Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bayberry Skilled Nursing & Healthcare Center during CMS and state inspections, most recent first.
A resident with hemiplegia and morbid obesity fell out of bed during incontinent care when a CNA turned her without bed rails and without another staff member present. The resident slid off the edge of the bed, sustained a left shoulder fracture, and was later placed in a sling. The CNA stated he could not get help, was unfamiliar with the resident’s care, and there were no rails on the bed.
Inaccurate MDS Tobacco Use Coding: Four residents were observed smoking in the STP unit, and smoking risk assessments identified them as smokers, but their MDS assessments coded Current Tobacco Use as No. An LVN stated the residents had scheduled smoking times, and the MDSC confirmed the item should have been coded as Yes because smoking was part of the treatment for residents in the STP unit.
Incomplete Diet Manual Reference for Ordered Diets A facility diet manual was missing reference information for puree, SB6, and minced and moist diets even though the diet spreadsheet listed those diets. During observation, an RNA/CNA could not locate the manual at first and stated she could not find SB6 information or know where to look if she had questions. The RD acknowledged approving the manual despite the missing mechanically altered diet details and stated nurses should have a reference for those diets.
SB6 diet foods were not served according to the planned menu for a resident receiving a texture-modified diet. During trayline observation, the resident's lunch tray contained chopped macaroni noodles and a regular cookie instead of the listed egg noodles and chopped cookie, and the kitchen staff member stated the tray items did not match the SB6 diet spreadsheet. The facility policy stated menus are planned to meet residents' nutritional needs in accordance with diet orders and the approved diet manual.
A resident on an SB6 soft and bite-sized diet with aspiration precautions was served a meal tray that included two wrapped hard candies. The tray was observed at bedside, the resident said the candy came with the tray, and the CNA and LVN both confirmed the candy should not have been on the tray. Facility menu records and IDDSI guidance indicated SB6 diets should avoid chewy foods such as candies and sweets.
Unsafe food handling and unsanitary kitchen equipment were observed when a DA used the same gloved hands to touch kitchen surfaces and then ready-to-eat food, while multiple pans, cutting boards, and a refrigerator shelf were found dirty or damaged. The ice machine bin was also dirty, and the MS stated the bin was only cleaned during the vendor’s 6-month service, with black particles transferred to a towel during wiping.
A resident’s popsicles were observed stored in the kitchen reach-in freezer with facility food, and staff stated the facility had no refrigerator or other way to store perishable foods brought in by family or visitors. CNA and RNS interviews confirmed that perishable items had to be eaten immediately, and the facility policy stated such foods could not be stored and should be consumed within two hours.
A shared glucometer was used on one resident and returned to the cart without being cleaned or sanitized, despite the IP stating it should be disinfected between resident uses. In a separate event, an RN supervisor assessed a resident’s swollen, reddened eye without gloves, even though the IP stated gloves should be worn when examining an eye area with visible inflammation. The resident had hemiplegia/hemiparesis and reported the eye had been painful and crusty for about a week.
Unsafe drug destruction and hazardous medication handling were observed when non-narcotic prescription drug destruction was documented with only one signature instead of two licensed witnesses, and hazardous meds such as valproic acid and spironolactone were stored or administered without safe handling practices. On one med cart, liquid valproic acid labeled with a NIOSH-2 warning had medication residue on the bottle and label and was not stored in a Ziplock bag, and an LPT and an LVN both stated they were not aware of proper hazardous drug handling; the LVN administered a NIOSH-labeled med without gloves.
Medication parameters were not followed for three residents. One resident’s insulin was held for blood glucose readings that were within the documented range, with no nursing note explaining the holds or physician contact. Another resident received PRN Norco when pain was charted as 0, and a third resident received midodrine despite SBP readings above the hold parameter. The DON stated staff should have clarified the orders with the provider and followed the parameters.
