Below 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 Barry Healthcare & Sr Living during CMS and state inspections, most recent first.
A resident with dementia, osteoarthritis, cognitive impairment, a history of falls, and wheelchair use was identified as high fall risk, yet the facility failed to implement and document new or progressive fall-prevention interventions after multiple unwitnessed falls. Staff found the resident on the floor on several occasions, including once entangled in an isolation bin with water spilled on the floor and wearing regular socks, and later on the floor by a dresser with drawers pulled out, an unlocked wheelchair in the corner, and again wearing regular socks. Post-fall care plan updates focused on ensuring or reminding use of non-skid footwear, without adding different or escalated interventions between events. The final fall resulted in a head hematoma and pain, with neuro changes noted, and ED evaluation confirmed two rib fractures. The DON and NP stated that facility policy requires new, progressive interventions after recurrent falls, which were not implemented in this case.
A newly admitted, largely nonverbal resident with Lupus and chronic pain arrived from another facility with prior PRN pain orders, but the admitting LPN did not complete an admission pain assessment, did not obtain nurse-to-nurse report, and did not administer PRN analgesia despite the resident yelling and grabbing at the groin. The baseline care plan and face sheet were incomplete and omitted chronic pain, and the night-shift LPN, who also did not review prior records or complete the admission assessment, treated the behavior as anxiety and gave PRN Ativan without documenting a comprehensive assessment. CNAs and surveyors reported the resident yelled or screamed most of the night and into the next day, with only one PRN Tylenol dose given the following morning and documented as ineffective, and no documented pain assessments each shift until later. These actions and omissions conflicted with facility policies and provider expectations that required admission pain assessment, review of prior records, appropriate use and reassessment of PRN pain medication, and timely provider notification when pain was not controlled.
The facility did not ensure that an RN was on duty for at least eight hours each day. Review of staffing schedules over several weeks showed multiple days without documented RN coverage for the required duration. The administrator acknowledged that there are occasionally days without RN coverage and reported that the facility has no specific RN staffing policy, instead stating they just follow regulations. At the time, 56 residents were living in the facility.
A deficiency occurred when the facility failed to track the causative organism for a UTI in a resident treated with Cipro. The October infection control log documented the UTI and antibiotic use but did not identify any organism, and the IP stated that no urine culture had been obtained, leaving the causative organism unknown. The administrator reported that she expects infectious organisms to be tracked, and the facility’s surveillance policy requires the IP to conduct ongoing surveillance for HAIs and other significant infections, but this was not followed in this case.
A resident with dementia and congestive heart failure was treated with Cipro for a presumed UTI without meeting UTI criteria and without obtaining a urine culture, despite the facility’s antibiotic stewardship policy requiring oversight of antibiotic use. The infection control log documented a UTI and Cipro administration but no causative organism, while the McGeer checklist indicated UTI criteria were not met. Physician orders and progress notes showed the resident received multiple doses of Cipro for a UTI, and the Infection Preventionist stated the antibiotic was started based on family request and physician order. The Administrator stated she would have expected a urine culture before starting an antibiotic for a UTI.
A long-term care facility failed to administer medications per physician orders for four residents, resulting in significant delays. Residents with complex medical conditions, including diabetes and hypertension, received medications hours past scheduled times. Staff attributed delays to heavy medication rounds and emergencies but did not notify physicians. The facility's policy required medications to be administered within one hour of the prescribed time, which was not followed.
Failure to Implement New Fall Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and document new fall-prevention interventions after falls for a resident who was assessed as high fall risk upon admission. The resident had dementia, osteoarthritis, cognitive impairment, a history of falls, and used a wheelchair. The care plan, initiated and revised over time, identified the resident as high risk for falls with goals that the resident would be free of falls and not sustain serious injury. A fall risk assessment documented the resident as high risk. Despite this, the resident experienced multiple falls, and the interventions added to the care plan did not represent new or progressive measures between falls as required by facility policy. On one occasion, a progress note documented that staff responded to yelling and found the resident lying on the floor in her room, with her feet facing the door and entangled in the bottom of an isolation bin, her wheelchair unlocked next to her legs, and water spilled on the floor from a basin near her head. The resident was wearing regular socks without shoes, and the call light was on the bed and not in use. The resident reported she was trying to get in her car and thought she may have fallen. She complained of bilateral lower extremity pain, and neuro checks were initiated. Following this fall, the care plan intervention documented was to ensure non-skid socks were on the resident. Subsequently, the resident had another unwitnessed fall, resulting in a new skin tear on the left elbow. The care plan intervention documented after this fall was to remind the resident to wear non-skid footwear and remind staff to make sure she had them on when needed. Later, the resident sustained another unwitnessed fall, where staff found her sitting on the floor in front of her dresser with two bottom drawers on the floor, her wheelchair unlocked in the corner, her walker next to the bed, and wearing regular socks and a brief. She had a skin tear to the left hand, a hematoma to the left side of the forehead, and complained of head and bilateral knee/hip pain. Neuro checks showed eyes slow to react and slurred speech. She was transferred to the ED, where imaging revealed two rib fractures. Interviews with the DON and NP confirmed that post-fall interventions are expected to be new, progressive, and documented on the care plan, and the facility’s fall policy requires additional or different interventions when falls recur, which did not occur in this case.
