Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Manor Llc during CMS and state inspections, most recent first.
Expired OTC and house stock medications were left piled in a medication room instead of being destroyed, despite prior pharmacy audits identifying multiple expired items. In addition, a discontinued lorazepam blister pack for a resident remained in a double-locked med cart and was co-mingled with other residents’ in-use meds. The DON stated there was no routine process for nursing staff to review and destroy expired or discontinued meds.
Improper glove use and hand hygiene during meal service: A cook repeatedly handled food, menu slips, the refrigerator door, and items in the dining room with the same gloves while serving meals, including cutting chicken nuggets by hand and returning to the steam table without glove changes or hand hygiene. The cook stated this was her normal routine, and the CDM said he was unaware of the practice and agreed gloves and hand hygiene should have been changed after leaving the serving area or touching potentially contaminated items.
Incomplete staff infection surveillance was cited because the facility did not maintain a current, ongoing system to track employee illnesses across all staff. The shared Staff Illnesses log captured only part of the workforce and lacked key details such as symptom onset, last date worked, work location, symptom resolution, and return-to-work criteria. Interviews showed inconsistent reporting and follow-up among the DM, LPN, administrator, and IP, while the facility policy and employee handbook did not provide clear return-to-work standards.
Failure to Protect a Vulnerable Resident from Verbal Abuse: An NA raised her voice at a resident during hands-on care after the resident reached toward another NA. The resident had impaired cognition, dysarthria after a stroke, and required extensive ADL assistance with two staff for transfers. The DON did not treat the event as abuse at first, the involved NA continued working the rest of the shift, and the SA report was filed later than policy required.
PRN lorazepam orders for two residents lacked required end dates and documented reassessment for continued use. One resident on hospice with CKD, HF, DM, depression, and no behaviors had lorazepam PRN entered from hospice standing orders without an end date. Another resident on hospice with Parkinson’s disease, dementia with behaviors, anxiety, and depression had scheduled and PRN lorazepam orders for restlessness/anxiousness with no end date or 14-day review identified in the care plan.
Failure to immediately suspend staff after alleged abuse: A nursing assistant was reported for smacking a resident’s hand away and raising her voice during care. The resident had impaired cognition, dysarthria after a stroke, and required extensive ADL assistance with 2-person mechanical lift transfers. The DON delayed notifying the administrator, the staff member continued working and providing resident care for the rest of the shift, and the SA report was filed well after the policy-required timeframe.
The facility failed to timely report an alleged abuse incident involving a resident with impaired cognition, dysarthria after a stroke, and extensive ADL needs. NA-C smacked the resident's hand away and raised her voice while assisting with care, but the DON did not notify the administrator immediately and the SA report was not filed within 2 hours. NA-C continued working the rest of her shift before being suspended, and the investigation later substantiated verbal abuse.
A resident with severe cognitive impairment and total dependence on staff was repeatedly inappropriately touched by a visiting assisted living resident in a common area. Staff observed suspicious behavior and the resident's skirt being moved but did not intervene or remove either individual from the situation, allowing the abuse to continue for an extended period. The incident was not promptly reported to facility leadership, and staff interviews revealed uncertainty about how to handle suspected abuse.
A resident with a history of cognitive impairment and complex medical needs was transferred to the ED without their most current POLST form, which specified DNR status, comfort-focused care, and no antibiotics. Facility staff interviews confirmed that the POLST was not printed or sent with the resident, resulting in the hospital relying on outdated information and requiring additional clarification from the family to determine the resident's true wishes.
The facility failed to ensure proper infection control during meal services, with dietary staff not performing hand hygiene and improperly handling cups. Additionally, the dishwasher's chemical sanitization solution was not adequately monitored, with levels consistently below required standards, risking contamination.
The facility failed to implement a process for antibiotic review, affecting four residents and potentially all 34 residents. Residents were treated with antibiotics for various infections, but the facility did not document outcomes to assess treatment efficacy. The infection preventionist and DON acknowledged the lack of documentation, and the consulting pharmacist highlighted the importance of addressing culture results. The facility's antibiotic stewardship policy was not followed, leading to the deficiency.
