Bay Ridge Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (CR #1) of 5 resident reviewed for notification of changes. RN A failed to notify CR #1's physician immediately when at approximately 6:30 am on [DATE], CR # 1 was delusional and looked pale yellowish. RN A failed to consult with CR #1's physician immediately for medical guidance when at approximately 8:00 am on [DATE], CR #1's oxygen saturation level was 84%. RN A waited until 12:30 pm to notify CR #1's physician regarding CR #1's change in condition after CR #1 became minimally responsive. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (CR#1) of 5 resident reviewed for quality care. The facility failed to ensure CR #1 received treatment and care promptly when CR #1 experienced a change in condition of altered mental status and respiratory decline with low Oxygen saturation level. The facility failed to obtain an order for interventions including order to send CR#1 to hospital for further evaluation and treatment when CR #1's altered mental status was first identified around 6:30am on [DATE] and a decline in respiratory status with low oxygen saturation level identified around morning med pass on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's discharge summary included an accurate reconciliation of all pre-discharge medications with post-discharge medication for 1 of 1 Residents reviewed for discharge medication reconciliation. The facility failed to complete an accurate reconciliation of medications for Resident #1 when he was discharged home on 1/31/2026. This failure could place residents at risk for discontinuity of care after being discharged from the facility to their home.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 5 Residents (Resident #1 and Resident #2) reviewed for medical records accuracy. Resident #1's October 2025 MARs did not reflect documentation that Diclofenac three times a day was done as ordered. Resident #2's October 2025 MARs did not document Accu-check as done on 10/2/2025. This deficient practice could place residents at risk for errors in their care and treatment. Record review of Resident #1's admission face sheet, dated 10/24/2025, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately to the State Survey Agency for Resident #2. - The facility failed to investigate and report (within 2 hours or 24 hours) an incident involving an unwitnessed fall in which Resident #2 sustained a hematoma to the forehead and skin tear to the eyebrow. This failure could place residents at risk of falls not investigated to prevent abuse and neglect. Record review of Resident #2's admission face sheet, dated 10/24/2025, revealed Resident #2 was an [AGE] year-old female admitted on [DATE]. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that residents were free of medication errors for 1 (Resident #1) of 5 residents reviewed for medication errors. Resident #1's October 2025 MARs did not reflect documentation that Diclofenac three times a day was done as ordered. This failure could place residents at risk of not getting their medications as ordered, which could result in residents not receiving the therapeutic benefits of the medication including increased pain and decreased quality of life. Record review of Resident #1's admission face sheet, dated 10/24/2025, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for 1 out of 3 residents (Resident #1) reviewed for adequate supervision. The facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent accidentsThis noncompliance was identified as Past Non-Compliance Immediate Jeopardy (IJ). The IJ began on 8/21/25 and ended on 8/31/25. The facility corrected the noncompliance by having implemented actions that corrected the non-compliance prior to surveyor entrance. This failure could expose residents living in the facility to safety and accident hazards. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person- centered care plan that included measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs identified in the comprehensive assessment for 3 of 12 residents reviewed for care plan accuracy (Residents #38, #17, #19), in that: 1. The facility failed to ensure the care plan for Resident #38's Hospice included a focus, goals, or interventions. 2. Facility failed to provide a care plan for Resident # 17's Dialysis. 3. Facility failed to document cerebral vascular accident affecting left side documented on Resident 19's care plan when they have right sided weakness. These failures placed residents at risk of not receiving needed services due to inaccurate comprehensive care plans.

Inspectors wroteBased on interview and record review the facility failed to coordinate the assessments with the pre admission screening and resident review (PASARR program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort which includes incorporating the recommendations from the PASRR level II determination and the PASARR evaluation report into a resident's assessment, care planning and transitions of care for 1 of 4 residents Resident #1 reviewed for PASARR. Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. The Facility failed to provide Resident #1 specialized services of PT, OT, and ST. Based on record review November 15, 2022 was the date listed in Simple LTC PASARR Portal. [...]

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to provide sufficient support personnel to carry out the functions of the food and nutrition service safely and effectively for 1 of 1 kitchen reviewed for dietary services. -The facility failed to provide sufficient dietary staffing for breakfast on 03/29/24. This failure could place residents at risk of not receiving meals at designated mealtimes and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received and was provided food prepared in a form designed to meet individual needs for 2 (Resident #1 and Resident #2) of 5 residents reviewed for food preparation. -The facility failed to ensure Resident #1 and #2 received a pureed diet as ordered by the physician. This failure could place residents at risk for poor intake, unmet nutritional needs, choking, and aspiration (when food or drinks enter the lungs).