Unsafe Medication and Supply Storage: The facility stored expired, unlabeled, and comingled meds and supplies in med rooms, med carts, and a treatment cart. An LPN and RN confirmed items such as expired hand sanitizer, expired supplements and wound dressings, open single-use saline bottles, an undated blood sugar test strip bottle, and open Duoneb packaging that exceeded the labeled discard time. The DON stated staff were expected to keep med areas organized, remove expired items, and separate external-use products from other meds.
A resident with severe cognitive impairment and Alzheimer's disease was physically abused by a CNA during a shower. The CNA forcefully turned the resident, causing injury, removed the resident's clothing despite protests, and was observed smacking the resident's hand and pulling their hair. The incident resulted in the resident experiencing pain, as documented in progress notes.
The facility failed to maintain a safe and sanitary environment for food storage and preparation, with issues including broken kitchen floors, improper thawing of chicken, and unclean food preparation equipment. Observations revealed insects under loose tiles, incorrect labeling of thawed chicken, and residue on the ice machine, can opener, and cutting boards. Staff interviews confirmed these deficiencies and the lack of adherence to facility policies.
The facility failed to provide a policy or storage for perishable food brought by family members, leading to the disposal of such food if not consumed immediately. Interviews with staff, including a CNA, LVN, ADON, and DON, confirmed the absence of refrigerators for resident food storage. The facility's policy did not address safe storage practices, potentially impacting 80 residents who consumed food orally.
The facility failed to provide pureed vegetables according to the menu for residents on pureed diets, affecting four residents. Pureed carrots were prepared without seasoning, resulting in a flavorless and gummy texture, unlike the well-seasoned regular carrots. The Dietary Supervisor confirmed that the facility's recipes required the regular textured carrots to be pureed, but this was not followed.
A multi-dose vial of Tuberculin PPD was found unlabeled and undated in the medication room refrigerator. A nurse acknowledged the vial could have been opened months ago and should have had an open date label. The pharmacy expiration reference list and FDA product information indicated that opened vials should be discarded after 30 days due to potential oxidation and degradation affecting potency.
A resident with dysphagia was given vanilla wafers instead of a suitable dessert for their Soft & Bite-Sized and Renal diet, risking choking. The facility's Dietary Manual and menu spreadsheet lacked proper IDDSI standards, leading to this oversight.
The facility failed to maintain a freezer in good working order, resulting in food not being kept frozen solid. Observations revealed that the temperature of the freezer was too high, causing items like supplement shakes and pie crusts to be soft and improperly frozen. The Dietary Supervisor confirmed the issue, noting that the health shakes had an incorrect consistency. The facility's policy requires freezers to keep food frozen solid.
Failure to Provide Safe Bed Positioning and Supervision During Incontinent Care
Penalty
Summary
The facility failed to ensure adequate supervision and safe positioning during incontinent care for a resident with multiple diagnoses including right-sided hemiplegia and morbid obesity. The resident’s care plan called for quarter rails on both sides of the bed to support positioning and mobility, and the facility’s repositioning policy directed staff to check the care plan, use two people and a draw sheet when turning a resident in bed, and encourage the resident to hold the side rail when applicable. During incontinent care, CNA 2 raised the bed and positioned himself on the resident’s left side, then asked the resident to turn to her right side while he applied the fitted sheet. CNA 2 stated the resident’s legs began sliding toward the edge of the bed and she rolled out of bed before he could prevent the fall. CNA 2 stated there were no rails attached to the bed, that he was not familiar with the resident’s care, and that he did not receive report or instructions from the charge nurse at the start of the shift. LVN 3 stated CNA 2 did not ask for help and only informed her after the resident had fallen. The resident stated she fell out of bed when CNA 2 placed her in a right-side lying position without instructing her to hold onto anything, and she was unsure whether there was a bed rail. The resident landed on her left side and had immediate significant pain in the left shoulder, then was sent to the hospital. The ED documented an impacted fracture of the surgical neck of the left humerus with extension to the greater tuberosity, and the resident was later observed wearing a sling on the left arm.