A resident's personal recliner was removed from his room without his consent, violating his rights and choices. The resident, who needed the recliner for comfort and medical reasons, was left to sleep in his wheelchair. Interviews revealed that the recliner was taken due to odor concerns, but no permission was sought, and there was uncertainty about its cleaning and return. A policy on resident rights was requested but not provided.
A resident receiving hospice care for end-stage kidney disease was not accurately documented in the MDS assessment. The MDS failed to indicate hospice services, despite the resident's face sheet and hospice plan of care confirming hospice enrollment. The RN and DON acknowledged the error, and the facility administrator noted adherence to the RAI Manual without a specific MDS policy.
A resident with edema did not have their legs elevated as per physician orders after their recliner was removed for cleaning. The resident, who had heart and kidney failure, was left to sleep in a wheelchair without leg elevation. Staff interviews revealed a lack of awareness and follow-through on the resident's care plan, and the facility did not provide a policy on edema when requested.
A resident with severe cognitive impairment and a history of falls experienced multiple falls due to the facility's failure to conduct a comprehensive reassessment and implement new interventions. Despite discussions in risk management meetings, interventions such as leaving the resident's walker at the bedside were not added to the care plan, leading to further incidents.
The facility failed to follow catheter care protocols for a resident with an indwelling catheter, missing several scheduled flushes, leading to catheter clogging and leakage. Additionally, the facility did not address urinalysis results for two residents with UTIs, failing to review and act on urine culture results in a timely manner. The breakdown in process was confirmed by the consulting pharmacist and the director of nursing.
A resident with diabetes and moderate cognitive impairment did not receive a physician-ordered A1C test following a consultant pharmacist's recommendation. The order was not addressed by nursing staff due to a lapse in communication and documentation procedures, as confirmed by an LPN and the DON.
A facility failed to ensure proper PPE use and wound care protocols for a resident on enhanced barrier precautions. Staff did not wear gloves and gowns during high-contact activities, such as transfers and wound care, despite facility policies requiring such measures. Observations showed improper glove use and lack of hand hygiene during wound care, confirmed by staff interviews.
Expired Medications Left Undestroyed and Discontinued Lorazepam Remained in Cart
Penalty
Summary
The facility failed to destroy expired over-the-counter and house stock medications that had been identified for disposal and were left stored in a medication room across from the dining room. During observation, the medications were found in bottles and blister packs placed in multiple plastic bags and piled on the counter in the medication room. RN-B stated the local pharmacy consultant had previously audited the medication carts and medication room and found expired medications that were placed there to be destroyed, but the medications remained in the room and had not been destroyed. The December 2025 destruction/return log listed multiple expired items, including loratadine, aspirin, Prostat liquid supplement, vitamin B6, docusate, ibuprofen, apple cider vinegar tablets, glucosamine/chondroitin, guaifenesin, zinc, cetirizine, and magnesium oxide, along with a continuous non-controlled drug destruction inventory sheet listing magnesium oxide and melatonin awaiting destruction. The facility also failed to immediately remove a discontinued controlled medication for R10 from the medication cart. During a controlled narcotic count on the Oak wing cart, RN-B found one blister pack of lorazepam for R10 in the cart. The pharmacy label showed lorazepam 0.5 mg with an expiration date of 6/27/25, and the Controlled Drug Receipt/Record/Disposition form showed it had been received on 6/28/24. RN-B acknowledged the medication had been discontinued and remained in the double-locked medication cart until it was to be destroyed. Review of the MAR showed R10 had received lorazepam 0.5 mg as needed for anxiety before dental, vision, or doctor appointments, and the order had later been discontinued on 5/07/25. The lorazepam remained co-mingled with in-use medications for other residents after discontinuation. The pharmacy consultant confirmed during interview that quarterly medication audits included review of medication carts, medication rooms, and medication administration observations, and her audit identified expired lorazepam, melatonin, loratadine, aspirin, vitamin B6, stool softeners, and magnesium oxide. The DON stated the facility did not have a process for licensed nursing staff, including nurse managers, to routinely review and destroy expired or discontinued medications, and that day shift nurses were expected to complete medication destruction when available.
