Average — CMS composite of the measures below.
A standard survey is most likely before around July 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Baywood Post Acute during CMS and state inspections, most recent first.
Multiple residents were found with bed rails in use without documented attempts at alternatives or completion of required quarterly assessments. The ADON confirmed that assessment forms were incomplete and that alternatives such as roll guards or foam bumpers were not documented as attempted prior to bed rail use, contrary to facility policy. These failures were identified through observation, interview, and record review.
Surveyors identified a medication error rate of 25.93% involving multiple residents, including missed doses due to unavailable medications, improper crushing of extended-release tablets, administration of incorrect medication dosages, failure to provide required medication ingredients, and lack of proper instructions for inhaler use. These errors were confirmed through direct observation, staff interviews, and review of physician orders and facility policies.
Surveyors found expired supplements and two bottles of latanoprost 0.005% eye drops, which had been opened beyond the recommended 42-day period, stored in a medication cart. An LVN confirmed that these medications should not have remained in the cart, as per facility policy requiring outdated or discontinued medications to be returned or destroyed.
Surveyors observed multiple infection control failures, including a urinary catheter bag placed on the floor, staff providing residents with ice from employee freezers, and repeated lapses in hand hygiene and glove use by CNAs and nurses. Medication administration practices were also deficient, with a nurse returning a cut tablet to its bottle and failing to clean a blood pressure cuff between residents. Wound care procedures were not followed, as a nurse did not change gloves or cleanse hands between dressing changes. Staff interviews confirmed these actions were inconsistent with facility policies.
A resident requested that only female CNAs provide her care and communicated this preference to staff and the administrator, but male CNAs continued to be assigned to her despite her wishes. The administrator confirmed awareness of the request, and facility policy supports honoring such preferences, but the request was not consistently followed.
Two residents received psychotropic medications, including Seroquel and Trazodone, without documented informed consent as required by facility policy. The DON confirmed that informed consent forms were missing from both residents' clinical records prior to the initiation of these medications.
Two discharged residents did not have their Discharge MDS assessments completed or submitted to CMS within the required timeframes. The assessments were overdue, not started, and not transmitted, as confirmed by the ADON during record review and interview, resulting in non-compliance with federal requirements.
Licensed nurses did not follow a physician's order to float a resident's heels using pillows or Prevalon boots while the resident was in bed. The resident, who had protein-calorie malnutrition, was repeatedly observed without the required heel protection, and a registered nurse confirmed the omission.
Surveyors observed that required nurse staffing information, including total actual hours, was not posted in a visible and accessible location for residents and visitors. The Infection Preventionist confirmed the absence of this information during the survey.
The facility did not act on consultant pharmacist recommendations for two residents: one continued to receive chewable Aspirin via NG-tube despite a recommendation to switch to a crushable film-coated form, and another had a note regarding duplicate therapy with Protonix and Pepcid that was not presented to the physician. These actions were not in accordance with facility policy requiring medication regimen review recommendations to be documented and acted upon.
The facility did not employ a full-time dietitian or designate a qualified full-time dietary manager as required, with the RD working only part-time and no dietary manager present for several months. This failure had the potential to result in unsafe food practices and food-borne illness for 38 residents receiving facility-prepared meals.
Surveyors found that the facility did not maintain the kitchen freezer and a meal cart in safe and proper working condition, with excessive ice buildup in the freezer and a meal cart missing a handle and unable to close properly. These deficiencies affected meal service for nearly all residents, as confirmed by the RD and Maintenance Manager.
Three four-person rooms were found to provide only 73.4 square feet per resident, which is below the required 80 square feet. Despite this, staff and residents reported no issues with space, privacy, or care delivery, and wheelchairs were accommodated without difficulty.
Failure to Attempt Alternatives and Complete Bed Rail Assessments
Penalty
Summary
The facility failed to ensure the proper use of bed or side rails for multiple residents by not attempting alternatives prior to their use and not completing required assessments. Observations revealed that several residents were found in bed with bilateral upper bed rails in the upright position. Record reviews and interviews with the Assistant Director of Nursing (ADON) confirmed that the Side Rail Assessment forms for these residents were incomplete, with sections regarding alternatives left blank and no documentation indicating that alternatives were offered or attempted before implementing bed rails. The facility's policy requires that alternatives such as roll guards, foam bumpers, lowering the bed, or concave mattresses be attempted prior to bed rail use, but this was not documented for the affected residents. Additionally, the facility did not complete quarterly bed or side rail assessments for several residents as required. For some residents, only one assessment was found in their records, with significant gaps between assessments, and in some cases, the only assessment was outdated. The ADON confirmed that the required quarterly assessments, which should be completed with the Minimum Data Set (MDS), were not performed for these residents. These failures were identified through observations, interviews, and record reviews, and had the potential to place residents at risk of entrapment and serious injury.
