Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Bay Terrace Rehabilitation And Health Center during CMS and state inspections, most recent first.
A resident reported an allegation of physical abuse by a CNA during the night shift, which was documented in the clinical record. Facility policy required that all alleged violations be reported to the Administrator, state agency, APS, and other required agencies immediately but no later than two hours after the allegation. Instead, the allegation was reported to the state agency approximately nine hours after it was made. An RN acknowledged not reporting the allegation right away and waiting for the day shift, and the DON confirmed that the reporting timeframe was not followed.
A resident with dementia and a care plan for false accusations alleged physical abuse by a CNA. Facility policy required staffing or room changes to protect residents from an alleged perpetrator, but the CNA remained on duty providing care to other residents for the rest of the shift. An LPN and an RN confirmed that the CNA continued working with residents, with the CNA only being stopped from caring for the accusing resident’s room, resulting in a failure to fully implement the abuse protection policy.
A resident with CHF and kidney disease requiring dialysis was admitted and assessed as having congestive heart failure, but the baseline care plan lacked CHF-related interventions and there was no timely physician order for fluid restriction despite a nutrition assessment referencing a 1500 mL limit. A physician note identified the resident as high risk for rehospitalization and called for strict I&O and daily weights, yet a formal fluid restriction order was not entered until several days later, only after the responsible party requested it. The next day, the resident was sent to the hospital from dialysis for chest pain and shortness of breath. In interviews, the MD, RN, and DON all confirmed the resident should have been placed on fluid restriction and monitoring upon admission and that this was not done in a timely manner.
Failure to provide ADL nail care for a dependent resident. A resident with terminal prostate cancer and delirium was documented as needing help with ADLs and personal hygiene, and a progress note stated he was smearing feces with his hands. During a bed bath, a CNA washed and shaved the resident but did not clean his fingernails, and dark debris was later observed beneath three fingernails on his left hand. The CNA, an LPN, and the DON confirmed the fingernails were not cleaned.
A resident with GERD had duplicate active Protonix orders, including a twice-daily order and a once-daily order, resulting in an excessive dose. A monthly pharmacy review identified the two current orders and asked for clarification, and the MD later confirmed the daily order should be discontinued. The ADON confirmed the duplicate orders remained active for 37 additional doses, and the DON could not explain how the discrepancy was missed.
A resident with significant upper extremity weakness and recent surgery was discharged home to a multi-story residence without confirmed DME delivery, home health services, or caregiver support. Although referrals for home health, skilled nursing, and DME were made and family attended a discharge care plan meeting, staff did not verify that services were active, did not set or confirm a start-of-care date with the agency, and did not confirm delivery of a hospital bed. The resident, who lived alone and could not manage fine motor tasks, arrived home without in-home assistance, reported difficulty with eating and self-care, and was later found by an HHA RN in unsafe conditions, unable to access food or medications, leading to emergency transport back to the hospital.
A resident with multiple chronic conditions did not receive appropriate bowel management after several days without a bowel movement, resulting in the need for fecal disimpaction during hospitalization. The facility also failed to obtain ordered STAT labs, provide nebulizer treatments due to lack of equipment, and secure IV access for fluids. Additionally, supplemental oxygen was administered and titrated without a corresponding physician order, and required documentation and reports were missing.
A resident with significant medical needs, whose care plan specified a preference for showers on certain days, was only provided bed baths throughout the month. Despite documentation of the resident's preference and total dependence on staff for bathing, CNAs consistently recorded that only bed baths were given, and no showers were provided as preferred.
A resident with severe cognitive impairment was admitted with an advanced directive specifying DNR status, but facility staff initially documented her as Full Code. Despite the resident's daughter providing updated DNR documentation, the change was not effectively communicated to providers, resulting in multiple provider encounters listing the resident as Full Code. During a medical emergency, staff were unable to promptly confirm the resident's code status, leading to confusion among EMS and facility staff.
A resident who was fully dependent on staff for activities of daily living did not receive adequate grooming and oral hygiene, as evidenced by poor physical condition upon hospital admission, including dirty linens, unclean catheter site, and poor oral care. Staff interviews revealed confusion and lack of access to functional shower beds, contributing to the failure to maintain the resident's hygiene.