Inaccurate MDS Tobacco Use Coding
Penalty
Summary
The facility failed to ensure accurate MDS coding for the Current Tobacco Use item for four sampled residents. Resident 42, Resident 49, Resident 52, and Resident 64 were observed smoking on the recreation patio in the STP unit during survey observations. Their admission records showed they were admitted on [DATE], 12/3/25, 5/16/24, and 11/7/24, respectively, and smoking risk assessments dated 11/7/25, 12/3/25, 11/11/25, and 11/10/25 identified each of them as smokers. Despite this information, the MDS for each resident, dated 5/12/25, 12/10/25, 5/15/25, and 11/10/25, coded Current Tobacco Use as No. The unit supervisor stated the residents were assigned to Group A with scheduled smoking times, and the MDS Coordinator stated the tobacco use item should have been coded as Yes because smoking was part of the treatment for residents in the STP unit. The facility policy on Resident Assessments stated that MDS information would consistently reflect progress notes, plans of care, and resident observations/interviews.
Incomplete Diet Manual Reference for Ordered Diets
Penalty
Summary
The facility failed to provide an accurate and complete diet manual reference for all diets provided in the facility. During a concurrent observation and interview at the nursing station, RNA/CNA 1 could not locate the diet manual and, after assistance, was able to find it; she stated she could not locate information for the soft and bite size (SB6) diet and would not know where to find information if she had questions about the diet. Review of the facility’s Generations Diet Manual for Bayberry Community, dated 10/20/25, showed that it did not include information on the puree, soft and bite size (SB6), and minced and moist diets. Review of the facility’s Diet Spreadsheet dated Tuesday Week 2 Day 11 showed that puree, SB6, and minced and moist diets were included. During interview, RD 1 stated he approved the diet manual on 10/20/25 and acknowledged that it did not include information regarding the puree, SB6, and minced and moist diets, and stated that mechanically altered diet information should be included so nurses have a reference. RD 1 was not aware of who provided the diet manual or the diet spreadsheets.
SB6 Diet Tray Did Not Match Planned Menu
Penalty
Summary
The facility failed to provide mechanically altered foods according to the menu for SB6 diets. During review of the diet spreadsheet, the SB6 lunch menu for Tuesday Week 2 Day 11 listed beef stroganoff (minced), egg noodles (chopped), spinach (chopped), white bread (slurry), and a chopped cookie. During a concurrent observation and interview in the kitchen during trayline on 1/06/2026 at 12 p.m., Resident 26's tray contained chopped pieces about 1/2 inch in length of beef stroganoff, chopped macaroni noodles, chopped spinach, slurry bread, and a regular cookie. DC stated that the items on the tray did not match the diet spreadsheet for the SB6 diet. The facility's Menus policy, dated March 2023, stated that menus are planned to meet residents' nutritional needs in accordance with physician diet orders, the approved diet manual, and federal/state regulations. The Registered Dietitian 2 was informed and acknowledged the findings on 1/07/2026 at 11:00 a.m.
Hard candy placed on tray for resident on SB6 diet
Penalty
Summary
The facility failed to prepare foods in a form designed to meet individual needs when hard candy was found on the meal tray of Resident 26, who had an order for an SB6 soft and bite-sized diet with aspiration precautions. During a concurrent observation and interview, the lunch tray was at the resident’s bedside and contained two pieces of wrapped hard candy along with the ordered meal items. Resident 26 stated that the people who brought the tray brought the candy. At 12:26 p.m., an LVN delivered a container of Ensure to the resident’s tray and left without acknowledging the hard candy. When interviewed, the CNA who delivered the tray stated the candy should not have been on the tray and did not know how it got there. The LVN confirmed that Resident 26 had an SB6 diet order and that residents on that diet should not receive candy. The facility’s diet spreadsheet for the lunch meal listed the foods intended for SB6 diets, and the facility’s menu policy stated menus are planned to meet residents’ nutritional needs in accordance with physician diet orders and the approved diet manual. The IDDSI guideline reviewed by surveyors stated Level 6 soft and bite-sized diets should avoid chewy foods such as lollies, candies, and sweets.
