Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Bayside Healthcare Center during CMS and state inspections, most recent first.
The facility failed to implement EBP for a resident with a midline catheter receiving IV antibiotics, failed to clean shared glucometers per manufacturer guidance, and failed to ensure proper hand hygiene during wound care for a resident with a stage III heel pressure ulcer. Staff used gloves only during midline catheter care, cleaned shared glucometers with alcohol prep pads, and a wound care nurse cleaned a wound and applied ointment and a dressing without hand hygiene or changing gloves between steps.
The facility failed to maintain an environment free from flies for multiple residents. Surveyors observed flies in resident rooms, hallways, the dining area, and the kitchen, including flies on residents, clothing, food items, and supplies. Residents and staff reported ongoing fly problems, and the pest control records showed only general pest and rodent services with no documented fly treatment or extermination request.
Improper Labeling of Enteral Feeding Supplies: A resident with dysphagia and a gastrostomy tube had enteral feeding and free water flush orders, but observations showed the feeding bag, free water flush bag, and syringe were not properly labeled. The DON stated the items should have been labeled with the resident’s name, date, and change information, and the Administrator acknowledged they were not labeled according to professional standards of practice.
Failure to assess a resident’s smoking status left the resident off the smoking list and without a documented safe/unsafe smoker evaluation. The resident had nicotine dependence, was documented as a smoker who liked to sit outside to smoke and socialize, and the MDSC, ADON, and Administrator confirmed no smoking assessment was completed on admission or quarterly as required.
A resident's privacy was compromised during catheter care when a wound care nurse left the door and bedside curtain open, exposing the resident to the hallway. The nurse acknowledged the oversight, and the Director of Nursing confirmed that privacy should have been maintained.
The facility failed to report incidents of resident-to-resident verbal and physical abuse to the State Survey Agency. One incident involved a resident throwing coffee at another during a verbal altercation, and another involved a resident in a verbal and physical altercation. These incidents were not reported as they were categorized as behavioral issues rather than abuse.
A facility failed to investigate incidents of resident-to-resident abuse, including one where a resident threw coffee on another and another involving a verbal and physical altercation. Despite documentation and discussions, no follow-up or investigation was conducted, and staff did not recognize these as abuse incidents.
The facility failed to maintain an effective infection control program, as it did not include infection-causing organisms in its surveillance. Additionally, a CNA used unsanitary gloves for catheter care, and an LPN performed wound care with unsecured hair touching her gloves, both of which are improper practices.
The facility did not maintain a system for feedback reports on antibiotic usage and resistance patterns. A review showed no documentation, and the DON/Infection Preventionist confirmed the lack of evidence regarding antibiotic practices.
A facility failed to conduct a required PASARR Level II evaluation for a resident diagnosed with Major Depressive Disorder and Delusional Disorder. The resident was admitted with a Level I PASARR, but no Level II evaluation was documented. The social worker confirmed the oversight and verified with the Office of Aging and Adult Services that the evaluation was necessary.
A facility failed to complete a Level II PASARR for a resident diagnosed with Major Depressive Disorder and PTSD. Despite these diagnoses being documented in the resident's medical records and quarterly MDS, the Level 1 PASARR assessment did not reflect any mental illness. No referral was made for a Level II PASARR evaluation, as confirmed by the social worker.
The facility failed to ensure CNAs performed proper hand hygiene during incontinence care for two residents. Observations showed that after providing care, one CNA did not perform hand hygiene after removing gloves and touched various items, while another CNA did not remove gloves before accessing a cabinet and failed to perform hand hygiene before handling barrier cream. Interviews confirmed these lapses, and the DON acknowledged the failure to follow the facility's hand hygiene policy.
Infection Control Failures During IV Care, Glucometer Cleaning, and Wound Care
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident with a left basilica midline catheter who was receiving IV ertapenem for a urinary tract infection. The resident was cognitively intact, and observation showed no EBP signage on the room door, no PPE available at the room entrance, and an empty ertapenem bag hanging from an IV pole beside the bed. When an LPN entered the room and disconnected and flushed the midline catheter, he used gloves only and stated he had not been informed that the resident required EBP because of the midline catheter. The DON and Administrator stated that EBP was not required for midline catheters. The facility also failed to clean shared glucometers according to the manufacturer’s instructions. The facility’s blood glucose meters were used for multiple residents, and the [NAME] Quintet AC glucometers were observed being cleaned with an alcohol prep pad. The facility’s policy required shared meters to be cleaned and disinfected after each use, and the manufacturer’s guide specified caviwipes disinfecting towelettes. Staff interviews confirmed that the glucometers were cleaned with alcohol prep pads, and the alcohol prep pad observed was saturated with 70% isopropyl alcohol. In addition, during wound care for a resident with a left heel stage III pressure ulcer, the wound care nurse cleaned the wound, applied ointment, and then placed a clean dressing without performing hand hygiene or changing gloves between steps. The nurse confirmed the failure to perform hand hygiene and change gloves after cleaning the wound and before applying the ointment and dressing. The DON also stated that hand hygiene and glove change should have occurred after cleaning the pressure ulcer and before applying the clean dressing.