Failure to Timely Report Allegation of Staff-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure immediate reporting of an allegation of staff-to-resident physical abuse in accordance with its abuse policy and regulatory time frames. The facility’s abuse policy, last updated January 2026, required that all alleged violations be reported to the Administrator, state agency, adult protective services, and other required agencies immediately but no later than two hours after the allegation is made. On 6/12/25 at 3:31 AM, an incident note in the clinical record documented that resident R83 alleged physical abuse by a CNA (E8). However, the allegation was not reported to the State Agency until 11:21 AM the same day, approximately nine hours after the allegation was made, exceeding the required reporting timeframe. During an interview on 4/23/26 at 11:06 AM, an RN (E6) confirmed that the allegation was not immediately reported and stated that the DON later informed her it should have been reported right away rather than waiting for day shift. In a separate interview at 11:14 AM, the DON (E2) confirmed these findings. The deficiency centers on the delayed reporting of the abuse allegation to the State Agency despite clear policy requirements for immediate notification. The survey findings were reviewed with the Nursing Home Administrator (E1), the DON (E2), and others at the exit conference on 4/23/26 at 3:00 PM.
Failure to Remove Accused Staff From Resident Care After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from further potential abuse by not immediately removing an accused staff member from resident care following an allegation of physical abuse. The facility’s abuse policy, updated January 2026, states that room or staffing changes are to be made as necessary to protect residents from the alleged perpetrator. On 6/12/25 at 11:21 AM, the facility reported an allegation of staff-to-resident physical abuse involving resident R83 and CNA E8. Record review of E8’s timesheet showed that after this allegation, E8 remained in the facility working with residents until 7:05 AM. During interview, LPN E7, who was assigned to R83’s unit at the time, confirmed that E8 continued caring for residents after R83’s accusation and stated that R83 had dementia and a care plan for false accusations, and that E8 was only stopped from caring for R83’s room for the rest of the shift. RN E6 also confirmed that E8 continued caring for residents after the allegation and stated that she instructed E8 to care for other patients. These findings were reviewed with the NHA (E1) and DON (E2) during the exit conference. The resident involved, R83, had dementia and a documented care plan for false accusations, which influenced staff’s decision to limit E8’s contact only with R83 rather than removing E8 from all resident care. Despite the facility’s written policy requiring protective staffing or room changes to safeguard residents from an alleged perpetrator, E8 remained on duty providing care to other residents for the remainder of the shift after the allegation of physical abuse was made.
Failure to Implement Timely Fluid Restriction and Monitoring for Resident With CHF and Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and monitoring consistent with professional standards of practice for a resident admitted with congestive heart failure and kidney disease requiring dialysis. The resident was hospitalized for multiple conditions, including heart failure, and then admitted to the facility with diagnoses of congestive heart failure and kidney disease. An admission assessment by an RN documented congestive heart failure, but the baseline care plan did not include any interventions related to this diagnosis. A nutrition assessment documented that the resident was on a therapeutic meal plan with a 1500 mL fluid restriction and indicated ongoing monitoring of oral intake, weight, skin integrity, and labs, yet the physician’s orders and dietary intake records did not contain an order for fluid restriction. A physician progress note documented that the resident had multiple complex comorbidities, including heart failure, and was at high risk for rehospitalization without proper care, specifying a plan for strict intake and output and daily weights. An admission MDS later confirmed that the resident was cognitively intact, experiencing shortness of breath, and had an active diagnosis of heart failure. A physician’s order for a 1500 mL fluid restriction was not written until several days after admission, at the request of the resident’s responsible party. The following day, nursing documentation showed the resident was sent to the hospital from dialysis for chest pain and shortness of breath. In interviews, the MD, the admitting RN, and the DON all confirmed that the resident should have been placed on a fluid restriction and monitoring upon admission, and the DON acknowledged that the fluid restriction order was not implemented in a timely manner.
Failure to Provide ADL Nail Care
Penalty
Summary
The facility failed to provide ADL care for a dependent resident, R10, who was admitted with terminal prostate cancer and delirium and was documented on the care plan as having a self-care deficit for ADLs and on the quarterly MDS as dependent for personal hygiene. A progress note stated that R10 was restless all night and was smearing feces with his hands. During a bed bath, a CNA washed and shaved the resident but did not check or clean his fingernails. Subsequent observation showed dark debris beneath three fingernails on R10's left hand, and the CNA confirmed she had not cleaned the fingernails during the bath. An LPN also confirmed the debris remained and stated she had not seen a nail-cleaning device available for use in a long time. The DON confirmed the fingernails were not cleaned during the bath.
Unnecessary Protonix Dosing Due to Duplicate Active Orders
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary drugs when Protonix was ordered in an excessive dose. The resident was admitted with GERD, and the record showed an initial order for Protonix 40 mg by mouth twice daily, followed by a later order for Protonix 40 mg by mouth once daily. A Monthly Consultant Pharmacist Report later documented that two Protonix orders were present and asked for clarification on whether both were current. The report was signed off and acknowledged by the provider, and the MD later confirmed that the daily Protonix order was to be discontinued. The ADON confirmed the resident had two active Protonix orders from the later order until the discontinuation, totaling 37 additional doses. The DON stated that the expectation was for the ADON or DON to monitor monthly pharmacy reviews and implement changes, but could not explain how the discrepancy was missed.