Unsafe Food Handling and Unsanitary Kitchen Equipment
Penalty
Summary
Food was not stored and prepared in a safe and sanitary environment when a Dietary Aide used gloved hands to touch a container of oil, refrigerator handles, a stove dial, and then touched ready-to-eat hamburger buns and cheese during meal tray line. The facility’s Food Preparation policy stated that plastic gloves should be worn to avoid direct contact with food, hands must be washed prior to putting on gloves and any glove changes, and the Sanitation and Infection Control policy stated to use tongs and utensils instead of hands. The 2022 Federal Food Code also states that single-use gloves are to be used for only one task and discarded when damaged, soiled, or when interruptions occur. Food preparation equipment and utensils were observed in poor condition in the kitchen, including a refrigerator with rusty shelves, sheet pans with grime and black residue, two large frying pans with thick black residue, and three heavily marred cutting boards. The facility’s policies stated that utensils and equipment are to be cleaned and sanitized after each use and that cutting boards may be nonporous acrylic and in good condition without deep cuts. The ice machine bin was also found dirty; the Maintenance Supervisor stated he cleaned the machine weekly and monthly but did not remove ice or clean the bin during those cleanings, and the vendor only cleaned the bin every six months. When the bin was wiped, black particles were transferred to the towel, and a prior maintenance report noted the ice bin was dirty with biofilm present.
Unsafe Storage of Perishable Foods Brought by Visitors
Penalty
Summary
The facility failed to ensure that residents had a safe location to store perishable foods brought in by family and other visitors, and it also failed to keep residents’ food separated from facility food. During a concurrent observation and interview in the kitchen, a resident’s popsicles were seen stored in the reach-in freezer with facility food, and the DC stated that the popsicles were kept there for the resident to eat at any time. The report also states that the facility had 78 residents who consumed food out of a total census of 78. During interviews, CNA 4 stated the facility did not have a refrigerator and that perishable food had to be consumed immediately. RNS 2 similarly stated there was no way to store perishable food and that residents had to consume food from outside right away. Review of CMS S&C-09-39 showed residents have the right to accept food from visitors, family, friends, or other guests, and that facilities are responsible for helping visitors understand safe food handling practices. Review of the facility policy titled Foods Brought by Family/Visitors, dated March 2022, stated perishable foods cannot be stored in the facility and should be consumed within two hours. RD 2 was informed of the findings and acknowledged them.
Infection Prevention Failures During Glucose Monitoring and Eye Assessment
Penalty
Summary
The facility failed to ensure safe infection prevention practices when a shared glucometer was not cleaned and sanitized between resident uses. During a medication administration observation, an LVN brought a glucometer and supplies into a resident’s room, used the device to obtain a blood glucose reading, removed gloves after leaving the room, and placed the glucometer back into the cart without cleaning or sanitizing it. The LVN also did not clean or sanitize the small tray that had been taken into the room. When interviewed, the LVN stated the glucometer did not need to be cleaned and sanitized after each use and said it was cleaned only three times during the shift. The Infection Prevention Nurse stated that nursing staff had been trained to clean hands with sanitizer before and after glove use during resident care. The IP also stated that the nursing staff should have cleaned and sanitized the glucometer with Sani-cloth wipes between resident uses and that it needed to remain wet for 2 minutes. The DON stated the facility was following CDC guidelines and manufacturer specifications for care and cleaning and relied on the IP nurses to educate staff on infection prevention workflow. The facility policy titled Cleaning and Disinfecting of Resident-Care items and Equipment stated that resident-care equipment, including reusable items, would be cleaned and disinfected according to current CDC recommendations and identified the glucometer as a critical item with high risk of infection. The facility also failed to ensure a licensed nurse wore gloves when assessing a resident’s swollen and reddened right eye. Resident 14 was admitted with diagnoses including hemiplegia and hemiparesis and required assistance with personal care. The resident’s right upper eyelid was observed to be red, swollen, and slightly watery, and the resident stated the eye area hurt a little and had been present for about a week. During assessment, the RN supervisor performed hand hygiene but did not don gloves before touching the resident’s right upper eyelid. The RN supervisor stated that because the skin area was intact, gloves were not needed. The Infection Preventionist stated that when assessing a resident’s eye area with visible signs and symptoms of inflammation, the licensed nurse should perform hand hygiene and wear gloves before touching the resident. The facility’s PPE policy stated that gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin.