Improper glove use and hand hygiene during meal service
Penalty
Summary
The facility failed to ensure staff followed sanitary guidelines for food handling during the noon meal service. During observation, Cook-A wore the same gloves throughout meal service while handling multiple tasks, including touching menu slips, opening the refrigerator door, retrieving an unwrapped sandwich, handling a tray of pears, and serving food from the steam table. She repeatedly used her gloved hands to hold chicken nuggets while cutting them into bite-sized pieces, picked up breadsticks and other items with the same gloves, and continued serving without changing gloves or performing hand hygiene after touching other items or leaving the steam table area. Cook-A also left the kitchen to deliver items to residents in the dining room and then returned to resume serving without glove change or hand hygiene. She reported this was her normal routine and stated she usually washed her hands before meal service and then used the same pair of gloves throughout serving. The certified dietary manager stated he was not aware she was not changing gloves or performing hand hygiene after touching potentially contaminated items such as the refrigerator door, and agreed she should have changed gloves and performed hand hygiene before returning to serve food after leaving the steam table area. The policy reviewed stated gloves were to be worn when handling food directly and changed between tasks, and that food service staff were to follow hand hygiene and infection control practices to prevent potential food borne illness.
Incomplete Staff Infection Surveillance
Penalty
Summary
Provide and implement an infection prevention and control program was cited because the facility did not have a current, ongoing system of surveillance for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases that included facility staff. The deficiency was identified as affecting all 29 residents. Review of the facility’s current staff listing showed 57 staff members, but the employee surveillance data sheet used as the infection control tracker captured only 22 current staff and 1 former employee. The Staff Illnesses log contained limited information and did not include all staff. It listed absences for some employees, including an activity aide who was COVID positive and absent from work, a nursing assistant with body aches, a nursing assistant with nausea/vomiting, and a nursing assistant with diarrhea. However, the log did not capture critical information such as date of symptom onset, last date worked, location or unit last worked, when symptoms resolved, the date the employee was allowed to return to work, or what standards would be used to determine return-to-work appropriateness. Interviews showed inconsistent handling of staff illness reports. The dietary manager stated he completed a form for employee illnesses and gave it to an unidentified office person. An LPN stated staff illness calls were reported to the scheduler so shifts could be covered, and he knew general return-to-work timing for fever, nausea, vomiting, or diarrhea, but was unaware of any management guidance for advising employees when they could return. The administrator was not aware of the staff illness form being used for surveillance and expected department supervisors and the IP to use it, while the IP stated she reviewed it about once a week and did not monitor call-ins from other departments as much as she should. The facility policy described surveillance for employee infections and use of standard criteria, but the employee handbook only stated that staff out sick or on extended leave must communicate with their manager about an anticipated return-to-work date and time.
Failure to Protect a Vulnerable Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure one resident was free from verbal abuse when an NA raised her voice at the resident during care. The incident occurred while NA-C, NA-D, and NA-E were assisting the resident with turning and personal care. During the interaction, the resident reached toward NA-E and placed his hand on her breast. NA-E responded by telling the resident the behavior was inappropriate and moved his hand away. NA-C then smacked the resident’s hand away and raised her voice at him. NA-D reported the incident to the charge nurse, who notified the DON. The resident involved had moderately impaired cognition on the 12/8/25 Significant Change MDS assessment and required extensive assistance with ADLs, including two staff for transfers with a mechanical lift. He used a Broda-type wheelchair and was transported by staff. His diagnoses included dysarthria following a stroke, cognitive communicative deficit, and mild cognitive impairment. His care plan identified altered communication related to cognitive communication deficit and cerebral infarction, and he was identified as a vulnerable adult at risk for abuse due to decreased cognition and physical abilities. The DON was notified by phone but did not treat the event as potential or actual abuse at that time and instructed staff to obtain written statements for review the next morning. The involved NA continued working and providing resident care for the remainder of the shift, and the administrator was not notified until the following morning. The facility later confirmed the incident involved verbal abuse, and the investigation found no additional allegations of mistreatment by the NA. The facility also confirmed the report to the SA was filed 16 hours after the incident was reported, despite policy requiring immediate notification and reporting within 2 hours, and that staff suspected of abuse were to be suspended immediately.