Failure to Control Flies in Resident Areas and Kitchen
Penalty
Summary
The facility failed to maintain an environment free from flies for 12 of 13 sampled residents reviewed for environment. The facility’s Pest Control Program policy stated it was to maintain an effective pest control program to eradicate and contain common household pests and rodents, and to use indoor and outdoor methods as appropriate for seasonal pests and flies. However, the Work Order Report documented flies in resident rooms on multiple dates, and the contracted pest control invoice showed only general pest and rodent control services with no documented indoor or outdoor treatment for flies. The pest control company’s office manager stated the facility did not request extermination services for flies and that the company did not provide fly extermination services. Survey observations and resident interviews documented flies in resident rooms, common areas, and the kitchen. A fly was observed in a resident’s room during wound care for a stage III pressure ulcer, flies were seen in another resident’s room and on a personal refrigerator, and two flies were observed in a wheelchair resident’s room. A resident reported having gnats and flies in her room, another resident stated flies were terrible and that she had complained multiple times without the facility placing fly baits or spraying her room, and a CNA reported swatting flies from a resident’s face during care. Additional observations found flies on a resident’s clothing protector in the dining room, on a resident’s shirt, in another resident’s room, and on Hall A near resident rooms. In the kitchen, flies were observed crawling on covered biscuits, jelly packets, and disposable lids, and the Dietary Manager confirmed flies were present and stated they entered when supplies were delivered.
Improper Labeling of Enteral Feeding Supplies
Penalty
Summary
The facility failed to ensure that an enteral feeding bag, a free water flush bag, and an enteral feeding syringe were properly labeled according to professional standards of practice for Resident #4. Resident #4 had diagnoses including dysphagia following a cerebral infarction and an encounter for attention to a gastrostomy tube, and the quarterly MDS indicated the resident received fluid and calories through enteral feeding. Physician orders included Isosource 1.5 calorie enteral feeding at 55 ml/hour every shift and free water flush at 40 ml/hour every shift. Observations on 09/15/2025 and 09/16/2025 showed the enteral feeding syringe was not labeled with the resident’s name and date, the enteral feeding bag was not labeled with the time the feeding was initiated or the rate of administration, and the free water flush bag was not labeled with the time the flush was initiated or the rate of administration. During interviews, the DON stated the enteral feeding bag, syringe, and free water flush bag should have been labeled properly with the resident’s name, date, and when changed, and the Administrator acknowledged the items were not labeled according to professional standards of practice.
Failure to Assess Smoking Status and Supervision Needs
Penalty
Summary
The facility failed to assess Resident #38’s smoking status to determine whether the resident needed supervision or assistance while smoking. Facility policy required all smoking residents to be evaluated using the Safe Smoking/Tobacco Use Assessment upon admission, quarterly, and with any significant change in the resident’s ability to handle smoking products, but Resident #38 was not identified on the facility’s smoking program list as either a safe or unsafe smoker. The resident was admitted on 05/15/2025 and had a diagnosis of nicotine dependence, unspecified, uncomplicated, with a start date of 05/14/2025. The resident’s care plan did not address smoking, and the electronic record did not contain documented evidence that a smoking assessment was completed upon admission or quarterly. Staff documentation noted that Resident #38 liked to sit outside on the patio to smoke and socialize, and another progress note identified the resident as a smoker. During interviews, the MDS Coordinator, Assistant DON, and Administrator each confirmed that the resident should have had a smoking assessment completed upon admission and quarterly, and that no such assessment had been completed as required.