High Medication Error Rate Due to Improper Administration and Omission
Penalty
Summary
The facility was found to have a medication error rate of 25.93%, with 7 errors out of 27 observed opportunities during medication administration for four residents. Specific incidents included a nurse failing to administer gabapentin and tamsulosin as ordered due to lack of medication on hand, and crushing and administering levetiracetam and Klor-Con ER tablets to a resident despite clear labeling that these medications should not be crushed. The nurse confirmed these actions during interviews, and review of facility policy indicated that long-acting or extended-release medications should not be crushed and alternatives should be sought. Additional errors included a nurse administering a lower dose of calcium carbonate (500 mg) than ordered (1250 mg) via a nasogastric tube to a resident, and another nurse administering a multivitamin tablet without the required folic acid ingredient to a resident as per physician order. There was also an instance where a nurse failed to instruct a resident to shake a Symbicort inhaler and rinse their mouth after use, contrary to the medication label instructions. These actions were confirmed through observation, interviews with the nursing staff, and review of physician orders and facility policies.
Expired and Over-Open-Period Medications Found in Medication Cart
Penalty
Summary
Surveyors observed that expired medications and medications that had been opened beyond their recommended usage period were stored in Medication Cart 1. Specifically, a bottle of Calcium Citrate Magnesium and Zinc with vitamin D3 and a bottle of Centrum Silver Women 50+ were found with expiration dates of 3/2025, and both were still present after this date. Additionally, two bottles of latanoprost 0.005% eye drops, each labeled to be discarded 42 days after opening, were found in the cart despite being opened on 2/17/25, which exceeded the allowable period. During the observation, the LVN confirmed the presence of these expired and over-open-period medications and acknowledged that they should not have been stored in the medication cart. The facility's policy requires contacting the dispensing pharmacy for instructions regarding the return or destruction of outdated or discontinued medications.
Infection Control Lapses in Hand Hygiene, Equipment Cleaning, and Medication Handling
Penalty
Summary
Multiple infection control deficiencies were observed throughout the facility, involving both nursing and ancillary staff. In one instance, a urinary catheter drainage bag and tubing for a resident were found on the floor, contrary to facility policy requiring these items to be kept off the floor to prevent infection. Staff confirmed the improper placement of the drainage bag. Additionally, staff were observed providing ice to residents using ice from trays stored in the employee room freezer, which was located next to employee food items. Both a CNA and activity staff confirmed this practice, while the registered dietitian stated that such ice should not be used for residents due to infection control protocols. Hand hygiene and glove use were not consistently followed. One CNA delivered a lunch tray to a resident without sanitizing hands, and another CNA left a resident's room with soiled items while still wearing gloves, only removing them after walking through the hallway. During medication administration, a nurse failed to change gloves and wash hands between giving oral medications, assisting with an inhaler, and administering eye drops. Another nurse cut a medication tablet in half, administered one half, and returned the unused half to the medication bottle, contrary to policy requiring disposal of unused portions. The same nurse also failed to clean a blood pressure cuff between residents during medication passes. During wound care, a nurse did not change gloves or cleanse hands between removing an old dressing and cleansing/applying a new dressing to a resident's heel wound. Staff interviews confirmed awareness that these actions were not in line with facility policies and infection control standards. Facility policies reviewed included specific instructions for hand hygiene, equipment cleaning, medication administration, and wound care, all of which were not followed in the observed instances.
Resident's Request for Female CNA Not Honored
Penalty
Summary
A resident who was admitted to the facility requested that only female CNAs provide her care, communicating this preference to licensed nurses, CNAs, and the administrator. Despite this request, male CNAs continued to be assigned to her, as confirmed by both the resident and a male CNA who was assigned to her and whom she refused. The administrator acknowledged being informed of the resident's preference and stated that it was discussed in a staff meeting, but the resident's request was not consistently honored. The facility's policy affirms residents' rights to have their preferences supported, but this was not followed in the resident's case.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to two residents. One resident, admitted with dementia, was prescribed Seroquel at two different dosages for behavioral disturbances. Review of the clinical record showed that there were no informed consent forms for either dosage of Seroquel. During an interview, the DON confirmed the absence of these consents in the resident's record. Another resident, admitted with insomnia, was prescribed Seroquel at two different dosages for psychosis and Trazodone for insomnia. The clinical record for this resident also lacked informed consent forms for all prescribed psychotropic medications. The DON was unable to locate any informed consents for these medications during a review. The facility's policy requires that no psychotropic medication be initiated without verified informed consent from the resident or their authorized representative.
Failure to Timely Complete and Submit Discharge MDS Assessments
Penalty
Summary
The facility failed to timely complete and submit Discharge Minimum Data Set (MDS) assessments for two residents who had been discharged. Review of the clinical records for these residents showed that their Discharge MDS assessments were overdue, had not been started, and had not been submitted to the Centers for Medicare & Medicaid Services (CMS) as required. This was confirmed during an interview with the assistant director of nursing (ADON), who acknowledged that the assessments were not completed or submitted within the required timeframes. Facility policy and the CMS Resident Assessment Instrument (RAI) Manual specify that Discharge MDS assessments must be completed within 14 days of discharge and transmitted to CMS within an additional 14 days. Despite these guidelines, the responsible staff did not initiate or submit the required assessments for the two discharged residents, resulting in non-compliance with federal regulatory requirements.