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was free from abuse for one (Resident #1) of fifty- one residents reviewed for abuse. The facility failed to prevent the AD from verbally abusing Resident #1. The AD made the statement where I come form snitches get stitches and end up in ditches. This failure could place 51 residents who participate in activities at risk of verbal abuse and decreased quality of life. Findings Included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were a cerebral infraction (area of tissue death to the brain), cognitive communication deficit (difficulty with thinking and using language), depression, and COPD (lung disease). [...]

Inspectors wroteBased on interview and record review failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, for one (Resident #1) of fifty- one residents reviewed for abuse. CNA B failed to report verbal abuse from the AD to Resident #1 to the Administrator. This failure could place 51 residents who participate in activities at risk of verbal abuse and decreased quality of life. Findings Included: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #1) of 5 residents reviewed for ADLs. -The facility failed to ensure Resident #1 received timely incontinence care. This failure could put residents at risk for discomfort, infection, and dignity issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident has the right to be free from abuse for 1 (Resident #1) of 5 residents reviewed for abuse. -The facility failed to ensure Resident #1 was free from abuse when CNA A allowed her significant other to verbally abuse Resident #1, allowed the significant other entry into the facility, and took him to Resident #1's room. The Significant other then threatened Resident #1 by pointing a gun at him. On 03/05/24 an Immediate Jeopardy (IJ) was identified. While the IJ template was removed on 03/07/24, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards for 1 (Resident #1) of 5 residents reviewed for quality of care. -The facility failed to provide a safe environment when CNA A allowed her significant other, who was armed with a pistol, entry into the facility's locked building, and access to Resident #1. -The facility failed to provide the Emergency Procedure - Workplace Aggression/Violence training. On 03/05/24 an Immediate Jeopardy (IJ) was identified. While the IJ template was removed on 03/07/24, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Residents #1, #2, and #3) out of 6 residents reviewed for infection control, in that: The Facility failed to sanitize blood pressure equipment used for multiple residents. This failure could place residents living in the facility at risk of exposure to infections.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to ensure residents were free from abuse and neglect for 4 (Resident #7, #8, #23, and #38,) of 21 residents on the North Hall and 2 (Resident #30 and #35) of 17 residents on the South Hall. The Administrator and DON failed to provide necessary protection from staff member (TA K) who verbally and mentally Intimidated residents by yelling at them in angry tones, slammed resident doors to create fear, threatened residents with physical abuse, used retaliatory behavior in not providing timely care and invaded resident privacy by entering residents rooms without knocking or asking permission when female residents were undressing affecting residents' psycho social well-being causing fear and psycho social harm. On 09/23/22 at 5:10 pm an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to fully investigate, prevent, and correct an alleged violations of abuse and neglect for 4 (Resident #7, #8, #23, and #38,) of 21 on the North Hall and 2 (Resident #30 and #35) of 17 on the South Hall. The facility did not thoroughly investigate and correct an allegations of abuse that resulted in Resident #7, #8, #9, #23, 30, #35, and #38 causing psycho social harm and fearby TA K, while allowing him to continue working with residents in the facility. The Administrator and DON failed to provide residents necessary protection from staff member (TA K) who was threatening physical and verbal abuse in retaliation against residents who alleged incidents of his abusive behavior On 09/23/22 at 5:10 pm an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were treated with respect and dignity, and care for each resident in a manner, and in an environment which promoted maintenance or enhancement of his or her quality of life, and recognizing each resident's individuality for 4 of 21 Residents (Residents #7, #8, #23, and #38,) on the North Hall and 2 of 17 Residents (Residents #30 and #35) on the South Hall of the facility reviewed for Dignity. The facility failed to ensure Residents #7, #8, #9, #23, #30, #35 and #38 dignity was protect when a TA (Transition Aide) was verbally abusive and threatened the residents. This failure could place residents at risk of feeling uncomfortable and disrespected and could decrease residents' self-esteem and/or quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs and preferences of 5 of 26 sampled residents (Residents #5, #30, #34, #8, and #4) reviewed for accommodation of needs. The facility failed to place call lights within reach for Residents #5, #30, and #34. The facility failed to place soap dispensers within reach in the communal bathrooms for Residents #8 and #4. The facility failed to provide space in the communal bathrooms to accommodate wheelchairs for Resident #8 and #4. These deficient practices could place residents at risk of their needs and preferences not being met and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups for 6 of (14) who attended the Resident Council Meetings reviewed for grievance response said their grievances were not addressed. The facility failed to address grievances voiced in the resident council meeting held in 08/28/2022, 09/07/2022, 09/15/2022 and 09/21/2022, when the residents consistently voiced fear of retaliation, verbal abuse, and threats from staff member TA K. This failure could place residents at risk unresolved grievances, a decreased sense of self-worth, and a decline in quality of life due to potential physical harm and mental anguish. Findings Included: [...]