Failure to Assess and Manage Pain for Newly Admitted Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to assess and manage pain for a newly admitted, largely nonverbal resident with known pain-related diagnoses. The resident was admitted from another nursing home with documented diagnoses including chronic pain and Lupus, and with PRN pain medication orders at the prior facility. On admission, the facility’s baseline care plan was handwritten, unsigned, and did not document the resident’s yelling/screaming, cognition, or communication status. The face sheet omitted the chronic pain diagnosis. Shortly after arrival, an LPN documented that the resident was yelling out, very restless, and grabbing at the groin area, but did not complete or document a pain assessment. The admitting nurse did not obtain nurse-to-nurse report from the sending facility, despite multiple attempts, and did not escalate the lack of report to the DON at the time of admission. From the time of admission through the following day, the resident was repeatedly observed and reported by staff and surveyors to be yelling or screaming continuously without a timely, comprehensive pain assessment or appropriate use of PRN pain medication. On the evening of admission, the night-shift LPN heard the resident yelling upon arrival, was told by the day-shift LPN that the resident had been yelling since admission and that the admission assessment and baseline care plan were incomplete, but did not complete the admission nursing assessment or a nonverbal pain assessment. Instead of reviewing the prior records or diagnoses, the night-shift LPN assumed the behavior was anxiety-related and administered PRN Ativan, documenting it as effective without documenting any assessment. CNAs reported that the resident yelled most of the night, sleeping only about an hour, and that they were told by nursing staff that “that’s just what she does,” despite the resident being new and nonverbal. The following morning, surveyors directly observed the resident yelling continuously in bed and later during transfer and at lunch. The MAR showed no PRN Tylenol given on the day of admission and only one PRN Tylenol dose given the next morning, which was documented as ineffective. There was no documented admission pain assessment or pain assessment every shift until a pain assessment order was entered the day after admission. A later pain evaluation documented that the resident was rarely or never understood, exhibited nonverbal sounds such as crying or moaning, and had pain indicators 1–2 days, with no scheduled pain regimen in place and only PRN Tylenol and positioning used. The DON and the nurse practitioner both stated that they expected an admission pain assessment within hours of admission, review of prior records for pain diagnoses, administration and reassessment of PRN pain medication, and timely notification of the provider when pain was not controlled. The facility’s own policies required pain assessment at admission and ongoing, and required the admitting nurse to conduct a pain assessment as part of the admission assessment, but these processes were not carried out for this resident, resulting in prolonged yelling/screaming without appropriate pain assessment or management. The facility also failed to obtain and document nurse-to-nurse report from the sending facility at or before admission, despite multiple attempts, and staff did not notify the DON when they were unable to obtain this baseline information. As a result, staff did not know whether the resident’s yelling and restlessness represented her baseline or a change in condition. The DON stated that it is standard practice and expectation to obtain report from the prior facility to understand the resident’s baseline and that staff should have reported the inability to obtain this information. The combination of incomplete admission assessment, lack of timely pain assessment, failure to administer PRN pain medication initially, reliance on an anxiolytic instead of analgesia without adequate assessment, and failure to secure prior-facility report led to the resident yelling/screaming for many hours without appropriate pain management, as documented by staff interviews, progress notes, MAR review, and surveyor observations.