Privacy Breach During Catheter Care
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident during medical care. Resident #32, who had a suprapubic catheter, was observed receiving catheter care from a wound care nurse (S5WCN) with the door and bedside curtain open, exposing the resident to the hallway. This lack of privacy was confirmed during an interview with S5WCN, who acknowledged that the door and curtain should have been closed to maintain the resident's privacy. The Director of Nursing/Infection Preventionist also confirmed that privacy should have been maintained during the procedure.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an alleged incident of resident-to-resident verbal and physical abuse to the State Survey Agency, as required by their policy. The incident involved two residents, one of whom threw coffee at the other during a verbal altercation in the dining room. Despite the facility's policy mandating immediate reporting of such incidents, the Director of Nursing and the Administrator determined that the incident was merely a verbal disagreement and did not report it. Additionally, another incident involving the same resident, who was involved in a verbal and physical altercation with an unidentified resident, was also not reported. The facility's policy requires all incidents of alleged abuse to be reported to the Administrator, Director of Nursing, and respective Department Head, and then to the Health Standard within two hours. However, the incidents on two separate occasions were not reported because they were categorized as behavioral issues rather than abuse. The Director of Nursing and the Administrator confirmed that these incidents were not reported to the State Survey Agency, as they did not involve staff and were not considered abuse under their definitions.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of resident-to-resident verbal and/or physical abuse involving two residents. The facility's policy mandates a timely and thorough investigation of all reports and allegations of abuse, but this was not adhered to in the incidents involving these residents. The first incident occurred when one resident threw coffee on another resident during a verbal interaction in the dining room. Despite the incident being documented in the care plans and discussed in a daily quality assurance meeting, no further follow-up or investigation was initiated. In another incident, a resident was involved in a verbal and physical altercation with an unidentified resident. The resident was observed yelling racial slurs and cursing, and subsequently fell while attempting to hit the other resident. The unidentified resident then began to hit the resident who had fallen. Although supervisors were notified of the alleged abuse, the incident was not investigated as an allegation of abuse, and the facility did not provide any documentation of an investigation. Interviews with facility staff, including the Director of Nursing/Infection Preventionist and the Administrator, revealed a lack of recognition of these incidents as potential abuse. The staff considered these incidents as mere altercations between residents and did not meet the definition of abuse since they did not involve staff. Consequently, no written statements or interviews with staff were conducted, and the facility failed to provide any documentation of an investigation as required by their policy.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies. Firstly, the facility did not include the infection-causing organism in their infection control surveillance for several months, from June to September 2024. This was confirmed by the Director of Nursing/Infection Preventionist, who acknowledged that while the organism information was available in residents' charts, it was not part of the facility's infection surveillance. This omission could hinder the facility's ability to track and manage infections effectively. Additionally, there were specific instances of improper infection control practices observed. A Certified Nursing Assistant used gloves stored in her pocket for catheter care on a resident, which is not a sanitary practice. The CNA admitted to this action, and the Director of Nursing/Infection Preventionist did not recognize it as a problem. Furthermore, a Licensed Practical Nurse performed wound care on another resident while her long hair, which was not contained, touched her gloves. The LPN acknowledged that her hair should have been secured before performing the procedure. These actions demonstrate a lack of adherence to proper infection control protocols.
Lack of Antibiotic Monitoring System
Penalty
Summary
The facility failed to maintain a system for providing feedback reports on antibiotic usage, antibiotic resistance patterns based on laboratory data, and antibiotic prescribing practices for practitioners. A review of the facility's Infection Control documentation revealed no documented evidence of such a system. During an interview, the Director of Nursing/Infection Preventionist confirmed the absence of documented evidence regarding antibiotic usage or resistance patterns in the facility.
Failure to Conduct Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a resident with newly identified mental health diagnoses was referred for a Pre-admission Screening and Resident Review (PASARR) Level II evaluation as required. Resident #60 was admitted with a Level I PASARR and later diagnosed with Major Depressive Disorder (MDD) and Delusional Disorder. Despite these diagnoses, there was no documented evidence of a Level II PASARR being completed for the resident. Interviews revealed that the social worker had never completed a Level II PASARR evaluation and confirmed that no evaluation was conducted for Resident #60 following the diagnoses, as required. The social worker later confirmed with the Office of Aging and Adult Services that a Level II PASARR was indeed necessary for the resident due to the mental health diagnoses.
Failure to Complete Level II PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure a Level II Pre-Admission Screening and Resident Review (PASARR) was completed for a resident diagnosed with mental illness. Resident #9, who was admitted with diagnoses of Major Depressive Disorder (MDD) and Post Traumatic Stress Disorder (PTSD), did not have a Level II PASARR assessment reflecting these mental health diagnoses. The resident's medical records and a quarterly Minimum Data Set (MDS) confirmed these diagnoses, yet the Level 1 PASARR assessment completed earlier did not document any mental illness. Furthermore, there was no evidence of a referral to the appropriate state-designated authority for a Level II PASARR evaluation, as required. This oversight was confirmed by the facility's social worker during an interview.
Failure in Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by Certified Nursing Assistants (CNAs) during incontinence care for two residents. The facility's policy on hand hygiene, revised on 08/30/2023, mandates that staff perform hand hygiene before and after direct contact with residents, after contact with body fluids, and after removing gloves. However, observations revealed that S3CNA did not perform hand hygiene after removing gloves following incontinence care for a resident, and subsequently touched various items such as a fall mat, door handle, and call bell. Similarly, S4CNA did not remove gloves after cleaning a resident's vaginal area and opened the resident's cabinet without performing hand hygiene. After removing gloves, S4CNA also failed to perform hand hygiene before reaching into her pocket for barrier cream. Interviews with the CNAs confirmed these lapses in hand hygiene, and the Director of Nursing acknowledged that the CNAs should have adhered to the facility's hand hygiene policy.
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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 Gretna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Wood At Woldenberg Village | 3.6 mi | ★★★★★ | 0 | 0 |
| Our Lady Of Wisdom Community Care Center | 3.7 mi | ★★★★★ | 0 | 0 |
| St Luke's Living Center | 4 mi | — | 0 | 0 |
| Wynhoven Community Care Center | 4.3 mi | ★★★★★ | 2 | 0 |
| Marrero Healthcare Center | 4.6 mi | ★★★★★ | 3 | 0 |
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