Unsafe Drug Destruction and Hazardous Medication Handling
Penalty
Summary
Safe pharmaceutical services were not maintained when non-narcotic prescription drug destruction was documented with only one staff signature instead of two licensed staff witnesses. During interview and record review, an LVN stated that non-narcotic medications were disposed of every 2 weeks and logged in the non-narcotic drug logbook, and confirmed that the disposal form required only one signature. Review of the Non-Narcotic Destruction logbook for April 2025 through August 2025 showed the medication destructions were not witnessed by two-person signatures for the listed dates. The DON later confirmed that non-narcotic drug destruction occurred monthly, every other Sunday, and that the form required two-person signatures as witness, but the logbook for April 2025 through August 2025 had only one signature. Hazardous drugs were also not stored and handled safely in the medication carts and during medication administration. On station 2, multiple liquid bottles of valproic acid labeled with a NIOSH-2 warning were observed in the medication cart, including one bottle with red medication dripping on the outer surface and label, and none of the bottles were stored in a Ziplock bag to prevent contamination. An LPT stated she did not know what the NIOSH-2 label was for and was not aware of safe handling. During medication administration, an LVN was observed giving spironolactone labeled as NIOSH to a resident without gloves and stated she did not know what the NIOSH label meant and did not recall an in-service on hazardous medication handling. The DON stated the facility needed to look into how to address handling hazardous drugs commonly used in the facility.
Medication Parameters Not Followed for Insulin, Pain Medication, and Midodrine
Penalty
Summary
The facility failed to ensure medication use parameters ordered by the physician were followed for 3 of 30 sampled residents. For one resident receiving NovoLOG insulin 3 units subcutaneously with meals and a hypoglycemia protocol for blood sugar less than 70 mg/dL, the MAR showed multiple doses were held and documented as no medication required/outside parameters when blood glucose readings were 87, 89, 92, 97, 99, 107, 108, and 111, but the nursing notes did not explain why the doses were held or whether the physician was contacted. The insulin order did not include a hyperglycemia parameter or instructions for when to call the doctor. A second resident received Hydrocodone-Acetaminophen 5-325 mg every 6 hours as needed for moderate to severe pain, but the MAR showed the medication was administered when pain was documented as zero on four occasions. A third resident received midodrine 5 mg every 8 hours for hypotension with instructions to hold if systolic blood pressure was greater than 130 mmHg, but the MAR showed the medication was given when blood pressures were 139/84 and 146/89. During interview, the DON stated nursing staff should have clarified the orders with the medical provider and followed the order if parameters were in place.
