Bay Shores Senior Care and Rehab Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility to accurately code the MDS (Minimum Data Set) for one resident (#24) and properly reflect one resident's (#61) pertinent care categories on the CMS (Centers for Medicare and Medicaid) 802 form of 22 residents reviewed for assessment accuracy, resulting in Resident #24 being miscoded as utilizing restraints on the MDS and Resident #61's infection not being designated on the CMS 802. Findings include: Resident #24: On 2/5/2025 at 11:30 AM, Resident #24 was observed resting in bed as we conversed about her time at the facility. The resident was asked if she required any usage of a restraint when in/out of bed and she stated she did not. The resident and motorized wheelchair was free was restraints. It can be noted in the survey system Resident #24 triggered for restraints. On 2/5/2025 at 12:44 PM, Nurse O was asked if Resident #24 utilized any type of restraint. The nurse stated, no, but said she did have enabler bars in the past. On 2/6/2025 at 11:10…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure timely assessment of transfer/mobility status for one resident (Resident #315) of four residents reviewed for care planning, resulting in unsupervised self-ambulation and transfer and an incomplete baseline care plan. Findings include: Resident #315: On 2/05/25, at 11:11 AM, Resident #315 was in their room in their bathroom with the door slightly ajar. While meeting with their roommate, Resident #315 hollered out, I got a problem in here. Resident #315 was observed standing on their pulled down pants with their socks half off all in a pile of bowel movement. There was a staff member walking by who was alerted who came quickly to assist the resident. On 2/06/25, at 12:12 PM, a record review of Resident #315's electronic medical record revealed an admission on [DATE] at 2:00 PM with diagnoses that included Alzheimer's disease, Hypertension and Glaucoma. A review of the Care Plan I have a potential/actual ADL deficit R?T (related to)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to update care plan interventions for 3 residents (R23, R24, R164) of 4 residents reviewed, resulting in the likelihood for missed interventions in treatment and unmet needs. Findings include: Record review of 'Facility Assessment Tool', dated 1/162025, page 8 under staff education: Person-Centered Care- This should include but not be limited to person-centered care planning, education of resident and family/resident representative about treatments and medications, documentation of resident treatment preferences, end-of-life care, and advanced care planning. Record review of the facility 'Call Light' policy, dated [DATE], revealed call lights will receive consistent and adequate response in order to best meet the individuals' needs of each resident. Procedure: Call lights will be placed within reach of the resident. Resident #23 Hydration: Observation was made on [DATE] at 09:56 AM of Resident #23 laying in his bed, thin in appearance with no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide Activities of Daily Living (ADL) for one resident (R164) of 18 residents reviewed for ADL care, resulting in residents feeling frustrated, anger, embarrassment from poor hygiene, unmet needs and complaints to the state surveyor. Findings include: Record review of the facility 'Activity of Daily Living (ADL) (Daily Life Functions) policy, dated 7/1/2008, revealed the purpose was to assist residents in achieving maximum functional ability with dignity and self-esteem. To provide assistance to residents as necessary. To supervise and assess resident function in order to plan care to maintain optimum ADL function as long as possible. To re-educate resident in techniques of daily life functions. To teach resident use of assistive devices to maintain optimum ADL function as long as possible. To improve the quality of life. Record review of facility shower M1 and M2 shower room schedules undated revealed that there were set days for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Number MI00150074. Based on observation, interview and record review, the facility failed to ensure timely completion of wound care for one resident (Resident #93) of one resident reviewed for dressing changes, resulting in missed wound care treatments, not following physician's orders and voiced frustration. Findings include: Resident #93: On 2/05/25, at 11:00 AM, Resident #93 complained there was two missed wound care treatments the week prior because they were short staffed. On 2/07/25, at 11:50 AM, a record review of Resident #93's electronic medical record revealed a readmission on [DATE] with diagnoses that included Lymphedema, Left lower leg fracture and