Failure to Ensure Safe Discharge with Confirmed Home Services and Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge home included confirmed durable medical equipment (DME), home health services, and adequate caregiver support. The resident was admitted with spinal stenosis, cervical disc disorder, muscle weakness, carpal tunnel syndrome, and a recent post-fasciotomy to the right arm, and was documented as cognitively intact with a BIMS score of 14/15. Despite these physical limitations, the facility discharged the resident home in the evening via medical transport to a three-story residence, where no caregiver support was present. The facility’s own policy required a post-discharge plan of care developed with the resident and representative, and orientation to ensure a safe and orderly transfer or discharge, but the record lacked evidence that services were confirmed as in place prior to discharge. Prior to discharge, the social worker documented that the resident would have a safe discharge home with services and supports in place, and that referrals for home health care, skilled nursing services, and DME had been made, with family members in attendance at the discharge care plan. However, the clinical record did not contain confirmation that these services were actually arranged and active before the resident left the facility. The resident was discharged with medications called to the pharmacy for home delivery, but there was no documentation that the hospital bed had been delivered or that home health nursing, therapy, or home health aide services were scheduled to start at the time of discharge. The social worker later acknowledged not informing the agency of a specific start-of-care date, assuming the agency and VA would contact the resident, and confirmed not calling to verify delivery of the hospital bed. After discharge, it was discovered that the hospital bed ordered days earlier was not delivered until the morning after the resident arrived home, and that therapy, RN, and HHA services had not yet begun or contacted the resident by the time the facility followed up. The resident reported living alone, being unable to use their hands, needing a caretaker, and having to rely on a sister-in-law for limited assistance with hygiene, meals, and rearranging furniture for the bed that arrived later. The significant other confirmed that no one lived with the resident, that they had their own health issues, and that neither they nor their son stayed with the resident after discharge. When a home health RN eventually visited, the resident was found sitting on a couch in minimal clothing, reporting not having eaten adequately for two days, having little or no accessible food, and being unable to open medications or bottles due to impaired fine motor skills. The RN observed the resident’s inability to grip or perform fine motor tasks, assisted with toileting, and then contacted the agency director and emergency services due to the unsafe conditions in which the resident had been left. These events led surveyors to determine that the facility failed to ensure services and caregiver support were in place prior to discharge, resulting in an immediate jeopardy situation.
Removal Plan
- Audited discharge documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs to determine if any residents were affected.
- Reviewed planned discharges by the Administrator, DON, Director of Social Services, and Director of Rehabilitation to ensure home health services, appropriate caregiver/family support, and necessary services to meet the resident's care needs are in place before discharge.
- Completed a root cause analysis identifying failure to have a robust discharge care plan meeting with the interdisciplinary team (IDT), resident, and resident representative.
- Reviewed the procedure for safe and effective discharge planning with the IDT.
- Re-educated the discharge planning IDT on the discharge policy and procedure to ensure sufficient preparation and orientation for a safe discharge.
- Implemented review of residents scheduled to be discharged to ensure appropriate discharge planning is in place.
- Implemented review of residents scheduled for discharge to ensure ADL support is in place, durable medical equipment is available prior to or on the discharge date, medications are available upon discharge, and identified needs/support are available.
- Implemented review of residents scheduled for discharge to ensure safe discharge planning is in place and to address any issues identified.
- Implemented oversight during utilization review by the NHA/designee to ensure discharge planning preparation and services are in place prior to discharge.
- Initiated audits and educational in-services to the IDT team and conducted staff interviews to confirm education received regarding discharge to the community and/or transfers to other facilities.
Failure to Provide Bowel Management, Timely Labs, and Ordered Treatments
Penalty
Summary
A resident with a history of diabetes, stroke with left-sided weakness, constipation, dementia, and a PEG feeding tube was admitted to the facility and was on a bowel protocol and prescribed daily laxatives. Despite this, the facility failed to initiate the bowel protocol after the resident went three days without a bowel movement, as required by facility policy. There was no documentation of additional bowel or laxative medication being ordered or administered after nine shifts without a bowel movement, and nursing notes lacked evidence of abdominal assessment or bowel sound documentation during this period. The resident ultimately required a fecal disimpaction procedure during a subsequent hospitalization, with hospital records confirming a large fecal stool burden and moderate fecal retention. In addition to the failure to manage the resident's bowel function, the facility did not obtain ordered blood work in a timely manner. Although STAT labs were ordered, there was no evidence that the facility had a plan to obtain the labs after initial attempts were unsuccessful, and the contracted laboratory was unable to obtain the samples. The facility also failed to provide a nebulizer treatment as ordered due to the unavailability of a nebulizer machine, resulting in missed doses of prescribed medication. Documentation showed that the facility did not have a plan to address the lack of equipment necessary to administer the ordered treatment. Furthermore, the facility failed to obtain peripheral intravenous access for the administration of ordered IV fluids and did not enter a supplemental oxygen order from the time oxygen was initiated during a respiratory crisis until the resident was transferred to the hospital. During this period, the resident's supplemental oxygen was titrated without a corresponding physician order in the medical record. The facility was also unable to provide evidence of required documentation and reports related to bowel management and clinical meetings, particularly over the weekend when the protocol should have been triggered.