Unsafe Medication and Supply Storage
Penalty
Summary
The facility failed to ensure safe storage of medications and supplies by allowing expired, unlabeled, and comingled drugs and products to remain in medication rooms, medication carts, and a treatment cart. During observation and interview, the surveyor found medications with different routes of administration stored together on the same shelf without dividers in the Station 2 medication room, including liquid prescription drugs, non-prescription pills, topical head lice medication, enemas, and rectal suppositories. The same area also contained expired Beneprotein, Ingress, nicotine gum, and opened single-use sterile normal saline irrigation bottles that were labeled to be discarded after opening. In the Station 1 medication room, three bottles of hand sanitizer were observed with an expiration date of 2022. On Medication Cart 1C, an opened and undated bottle of blood sugar test strips was stored even though the label directed that the bottle be discarded 90 days after first opening, and Duoneb packaging was open with an open date of 12/22/25 even though the box instructed that it be discarded 2 weeks after opening. In the treatment cart on Station 1 hallway, an opened packet of Aquacel Advantage sterile dressing and an expired box of Adaptic non-adherent dressing with an expiration date of 10/31/2024 were found stored with wound care supplies. Staff members who were present during the observations confirmed the findings and stated the items should have been thrown out. The DON stated the expectation was for nurses to follow the medication storage room and medication cart cleaning schedule and procedure, and that the night shift was responsible for ensuring medications were not comingled, expired medications were removed, and medication areas were cleaned and organized. The DON also stated wound treatment nurses were expected to clean their carts and dispose of open and expired items. Facility policies reviewed stated that opened multi-dose containers are to be dated, single-dose or single-use vials are not to be used on multiple residents, multi-dose vials are to be discarded within 28 days unless otherwise specified, and external-use medications and biologicals are to be clearly marked and stored separately from other medications.
Resident Physically Abused During Shower by CNA
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) physically abused a resident with severe cognitive impairment and Alzheimer's disease. The resident, who had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment, was subjected to forceful handling during a shower. Multiple staff interviews confirmed that the CNA forcefully turned the resident while on a shower chair, causing the resident's arm to hit the wall, and forcefully removed the resident's clothing despite the resident verbally protesting. Witnesses also observed the CNA smacking the resident's hand and pulling the resident's hair after the resident pinched the CNA's hand. Progress notes documented that the resident experienced new pain in the left shoulder and showed signs of pain following the incident. The facility's policy clearly states that residents have the right to be free from abuse, including physical abuse. The actions of the CNA, as observed and reported by other staff and documented in the resident's records, resulted in the resident experiencing physical abuse and pain.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food storage and preparation, as evidenced by several observations and interviews. The kitchen floors were found to be in poor condition, with broken and missing tiles, leading to an uneven surface. Insects were discovered under loose tiles, and there was a significant build-up of black and brown residue under the warewashing sink. The Maintenance Supervisor acknowledged the floor's poor condition and the Administrator admitted that the kitchen floors were not an active part of the facility's Performance Improvement Project, despite receiving bids to fix the floor. The facility also failed to ensure safe thawing practices for chicken. A pan of raw chicken was observed in the refrigerator with incorrect labeling, and the Dietary Supervisor confirmed that the label did not reflect the actual date the chicken was placed in the refrigerator. The chicken was thawed under running water without proper temperature control, and there was no documentation of critical control points to ensure safe thawing. The Dietary Supervisor instructed the staff to discard the improperly thawed chicken. Additionally, the facility did not maintain cleanliness of food preparation equipment. The ice machine was not cleaned according to the manufacturer's instructions, with dark residue found on sensors inside the machine. The can opener and cutting boards were also found to be unclean, with residue and particles present. The facility's policies and procedures for cleaning these items were not followed, as evidenced by the observations and interviews with staff.
Lack of Food Storage Policy for Resident Meals Brought by Family
Penalty
Summary
The facility failed to ensure that family members could bring in food for residents and that there was a location to safely store perishable food. Interviews with staff, including a Certified Nursing Assistant (CNA), a Licensed Vocational Nurse (LVN), the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed that the facility did not have refrigerators available for storing resident food. As a result, perishable foods brought in by family members were discarded if not consumed immediately. The DON confirmed that family members were informed not to bring food into the facility due to the lack of storage options. A review of the facility's policy titled 'Food Brought by Family/Visitors' indicated that family members should notify nursing staff of their intention to bring food, and the Clinical Dietitian or a Nurse Supervisor should ensure the food aligns with the resident's diet plan. However, the policy did not provide guidelines for the safe storage of food brought in by family members. This lack of a clear policy and storage solution had the potential to result in foodborne illness and decreased food intake, affecting all 80 residents who consumed food orally.