Obesity. Resident #93 required assistance with all Activities of Daily Living and had intact cognition. A review of the TREATMENT ADMINISTRATION RECORD 1/1/2025-1/31/2025 revealed Cleanse left leg with wound cleanser, use wet to dry dressing, cover with super absorber and ABD pad and wrap with kerlex and ace wrap twice a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to prevent pressure ulcer (wounds caused by pressure) development and worsening for two residents (#4 and #217) of two residents reviewed resulting in Resident #4's Stage II (partial thickness loss of first and second layer of skin) pressure ulcer progressing to a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle), and Resident #217 developing an unstageable Deep Tissue Injury (DTI- pressure ulcer with unknown depth), unnecessary pain and the potential for decline in overall health. Findings include: Resident #4: On 2/6/25 at 9:55 AM, an interview was completed with Registered Nurse (RN) N on 2/6/25 at 9:55 AM. When queried regarding the etiology of Resident #4's pressure ulcers, RN N revealed they believed the pressure ulcer worsened at the facility. Review of the facility-provided CMS-802 Resident Matrix form detailed Resident #4 did not have a facility- acquired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide feeding assistance for Resident #43 and to prevent weight loss for Resident #23, resulting in Resident #43 to be observed with no dining assist at bedside and Resident #23 experiencing a 10 pound weight loss. Findings include: Record review of the facility 'Weight Policy' dated 11/21/2024 revealed each individual's weight will be determined and documented upon admission to the facility . Subsequent weights will be obtained monthly, unless physician's orders or an individual's condition warrants more frequent determinations. Re-Weights will be done for a weight change of +/- 3# (pounds) for anyone under 100 pounds and for +/- 5 pounds for anyone 100 pounds or over. Record review of the facility 'Diet Types' dated 9/26/2019 revealed each resident and guest admitted to the facility will be assessed by a Registered Dietitian and/or Clinical Certified Dietary Manager. Assessment will take place to evaluate the need for medical nutrition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This Citation pertains to Intake Numbers MI00149163 and MI00149254. Based on interview and record review the facility failed to ensure appropriate indication of a psychotropic drug dosage increase for one resident (Resident #47) and failed to ensure informed consent was obtained prior to administration of psychotropic medications for one resident (Resident #46) of four residents reviewed for unnecessary medications, resulting in Residents #46 and #47 bring administered antipsychotic medications without appropriate consent and risk versus benefit analysis of the medications explained to the resident/responsible party and the increased potential for serious side effects and adverse reactions . Assessment and Documentation: (c.) (ii.) Informed consent forms the resident and/or responsible party along with education regarding potential side-effects . Findings include: Record review of the facility 'Use of Psychotherapeutic Medications' policy, dated 6/23/2019, revealed a resident will not receive psychotherapeutic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure proper insulin administration and provide the proper medication dosage for two residents (Resident #57, Resident #164) of five residents reviewed for medication administration, resulting in unsafe injection practices, the uncertainty of an accurate insulin dose administered and improper medication reconciliation after hospitalization. Findings include: Resident #57: On 2/06/25, at 7:30 AM observation of Nurse H prepare am medications for Resident #57. Nurse H had the insulin pen resting on top of the medication cart. Nurse H picked up the insulin pen, screwed a needle onto the pen and dialed the pen to 5 units. Nurse H did not prime the needle with the required 2 units prior to administration into Resident #57's abdomen. On 2/06/25, at 9:44 AM, the Director of Nursing (DON) was alerted that Nurse H failed to prime the insulin pen needle with the required 2 units of insulin prior to administration. The DON was asked to provide the policy for medication administration and how to clean the blood glucose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure safe medication storage for one medication cart of four medication carts reviewed during the medication storage task, resulting in medications stored unlabeled in a clear plastic medication cup. Findings include: On 2/07/25, at 1:00 PM, During medication storage task, an observation of Center hall medication cart along