Failure to Honor Resident's Shower Preference for Personal Hygiene
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including diabetes, stroke with left-sided weakness, dementia, and a PEG feeding tube, did not receive personal hygiene services in accordance with their stated preferences. The resident, who is nonverbal, had their spouse respond to the Minimum Data Set (MDS) assessment, indicating that it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. The resident's care plan specified a preference for showers on Sundays and Thursdays during the evening shift, with bed baths on other days unless otherwise specified. Despite this documented preference, review of the resident's care records for the entire month of November showed that the resident was only provided bed baths on all scheduled shower days. Documentation by multiple CNAs consistently indicated that the resident, who was totally dependent and required assistance from one or more staff, did not receive a shower at any point during the month. The findings were reviewed with facility leadership during the exit conference.
Failure to Document and Communicate Resident's Code Status Change
Penalty
Summary
A deficiency occurred when the facility failed to have a process for documenting and communicating a resident's code status decision to staff and providers. The resident, who had a history of dementia and a severe cognitive impairment as indicated by a low BIMS score, was admitted with an advanced directive specifying Do Not Resuscitate (DNR) status. Despite this, upon admission, facility staff had the resident complete a resuscitation policy form marking her as Full Code, and this was entered into the electronic medical record (EMR). The resident's daughter, who was the power of attorney (POA), later provided the advanced directive and completed a facility form indicating DNR, but this change was not effectively communicated to the providers responsible for the resident's care. Throughout the resident's stay, multiple provider notes and orders continued to list the resident as Full Code, even after the DNR documentation was uploaded into the EMR. There were at least twelve provider encounters, many with the daughter/POA present, where the code status could have been clarified, but the providers were not notified of the updated DNR status. The facility's process for handling code status orders was inconsistent, with responsibilities shifting between guest services, nursing, and social work, and there was no clear mechanism to ensure that changes in code status were communicated to all relevant staff and providers. The lack of communication and documentation led to confusion among staff and emergency medical services (EMS) regarding the resident's code status during a medical emergency. When EMS arrived, the nurse was unsure of the resident's code status and was unable to immediately provide the correct documentation. The resident was wearing a hospital DNR wristband, but the facility's records still indicated Full Code. This confusion persisted until EMS was eventually provided with the correct DNR documentation signed by the daughter. Interviews with staff and the resident's family confirmed that the facility did not have a reliable process to ensure that the resident's wishes regarding life-sustaining treatment were consistently documented and communicated.
Failure to Provide Adequate Hygiene and Grooming for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was dependent on staff for all activities of daily living due to multiple medical conditions including diabetes, stroke with left-sided weakness, dementia, a PEG feeding tube, and a suprapubic catheter, did not receive adequate grooming and oral hygiene care. Documentation in the resident's clinical record and Minimum Data Set (MDS) indicated complete dependence on staff for oral hygiene, bathing, and personal hygiene. Despite this, photographic evidence taken upon the resident's hospital admission showed poor hygiene, including crusty, dark debris around the suprapubic catheter, greasy hair, stained linens, cracked and flaking lips, a tongue with dry white patches, and teeth with plaque buildup. The resident's back was also observed to have hyperpigmented, scaly, and rough skin patches consistent with poor hygiene. Interviews with facility staff revealed confusion and lack of awareness regarding the availability and functionality of shower beds necessary for bedbound residents. Some staff stated that shower beds were unavailable, broken, or could not fit into the shower rooms due to structural barriers, while others noted drainage issues when using the available equipment. The nurse practitioner confirmed that the resident was not being properly cleaned, as the skin condition observed should have been removable with basic hygiene measures. These findings demonstrate that the facility failed to provide the necessary services to maintain the resident's grooming and oral hygiene.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Dover
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Center At Eden Hill, Llc | 1.7 mi | ★★★★★ | 3 | 0 |
| Complete Care At Silver Lake Llc | 2.5 mi | ★★★★★ | 13 | 0 |
| Cadia Rehabilitation Capitol | 2.9 mi | ★★★★★ | 6 | 1 |
| Westminster Village Health | 3 mi | ★★★★★ | 13 | 1 |
| Evergreen Post Acute | 8.6 mi | ★★★★★ | 5 | 0 |
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