Bayside Manor LLC

Inspectors wroteBased on observation, interview and document review the facility failed to destroy expired over the counter medication (OTC) for 1 of 2 sampled medication rooms. In addition, the facility failed to ensure 1 of 1 resident's (R10) lorazepam (anti-anxiety medication) was immediately removed from 1 of 2 medication carts and not co-mingled and stored with in-use medications for other residents.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure staff followed sanitary guidelines on appropriate food handling during 1 of 1 meal service. This had the potential to affect all 29 residents who received meals served from the kitchen.

Inspectors wroteBased on interview and document review, the facility failed to have a current, ongoing system of surveillance for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases that included facility staff. This had the ability to affect all 29 residents.

Inspectors wroteBased on interview, document review, the facility failed to ensure 1 of 1 resident (R27) was free from verbal abuse.

Inspectors wroteBased on interview and document review the facility failed to ensure an as needed psychoactive medication Lorazepam (antianxiety medication) was not used beyond 14 days without a rationale for continued use and an identified review date for 2 of 5 sampled residents (R2 and R11) reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review the facility failed to ensure safety for 1 of 4 sampled residents (R27) by suspending 1 of 1 nursing assistant (NA)-C, following an allegation of abuse.

Inspectors wroteBased on interview and document review, the facility failed to ensure the administrator and State Agency (SA) were notified within 2 hours of an allegation of physical and verbal abuse for 1 of 1 resident (R27).

Inspectors wroteBased on interview, and record review the facility failed to protect 1 of 2 residents (R1), who did not have the capacity to consent from inappropriate touching from an assisted living resident (AL-R) who was visiting. This resulted in an immediate jeopardy (IJ) when R1 was inappropriately touched repeatedly over the course of approximately 38 minutes without intervention by staff. The IJ began on 11/21/25, when staff members suspected AL-R of inappropriate touching and did not remove and/or intervene to stop the touching which resulted in AL-R repeatedly inappropriately touching of R1's thighs and in-between her legs by AL-R. The Administrator, director of nursing (DON), resident service coordinator, and regional director of operations (via phone) were notified of the past non-compliance (PNC) IJ on 12/5/25 at 1:50 p.m. [...]

Inspectors wroteBased on observation, interview and document review the facility failed to convey a resident's most current Provider Order for Life Sustaining Treatment (POLST) form to the receiving provider when 1 of 1 resident (R1) was transferred to the emergency department (ED), reviewed for discharge.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure dietary staff followed appropriate infection control practices when handling cups and performing hand-hygiene during food service in the dining room and passing meal trays to resident rooms. In addition, the facility failed to ensure dishwasher chemical sanitization solution was monitored to ensure dishes were properly sanitized. This had the potential to affect all 34 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to implement a process for antibiotic review to determine the efficacy and resident outcomes (appropriate medication, dose, and duration) for 4 of 4 residents R12, R27, R1, and R31 reviewed. Further, this had the potential to affect all 34 residents living in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident rights and choices were protected for 1 of 1 resident (R16) when his recliner was removed from his room against his wishes.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident status was accurately identified in the Minimum Data Set (MDS) assessment for 1 of 1 resident (R5) reviewed for hospice.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow physician orders for leg elevation for 1 of 1 resident (R16) reviewed for edema.

Inspectors wroteBased on observation, interview, and document review, the facility failed to conduct a comprehensive reassessment after a fall incident and ensure new interventions were implemented to prevent further falls for 1 of 1 resident (R11) reviewed for falls.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow provider's order of catheter flush for 1 of 1 resident (R12) reviewed with indwelling catheter to minimize the risk for urinary tract infections (UTI). Additionally the facility failed address urinalysis (test of the urine to detect infection) results for 2 of 2 residents (R5 and R12) reviewed for UTI.

Inspectors wroteBased on interview and document review the facility failed to ensure the provider's response to the monthly medication review was followed for 1 of 5 (R18) residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure personal protective equipment (PPE) was utilized for 1 of 2 residents (R136) reviewed for enhanced barrier precautions (EBP). Additionally, the facility failed to ensure proper glove use and hand hygiene was performed during wound care for 1 of 3 residents (R136) reviewed for pressure ulcers.

Inspectors wroteBased on interview and document review, the facility failed to ensure an advance directives was accurately documented on the resident's electronic health record (EHR) banner and physician orders which affected 1 of 30 residents (R14) reviewed for advance directives. This resulted in an immediate jeopardy (IJ) for R14 who would have been denied cardiopulmonary resuscitation (CPR) contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE] when R14's Provider Orders for Life-Sustaining Treatment (POLST) identified R14 wished to have CPR administered, however, the physician orders in the EHR and EHR banner indicated R14 was do-not-resuscitate (DNR). The administrator was notified of the IJ on [DATE], at 8:03 p.m. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide sufficient staffing to ensure residents received care and assistance as needed and requested. These deficient practices had the potential to affect all 30 residents who resided in the facility.

Inspectors wroteThe facility's request for a waiver was accepted and and approved by the State Agency following the survey exited 10/10/23. This will remain in effect until such time as the registered nurse (RN) coverage can be filled and the facility achieves compliance. F727: CFR 483.35 (b)(1), RN coverage 8 consecutive hours a day, 7 days a week.

Inspectors wroteBased on observation, interview, and document review, the facility failed to post visual alerts with instructions regarding current infection prevention recommendations for source controls at the facility entry door per Centers for Disease Control (CDC) recommendations. In addition, the facility failed to ensure proper infection control practice while removing medications from bottle for 1 of 2 residents (R30) and sanitize facility glucose monitor per manufacturer's recommendations for 1 of 1 (R12). Further, based on interview and document review, the facility failed to have a water management program consistent with nationally accepted standards, e.g., ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) or CDC. This had the potential to effect all 30 residents who resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure controlled medications were stored in a manner to prevent and minimize the risk of diversion for 1 of 1 medication storage rooms in the facility.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure residents were provided care in a dignified and respectful manner for 1 of 2 residents (R17) who were observed during care interactions.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide timely toileting, incontinence care and repositioning for 2 of 3 residents (R17 and R18) who were dependent upon staff for assistance with activities of daily living (ADL).

Inspectors wroteBased on interview, observation and document review, the facility failed to ensure staff provided a walking program to meet the assessed needs for 1 of 2 residents (R14) reviewed for restorative services.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure care planned interventions to prevent falls were implemented for 1 of 3 residents (R13) reviewed for falls.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a system for periodic reconciliation of controlled substances for 2 of 2 (R20, R22) residents stored in a refrigerator.

Inspectors wroteBased on interview and document review, the facility failed to ensure written notice of transfer was sent to the resident and/or resident representative for 2 of 2 residents (R15 and R16) reviewed for hospitalization.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure provider orders for nothing by mouth (NPO)was followed for 1 of 1 (R1) who had outside procedures requiring NPO before appointments resulting in resident missing appointment.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper hand hygiene and glove use practices were maintained for 1 of 3 residents (R2) observed during peri care and medication administration.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure safe transfer techniques using a gait belt and failed to complete a comprehensive post fall analysis and investigation for 2 of 3 residents (R1, R2) reviewed for falls. The facility's failures resulted in actual harm when R1 sustained a pelvic and R2 sustained a rib fracture.

Inspectors wroteBased on interview and record review the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours a day in a 24-hour for 22 days between 4/30/23 through 9/28/23. This had the potential to effect all residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to report a fall with major injury to the state agency (SA), within the two-hour requirement, for 1 of 3 residents (R1) reviewed, when R1 had a fall with a fractured pelvis.