PRN Lorazepam Orders Lacked Required End Dates and Reassessment
Penalty
Summary
The facility failed to ensure that as-needed psychoactive medication lorazepam was not used beyond 14 days without a documented rationale for continued use and an identified review date for 2 of 5 sampled residents, R2 and R11. The report states that the facility policy limited psychotropic PRN orders to 14 days unless the provider documented a rationale to extend use and identified a review date, and that this applied even to hospice orders. The consulting pharmacist also stated she would expect all psychoactive PRN medications to have an end date identified. R2’s records showed moderately impaired cognition, no behaviors, partial assistance with care, and hospice enrollment for chronic kidney disease with heart failure, kidney cancer, end-stage heart failure, edema, diabetes, major depressive disorder, and a history of alcohol abuse in remission. Hospice standing orders included lorazepam 0.5 mg every 4 hours PRN for anxiety, with the option to increase to 1 mg if ineffective, and the November 2025 MAR listed lorazepam PRN for anxiety/nausea/vomiting/insomnia with a start date of 11/11/25 and no end date. The consultant nurse confirmed the order had been entered from hospice standing orders and had no end date. R11’s records showed severe cognitive impairment, need for staff assistance with ADLs, wheelchair use, hospice services, Parkinson’s disease with dyskinesia, dementia with behaviors, anxiety, and major depressive disorder. Hospice standing orders included lorazepam 0.5 mg every 4 hours PRN for anxiety, and the November 2025 MAR listed lorazepam 0.5 mg BID for restlessness and a separate lorazepam 0.5 mg every 2 hours PRN for anxiousness, restlessness, and nausea, both with no identified end date for reassessment. The care plan addressed psychosocial well-being and medication administration, but it did not identify the 14-day reassessment requirement for continued lorazepam use.
Failure to Immediately Suspend Staff After Alleged Abuse
Penalty
Summary
The facility failed to ensure resident safety by not immediately suspending a nursing assistant after an allegation of abuse involving a resident with impaired cognition and significant physical assistance needs. R27 had diagnoses including dysarthria following a stroke, cognitive communicative deficit, and mild cognitive impairment. His 12/8/25 Significant Change MDS showed moderately impaired cognition, extensive assistance with ADLs, two-person assistance for transfers with a mechanical lift, and use of a Broda-type wheelchair. His care plan identified altered communication related to cognitive communication deficit and cerebral infarction, and he was considered a vulnerable adult at risk for abuse due to decreased cognition and physical abilities. On 11/30/25, while NA-C was assisting with turning R27 with NA-D and NA-E, R27 placed his hand on NA-E’s breast. NA-C responded by smacking R27’s hand away and raising her voice at him. NA-D reported the incident to the charge nurse, who notified the DON at 4:36 p.m. The DON instructed RN-D to obtain written statements and place them under her office door for review the next morning. NA-C continued working her assigned shift and provided resident care until 10:30 p.m., and there was no indication the administrator was notified until the next morning. The facility later determined verbal abuse was substantiated, but physical abuse was not substantiated because of conflicting staff statements and R27’s inability to participate in the interview process due to impaired cognition. The investigation confirmed NA-C had raised her voice at R27, and she was terminated after the interview on 12/4/25. The facility’s abuse policy required immediate notification of the supervisor and administrator, immediate suspension of the involved staff member in alleged staff-to-resident abuse, and reporting suspected abuse to the State Agency within 2 hours of notification. The report was filed to the SA 16 hours after the incident was reported, and NA-C was not suspended until after the administrator was notified the following morning.