Failure to Provide Properly Seasoned Pureed Vegetables
Penalty
Summary
The facility failed to provide pureed vegetables according to the menu for residents receiving pureed diets, which affected four out of five residents on such diets. During an observation in the kitchen, it was noted that pureed carrots were prepared without seasoning, resulting in a flavorless and gummy texture. The Dietary Supervisor (DS) confirmed that the pureed carrots lacked flavor and had an unpleasant texture compared to the well-seasoned regular carrots. Interviews revealed that the cook, identified as C1, prepared the regular textured carrots with seasoning but did not add any seasoning to the pureed carrots. The DS confirmed that the facility's recipes required the regular textured carrots to be pureed rather than preparing a separate batch for the pureed texture. The facility's policy on standardized recipes indicated that these should be used when preparing menu items, but this was not followed for the pureed carrots.
Improper Labeling of Tuberculin PPD Vial
Penalty
Summary
The facility failed to ensure proper labeling of biologicals, specifically a multi-dose vial of Tuberculin Purified Protein Derivative (PPD), which was found unlabeled and undated in the medication room refrigerator. During an observation and interview, a Registered Nurse acknowledged that the vial could have been opened months ago and should have had an open date label. Further review with the Infection Preventionist revealed that the pharmacy expiration reference list indicated that opened tuberculin test vials should be discarded after 30 days. The Tuberculin PPD product information from the FDA also stated that vials in use for more than 30 days should be discarded due to possible oxidation and degradation affecting potency. This oversight had the potential to lead to residents receiving false test results due to reduced potency of the Tuberculin PPD.
Inappropriate Food Texture Provided to Resident with Dysphagia
Penalty
Summary
The facility failed to provide the appropriate texture of food prescribed for a resident diagnosed with oropharyngeal phase dysphagia, a condition affecting swallowing. The resident was assessed by a Speech Language Pathologist (SLP) and prescribed a Soft & Bite-Sized diet with Mildly Thick Liquids, along with a Renal diet. During a tray-line food service observation, it was noted that the kitchen staff placed vanilla wafers, broken into bite-sized pieces, on the resident's tray, which was not suitable for the prescribed diet. The Dietary Supervisor initially was unsure if the wafers were appropriate and later confirmed with the SLP that they were not suitable for the resident's diet. The SLP explained that vanilla wafers should be soaked in milk to soften them for a Soft & Bite-Sized diet, but milk was not appropriate for the Renal diet. The resident was edentulous, meaning they had no teeth, which increased the risk of choking on the wafers. The facility's Dietary Manual indicated that dry cookies were to be avoided for residents on a Soft & Bite-Sized diet. The menu spreadsheet used in the kitchen did not include the IDDSI standards for the Renal diet, contributing to the oversight.
Freezer Malfunction Leads to Improper Food Storage
Penalty
Summary
The facility failed to maintain all equipment in good working order, specifically one of three freezers, which did not keep food frozen solid. During an observation, the temperature of freezer 1 was recorded at 19 degrees Fahrenheit, and items inside, such as supplement shakes and pie crusts, were found to be soft and not frozen solid. In a subsequent observation and interview with the Dietary Supervisor, it was noted that several uncooked pie dough crusts and angel food cakes were also soft to the touch. The health shakes stored in the freezer had an inappropriate gooey consistency with ice build-up, indicating they were not properly frozen. The facility's policy on food storage, dated 2017, requires that all freezer units be kept in good working condition and that frozen foods be maintained at a temperature to keep them frozen solid.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Concord
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Pass Healthcare Center | 1.2 mi | ★★★★★ | 6 | 0 |
| Concord Post Acute | 1.5 mi | ★★★★★ | 5 | 0 |
| Diablo Valley Post Acute | 1.7 mi | ★★★★★ | 15 | 0 |
| Legacy Post Acute Care | 2.9 mi | ★★★★★ | 2 | 0 |
| Pleasant Hill Post Acute | 3.2 mi | ★★★★★ | 22 | 0 |
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