Failure to Follow Physician Order for Heel Protection
Penalty
Summary
Licensed nurses failed to follow a physician's order to float a resident's heels while the resident was in bed. The resident, who was admitted with a diagnosis of protein-calorie malnutrition, had a physician order dated 11/4/24 requiring his heels to be floated with pillows at his calves or by using Prevalon boots whenever he was in bed. Observations on multiple occasions showed the resident lying in bed without pillows at his calves or Prevalon boots in place. During an interview, a registered nurse confirmed that the resident's heels should have been floated as per the physician's order, and acknowledged that this was not being done. The facility's job description for licensed vocational nurses includes providing basic wound care and treatments as ordered by healthcare providers.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information, including total actual hours, was posted in a clearly visible and prominent location that was readily accessible to residents and visitors. During multiple observations at the nurse station on different days, surveyors noted that there was no nurse staffing information or total actual hours posted. In a concurrent observation and interview, the Infection Preventionist confirmed that the required staffing information was not available for residents or visitors on a daily basis.
Failure to Act on Consultant Pharmacist Recommendations for Two Residents
Penalty
Summary
The facility failed to ensure that recommendations made by the consultant pharmacist during monthly drug regimen reviews were acted upon for two residents. For one resident, the consultant pharmacist recommended changing chewable Aspirin to a plain film-coated form that could be crushed and administered via NG-tube, as the current form was not suitable for crushing. Despite this recommendation, the resident continued to receive the chewable form, and the recommendation was not implemented, as confirmed by the DON upon review of the clinical record. For another resident, the consultant pharmacist identified duplicate therapy with Protonix and Pepcid and documented a note to the attending physician requesting evaluation of this issue. However, the note was not presented to the physician, and there was no evidence of a physician's response or signature. The facility's policy requires that resident-specific medication regimen review recommendations be documented and acted upon by the nursing care center and/or physician, which was not followed in these cases.
Failure to Employ Full-Time Dietitian or Dietary Manager in Food Service Operations
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, the facility did not have a full-time dietitian and did not designate a full-time, qualified dietetic supervisor or dietary manager during the period reviewed. Review of the Food and Nutrition Services schedules for February, March, and April 2025 showed that no dietary manager was working in the facility, and the Registered Dietitian (RD) was only present two days per week, working approximately 20 hours per week. Both the RD and another staff member confirmed that the RD was part-time and that there was no designated full-time dietary manager during this period. Facility policy required that if a dietitian is not employed full-time, a director of food and nutrition services must be designated. Additionally, state regulations mandate that a facility employing a part-time RD must also employ a full-time dietetic services supervisor. The lack of a full-time dietitian or a qualified full-time dietary manager had the potential to result in unsafe food practices and food-borne illness for the 38 residents consuming facility-prepared foods.
Failure to Maintain Kitchen Freezer and Meal Cart in Safe Operating Condition
Penalty
Summary
Surveyors identified that the facility failed to maintain essential kitchen equipment in safe and proper working condition. During a kitchen tour, significant ice buildup was observed inside the reach-in freezer, including on the exterior of the freezer doors and along both sides of the freezer gaskets. The Registered Dietitian confirmed the presence of ice in these areas and stated that such accumulation should not occur, as maintenance is responsible for keeping the freezer in good condition. The Maintenance Manager acknowledged awareness of the issue and confirmed that ice buildup could affect the freezer's functionality. Additionally, during a meal pass observation, Meal Cart 3 was found to be missing a proper handle, and its door was detached and unable to close properly. The Registered Dietitian stated that the meal cart should have been maintained in proper working condition. These deficiencies were observed to potentially impact 38 out of 39 residents who received meals prepared in the kitchen. Review of facility policy and the 2017 Food Code confirmed that equipment must be maintained in a state of repair and cleanliness, with regular inspections and immediate repairs as needed.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that three resident rooms met the required minimum space of 80 square feet per resident for multiple occupancy rooms. Specifically, three four-person rooms were each measured at 73.4 square feet per resident, which is below the regulatory standard. Observations during the survey confirmed that staff and residents were able to move freely within these rooms, and wheelchairs were accommodated without issue. Interviews with residents revealed no concerns regarding space or privacy, and there was no indication that the lack of space inhibited the provision or receipt of care and services.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Camden Postacute Care, Inc | 0.9 mi | ★★★★★ | 0 | 0 |
| Creekside Post-acute | 1.2 mi | ★★★★★ | 2 | 0 |
| A Grace Sub Acute & Skilled Care | 1.5 mi | ★★★★★ | 3 | 0 |
| Childrens Hc Org No Ca -pediatric Hospital D/p Snf | 1.7 mi | ★★★★★ | 0 | 0 |
| Empress Care Center, Llc | 2.1 mi | ★★★★★ | 0 | 0 |
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