Bayside Care Center

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for two resident (#7 and #83) out of four residents sampled for medication administration. This resulted in 3 errors out of 28 medication administration opportunities for a medication error rate of 10.71%.

Inspectors wroteBased on observations, records review, and interviews, the facility failed to ensure dignity was maintained related to incontinence needs for one resident (#65) out of four residents observed.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the Preadmission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability with qualifying mental health diagnosis, were updated and accurate, and failed to submit recommendations for a level II PASARR for two residents (#4 and #63) of two residents reviewed.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who smoked followed the facility's smoking rules/policies regarding observed loose smoking items inside the facility, and residents smoking unsupervised within the facility's parking lot, for three residents (#51, #32 and #30) out of thirty-four residents reviewed, during two days (3/16/2026, 3/18/2026) of four days observed.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure 1. Medications were stored safely and out of the residents' reach for one resident (#19) out of three residents observed, and in one medication cart (West High) of 3 medication carts observed; 2. Did not ensure expired medications were discarded in one medication cart (West High) of two and in one medication room (East) of two medication storage rooms and 3. Did not ensure chemicals were not stored with wound care supplies in one storage room (East) of two observed.

Inspectors wroteBased on observations, records review, and interviews, the facility failed to follow contact isolation precaution protocols in one room (9) out of one room observed with contact precautions.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide a clean, comfortable, and homelike environment for residents living on one (West) out of two units.

Inspectors wroteBased on observation, record review, and interview, the facility failed to confirm the accuracy of a Pre-admission Screening and Resident Review (PASRR) and to correct the document for six (Residents #9, #72, #18, #51, #43, and #26) out of forty residents sampled when mental illness or suspected mental illness diagnoses were identified and added to the resident's medical diagnoses.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5.00%. Forty-two medication administration opportunities were observed and five errors were identified for two (#54 and #55) of three residents observed. These errors constituted a 11.9% medication error rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident #55) of three residents sampled failed to have a baseline care plan developed and implemented within 48 hours of admission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the comprehensive care plan for one (Resident #17) of one sampled residents for dental services. On 11/28/2023 at 10:00 a.m., Resident #17 was observed laying in bed dressed in her night cloths, and missing her bottom teeth. During an interview on 11/28/2023 at 10:00 a.m., Resident # 17 said she had a hard time eating her food because she was missing a few teeth. She said she spoke with the dentist when they came to the facility and told them that she wanted dentures so she could eat her food properly. She said she had been waiting for a while for someone to get back to her regarding her dentures, but she had not heard back from social services or the dentist. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to store the urinary catheters of two (Residents #70 and #60) out of seven residents in a sanitarily manner and to obtain physician orders for the care of an urinary catheter for one (Resident #60) out of the two sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to monitor the blood pressure related to the use of a hypotensive medication and to administer a hypotensive medication within the physician ordered parameters for two (Residents #39 and #59) out of five residents sampled for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in a manner such that unauthorized personnel, visitors, and residents did not have access to medications in three medication carts, one of two treatment carts, and ensure overstocked medications were stored in a locked medication room.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure laboratory tests were obtained per physician orders and acted upon in a timely manner for two (Residents #86 and #43) out of three residents sampled for laboratory services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate dental services in accordance with professional standards of practice for one (Resident #17) of six residents sampled for dental care.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to ensure care planned interventions were implemented related to not positioning floor mats at bedside and not positioning a call light or manual call bell within reach for one resident (#19) of thirty-two sampled residents, for three days (11/16/21, 11/17/21, and 11/18/21) of three days observed.

Inspectors wroteBased on observations, staff interviews and medical record review, the facility failed to provide Activities of Daily Living (ADL) care related to fingernail care during three of three days observed (11/16/2021, 11/17/2021, and 11/18/2021) for one resident (#1) of thirty-two sampled residents.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to ensure respiratory care consistent with professional standards of practice was implemented for one resident (#19) of six residents receiving respiratory treatment.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the medication error rate was below 5.00%. A total of twenty-nine medications were observed, and twenty-eight late medications were identified for two residents (#58 and #9) of three residents observed. The late medications constituted a medication error rate of 96.55 percent.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (#28) was free of a significant medication error by staff (C, D) failing to contact the physician for approval prior to administering Zolpidem (sleeping pill) outside of the prescribed time and allowing the resident to go outside of the building alone, and the facility failed to ensure one resident (#28) was administered tremor medication as ordered to maintain the highest practicable mental and physical well-being out of three residents sampled.

Inspectors wroteBased on observation, medical record review, facility policy review, interviews, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance Committee. The facility was actively involved in the effective creation, implementation and monitoring of the POC for deficient practice at F695 identified during a recertification survey, conducted on 11/15/2021 through 11/18/2021. The POC completion date was 12/18/2021. On 1/11/2022 on the revisit survey deficient practice was again identified at F695.