with Clinical Care Coordinator (CCC) J was conducted. CCC J opened up the second medication drawer. There was a clear plastic unlabeled medication cup filled with numerous medications sitting in the container labeled 227-1. CCC J removed the medication cup that housed Resident #710's am oral medications and began to look for the Nurse assigned to the medication cart. On 2/07/25, at 1:05 PM, Nurse I approached the medication cart and CCC J offered, you can't store med's in a cup in your drawer. Nurse I offered, they put them in there because the resident was unavailable. A record review of Medication Administration Record for Resident #710 along with Nurse I and CCC J revealed the am…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow infection control practices related to the use of: (1.) Personal Protective Equipment (PPE), follow-up with employee health call-ins and (2.) proper hand hygiene, clean accu-check machine properly during medication pass and keep wound vac tubing off floor resulting in the likelihood for cross contamination and prolonged illness. Findings include: Record review of the facility 'Infection Prevention and Control Program' policy dated 11/22/2019 revealed the purpose of this policy is to provide guidelines for maintaining an infection prevention and control program that provides a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection. Record review of the facility 'Director of Infection Control' job description dated 10/1/2020, revealed that key duties and responsibilities: Plan, implement, and evaluate infection prevention and control measures. Personal Protective Equipment:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the dignity of 6 residents (#21, #75, #65, #79, #151, and #148) and 4 of 4 residents from the confidential resident group, by answering call lights in a dignified and timely manner, resulting in verbalizations of anger, frustration, and fear, with the likelihood for falls with injuries and hospitalization. Findings Include: Resident # 75: Review of the Face Sheet, Minimum Data Set (MDS, dated [DATE]), nurse's and physician notes dated 1/24 through 2/24, revealed, Resident #75 was 94 years-old, admitted to the facility on [DATE], had cognitive decline and required staff assistance with all Activities of Daily Living (ADL's). The residents diagnosis included, Anxiety Disorder, [NAME] Lymphoma, Mood Disorder, Embolism and Thrombosis, Dementia, Hearing Loss and age related debility. Review of the Falls Risk and Behavioral care plan's dated 4/23, revealed the resident was to have her call light accessible, yelled out for assistance,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that three Certified Nurse Assistant and three licensed nurses yearly performance reviews were conducted, resulting in the lack of yearly job performance evaluation for 6 of 8 staff reviewed. Findings include: Record review of the facility job descriptions of Certified Nurse Assistant dated [DATE], Licensed Practical Nurse dated [DATE]. and Registered Staff Nurse dated [DATE], revealed that each position had specific job duties to perform at different levels of care for the residents. Each job description revealed that the level of care to be provided for the residents related to each position of Certified Nurse Assistant (CNA), Licensed Practical Nurse (LPN) and Registered Nurse (RN). In an interview and record review on [DATE] at 12:55 PM with facility staff scheduler P regarding employee call-ins. Scheduler P stated that normal staffing is 13 Certified Nurse Assistants (CNA's) on day shift, 10 on second shift, and 8 CNAs on nights. All CNA's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 97 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 02/06/24 at 09:00 A.M., An interview was conducted with Director of Maintenance H regarding the facility maintenance work order system. Director of Maintenance H stated: We have the TELS software system. On 02/06/24 at 09:32 A.M., 11 of 11 conference room chairs were observed (etched, scored, particulate), creating a bacterial harborage and cross-contamination concern. On 02/06/24 at 10:40 A.M., A common area environmental tour of the facility was conducted with Director of Housekeeping and Laundry Services I. The following items were noted: Lobby Restroom: The return-air ventilation grill was observed heavily soiled with dust and dirt deposits. The interior baffles and plenum were also observed heavily soiled with accumulated dust…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to implement and/or develop a care plan for two (R#6, R#59) Residents, resulting in Resident #6 to have a cardiac pacemaker with no interventions for pacemaker checks/follow-up and Resident #59 to not receive showers/bathes as care planned