Managerial Control · Organization
Stewart, James
Operational/Managerial Control · Individual
Nearby options
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#2
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3-star overall rating with 3-star inspections with 13 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Desert Springs Post Acute
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