Inspectors wroteF584 / N1337 / N1338 - Clean, Comfortable, Homelike Environment Based on observation, interview, and record review the facility failed to maintain a clean, sanitary, comfortable, and homelike environment for 2 of 2 hallways (North and South ) and 2 of 4 bathrooms ( North And B and South A and B) observed for environment as evidence by: A. The 2 hallways( North and South) in the facility had a strong odor of urine. B. 2 of 4 communal bathrooms were dirty with feces. This failure could place residents at risk for a diminished quality of life and a diminished clean, homelike environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure prompt efforts to resolve grievances for 6 of 14 (Resident #28, #35, #8, #30, #23, #7) residents reviewed for resident rights. The facility did not promptly resolve multiple grievances for Resident #38, #35, #8, #30, #23, and #7 that included quality of care, resident rights and staff treatment towards residents. This failure placed residents at risk of unresolved grievances, and at risk for a decreased quality of life.

Inspectors wroteBased on observation, record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial needs for 3 of 18 residents (Residents # 24, #30) reviewed for care plans as follows: Resident #24 did not have a comprehensive care plan for his weight loss (peripherally inserted central catheter) or his diagnosis of Clostridioides Difficile. Residents # 30 did not have a care plan for psychotropic drug use. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 3 of 26 residents (Resident's# 5, 17 and 34), reviewed for activities of daily living. The facility failed to provide timely incontinence care for Resident #5. The facility failed to provide nail care for Resident's #17 and #34. The facility failed to provide oral care for Resident #34. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, skin breakdown, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that it is not possible or resident preferences indicated otherwise for 2 Residents 0f 4 (Resident #'s 10 and 24) reviewed for weight loss. The facility failed to ensure Resident #10 did not have unplanned weight loss of 5% in 30 days. The facility failed to ensure Resident # 24 did not have unplanned weight loss of 7.7 % in 30 days. This failure could place residents at risk of not maintaining their nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quality assessment and assurance committee met at least quarterly. The facility failed to hold QAPI meetings at least Quarterly. This failure could place residents at risk for not receiving quality medical care, decreased quality of life, and exposure to safety hazards.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to prevent the development and transmission of communicable diseases and infections for 2 of 2 residents reviewed for infection prevention and control . A. The facility failed to initiate transmission-based precautions to prevent the spread of infections for Resident # 24. B. The facility failed to change gloves and perform hand hygiene when moving from a clean to a dirty area during incontinent care for Resident #22. This failure could place residents at risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area, for the entire facility reviewed for call system functioning. The facility's call system was not fully functional. The system did not have a working audible signal that was consistently used. This failure could place residents at risk of being unable to call for assistance from staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure all pre-admission screening and resident review (PASRR) program, for 1 of 2 residents (Residents #30) reviewed for PASRR evaluations. The facility failed to accurately complete the PASRR 1012 form for Resident # 30. This failure could affect residents with psychiatric diagnoses who may not be evaluated and receive needed PASRR services.

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse aides are able to demonstrate appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for TA K who was 1 of 9 (CNA F, CNA G, CNA H, CNA I, CNA L, CNA M, CNA N, TA O) CNAs, and [NAME] reviewed. TA K (Training Aide) was not trained in the competency in skills and techniques necessary to care for residents' needs. This failure could place residents requiring incontinent care at risk for the spread of infections, skin breakdown, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents with PRN orders for psychotropic drugs were limited to 14 days for 1 (Resident#30) of 21 residents whose medication regimens were reviewed in that: Resident #30's order for PRN Lorazepam (antianxiety medication) was not discontinued after 14 days. This failure could place residents administered PRN psychotropic medications at risk of adverse side effects from prolonged use of psychotropic medications including stroke and death. Findings Included: Resident #30 Review of Resident #30's face sheet not dated revealed that he was admitted to the facility on [DATE] and was [AGE] years old. Review of Resident #30's CCD dated 9/25/22 revealed that he had diagnoses including anxiety disorder, displaced fracture or left humerus, malignant neoplasm of lung, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the actual hours worked by the licensed and unlicensed nursing staff directly responsible for direct resident care per shift on a daily basis. For a minimum of 18 months. The facility failed to update the daily staffing information posting on 09/20/22 to 09/26/22. This failure could place the residents, families, and visitors at risk of not having access to information regarding the daily nurse staffing data and facility census.