Failure to Ensure Daily RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight hours daily as required. Review of the facility’s daily staffing schedules from 12/1/25 through 1/15/26 showed that there was no documentation of an RN working at least eight hours on 12/6/25, 12/7/25, 12/14/25, 12/20/25, 12/21/25, 12/28/25, 1/3/26, 1/4/26, 1/11/26, or 1/14/26. During an interview on 1/13/25 at 10:00 AM, the Administrator stated there are occasionally days without RN coverage in the building. On 1/15/26 at 10:04 AM, the Administrator further stated the facility does not have a policy regarding RN staffing and instead just follows the regulations. The facility’s CMS-671 form dated 1/13/26 documented that 56 residents were living in the facility at the time these staffing practices occurred. The deficiency centers on the lack of consistent RN coverage for at least eight hours each day, as evidenced by staffing records and confirmed by the Administrator’s statements, in a facility housing 56 residents.
Failure to Track Causative Organism for Resident UTI in Infection Control Log
Penalty
Summary
The deficiency involves the facility’s failure to track infectious organisms as part of its infection prevention and control program for one resident with a urinary tract infection (UTI). The facility’s Infection Control Log for October 2025 shows that the resident was treated with the antibiotic Cipro for a UTI but does not list a causative organism. The Infection Preventionist reported that the resident’s urine was not cultured, so the facility does not know which organism caused the UTI. The Administrator stated that she expects the facility to track infectious organisms in the facility. The facility’s written policy on Surveillance for Infections, revised April 2025, states that the infection preventionist conducts ongoing surveillance for healthcare-associated infections and other epidemiologically significant infections that may require transmission-based precautions and other preventive interventions. These findings show that, despite having a policy requiring ongoing surveillance of infections and organisms, the facility did not obtain or document culture results for the resident’s UTI and therefore did not track the causative organism in its infection control log.
Failure to Follow Antibiotic Stewardship Policy for UTI Treatment
Penalty
Summary
The facility failed to follow its antibiotic stewardship policy when managing antibiotic use for one resident with dementia and congestive heart failure who was admitted with a diagnosis that later included a urinary tract infection (UTI). The infection control log for October 2025 documented that the resident had a UTI and received the antibiotic Cipro, but did not list a causative organism. The Infection Preventionist reported that no urine culture was obtained because the family requested an antibiotic and the physician ordered it. The resident’s Revised McGeer Criteria for Infection Surveillance Checklist dated 10/24/25 documented that UTI criteria were not met, yet a physician order dated the same day directed Cipro 250 mg orally twice daily for 7 days for a UTI. The Medication Administration Record showed the resident received 13 doses of Cipro, and progress notes from 10/24/25 through 10/30/25 documented that the resident was receiving antibiotics for a UTI. The facility’s antibiotic stewardship policy stated that antibiotics would be prescribed and administered under the guidance of the antibiotic stewardship program to monitor antibiotic use, and the Administrator stated she would expect urine cultures to be obtained prior to starting an antibiotic for a UTI. These findings show that the facility did not obtain a urine culture or confirm UTI criteria before initiating and continuing antibiotic therapy, and did not adhere to its own antibiotic stewardship policy in monitoring and guiding antibiotic use for this resident.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician orders for four residents, leading to significant delays in medication administration. For Resident 1, medications were consistently administered two hours or more past the scheduled times, with instances of medications being given up to four hours late. The resident expressed dissatisfaction with the delays, which were attributed to the resident's personal activities and emergencies that arose during medication rounds. Despite the resident's complaints, the staff did not notify the physician about the delays. Resident 2 also experienced delays in medication administration, with medications being given several hours after the scheduled times. The resident's medications included those for serious conditions such as diabetes and hypertension. The staff did not contact the physician regarding these delays, and the resident's cognitive status was noted as intact, indicating awareness of the medication schedule. Residents 3 and 5 faced similar issues, with medications administered hours before or after the scheduled times. These residents had complex medical conditions requiring timely medication administration, including diabetes, hypertension, and chronic obstructive pulmonary disease. The staff cited heavy medication rounds and emergencies as reasons for the delays, but no communication with the physician or nurse practitioner was documented. The facility's policy required medications to be administered within one hour of the prescribed time, which was not adhered to in these cases.
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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 Barry
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pittsfield Manor | 13.2 mi | ★★★★★ | 0 | 0 |
| Eastside Health And Rehabilitation Center | 14.3 mi | ★★★★★ | 0 | 0 |
| Avenir At Maple Grove | 17.3 mi | ★★★★★ | 2 | 0 |
| Beth Haven Nursing Home | 18.7 mi | ★★★★★ | 0 | 0 |
| Beloved Health And Rehabilitation Center | 19.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.