for twice weekly with likelihood for missed care intervention. Findings include: Surveyor request for a Care Planning policy from facility was notified that the facility follows the RAI (Resident Assessment Instrument) manual 3.0, 2019. Record review of the CMS Resident Assessment Instrument 3.0 page 1-5 revealed that the purpose of the manuals to offer guidance about how to use the Resident Assessment Instrument (RAI) correctly to effectively to help provide appropriate care. Providing care to residents with post-hospital and long-term care needs is complex and challenging work. Clinical competence, observational, interviewing, and critical thinking skills, and assessment expertise for all disciplines are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to meet professional standards, to ensure 1) medications were not left at the bedside for 1 resident (Resident #88) who verbalized she chocked on a medication, 2) to document the incident on the facility occurrence report, and 3) to make a swallowing referral for further evaluation of change of condition, resulting in verbalization of fear of chocking on medications. Findings Include: Review of the Face Sheet, nursing notes dated 2/1/24 through 2/7/24, physician orders dated 1/11/23 through 1/11/24, revealed Resident #88 was 69 years-old, alert with confusion, admitted to the facility on [DATE], and required staff assistance with Activities of Daily Living/ADL's. The residents diagnosis included, [NAME] Matter Disease (decrease in white brain matter, may lead to dementia and cognitive decline), Alcohol Dependence, Encephalopathy (enlargement of brain), Anxiety, and Altered Mental Status. Review of the facility SLP (Speech Therapy) Evaluation and Plan of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the provision of bathing and hygiene care for one Resident (#59) of two reviewed, resulting in the likelihood for foul body odors, lack of bathing and showers per resident preference, and verbalization of dissatisfaction. Record review of facility 'Activities of Daily Living (ADL's)' policy dated 7/1/2008, revealed the purpose was to assist residents as needed in achieving maximum functional ability with dignity and self-esteem to improve quality of life. Procedure: (1.) Staff will utilize the care plan/[NAME] to determine level of assistance and interventions required for each resident to complete Activities of Daily Living which include transfers, toileting, bed mobility, locomotion, eating, dressing and personal hygiene . Resident #59: Observation on 2/5/2023 at 9:22 AM during the initial tour of the resident living area of the facility revealed Resident #59 to be lying in bed in a t-shirt, gripper socks and wet brief. Unit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure adequate supervision and monitoring to prevent injuries from falls for two residents (Resident #33, Residednt #63), resulting in falls with injuries and the likelihood for a decline in overall health status. Findings include: Record review of the facility 'Falls Reduction Program' policy, dated 9/25/2016, revealed the purpose was to provide a safe environment for residents, modify risk factors, and reduce risk of fall related injury. (4.) Determine the need for ongoing assessments/interventions based on Minimum Data Set (MDS) reviews, fall risk history, and interdisciplinary team (IDT) member recommendation. The IDT to review each incident to complete root cause analysis . Review of the Resident Right booklet given to all residents upon admission, stated You have a right to be treated with respect and dignity. Review of the facility Call Light Policy, dated 5/17, stated Call Lights will receive consistent and adequate response in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure narcotic reconciliation was completed accurately, resulting in scribbled over narcotic numbers and lack of signature with the likelihood of narcotic diversion going unnoticed. Findings include. On 2/06/24, at 10:29 AM, During medication storage task, an observation of the [NAME] Medication cart 3 narcotic reconciliation document revealed no signature of narcotic reconciliation during am cart/keys exchange. Nurse N was asked if they signed the narcotic reconciliation document when they took over the medication cart and Nurse N stated, oh I forgot to sign. A record review of the CONTROLLED MEDICATIONS SHIFT CHANGE SIGN OUT SHEET revealed no signature for 2-6-24 7 A From the dates 1-30-24 through 2-6-24 there were 6 times the numbers were scribbled over one another. A review of two other controlled medications shift change forms revealed five other days nurses scribbled over numbers. On 2/06/24, at 10:39 AM, an observation of [NAME]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.