Failure to timely report alleged abuse and protect the resident
Penalty
Summary
The facility failed to ensure the administrator and State Agency were notified within 2 hours of an allegation of physical and verbal abuse involving one resident. On 11/30/25 around 5:00 p.m., NA-C was assisting with turning the resident when he placed his hand on NA-E's breast. NA-C smacked the resident's hand away and raised her voice at him. NA-D reported the incident to the charge nurse, who notified the DON at 4:36 p.m., but the administrator was not notified until the morning of 12/1/25, and the State Agency report was not filed until 9:14 a.m. on 12/1/25, about 16 hours after the incident was reported. The resident involved had moderately impaired cognition, required extensive assistance with ADLs, needed 2 staff and a mechanical lift for transfers, used a Broda-type wheelchair, and was transported by staff. He had diagnoses of dysarthria following a stroke, cognitive communicative deficit, and mild cognitive impairment. His care plan identified altered communication related to cognitive communication deficit and cerebral infarction, and he was identified as a vulnerable adult at risk for abuse due to decreased cognition and physical abilities. The DON stated she did not think of the event as potential or actual abuse when it was first reported and instructed staff to obtain written statements and place them under her office door for review the next morning. NA-C continued working her assigned shift and provided resident care until 10:30 p.m. on 11/30/25, and no action was initiated until the following morning. The investigation later confirmed verbal abuse, with NA-D and NA-E stating NA-C raised her voice at the resident, and NA-C was terminated after the substantiated verbal abuse finding.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse by Visitor
Penalty
Summary
A resident with severe cognitive impairment, Parkinson's disease with dyskinesia, and total dependence on staff for mobility and personal care was subjected to repeated inappropriate touching by a visiting assisted living resident over approximately 38 minutes. The resident was unable to consent or protect herself due to her medical condition, which included dementia and physical limitations. The incident occurred in a common area, where the perpetrator lifted the resident's skirt and made skin-to-skin contact with her thighs and vaginal area multiple times, as captured on facility surveillance footage. Staff present in the area observed unusual behavior, such as the perpetrator watching staff closely and remaining near the resident, as well as the resident's skirt being repeatedly bunched up. Despite these observations and suspicions of inappropriate contact, staff did not intervene to remove the perpetrator or the resident from the situation. One staff member pulled the resident's skirt down several times but did not take further action, citing uncertainty about how to handle the situation and fear of the perpetrator's reaction. The incident was not immediately reported to facility leadership, and the administrator and DON were only notified the following day. Interviews with staff revealed a lack of clarity regarding their responsibilities in suspected abuse situations, with some staff expressing uncertainty about the resident's ability to make decisions and discomfort with the situation. The failure to intervene and report promptly allowed the inappropriate contact to continue for an extended period, leaving the resident unprotected despite her vulnerability and care plan identifying her as at risk for abuse or neglect.
Removal Plan
- Education for all staff covering definitions and types of abuse, staff responsibilities for prevention and reporting, mandatory reporting timelines and procedures, internal facility reporting process, resident rights and protections, zero-tolerance policy and disciplinary actions
- AP banned from facility
- Assessment of R1 for injury and mental anguish as able
Failure to Send Current POLST Form During Resident Transfer
Penalty
Summary
The facility failed to provide the most current Provider Order for Life Sustaining Treatment (POLST) form to the receiving provider when a resident was transferred to the emergency department. The resident's POLST specified Do Not Resuscitate (DNR) status, comfort-focused treatment, no artificial nutrition by tube, and no antibiotics, with a preference for no hospital transfer unless comfort needs could not be met at the facility. Despite these clear directives, the POLST was not sent with the resident during the transfer to the hospital. Interviews with facility staff revealed that the standard process for emergency transfers included sending the face sheet, order summary, medication administration record, and the current POLST form with the resident. However, the LPN responsible for the transfer did not print or send the POLST, and the care coordinator who initiated the process left the building before the transfer was completed, also not ensuring the POLST was included. As a result, the hospital only had access to an outdated POLST, which led to confusion regarding the resident's wishes, particularly concerning the administration of antibiotics. The resident had a history of moderately impaired cognition, paranoid schizophrenia, intellectual disabilities, and diabetes. Upon admission to the hospital, the absence of the current POLST led to a review of an older version, which did not reflect the resident's most recent preferences. This discrepancy was only clarified after discussions with the resident's family and review of the available documentation, but the initial failure to send the correct POLST form resulted in a lack of immediate clarity regarding the resident's treatment preferences during the hospital stay.
Infection Control and Sanitization Deficiencies in Dietary Services
Penalty
Summary
The facility failed to ensure proper infection control practices were followed by dietary staff during meal tray delivery and dining room food service. On multiple occasions, a dietary aide was observed handling meal trays and interacting with residents without performing hand hygiene. The aide touched various surfaces and objects in residents' rooms, including bed remotes and blankets, and even picked up debris from the floor, all without washing hands before or after these actions. This lack of hand hygiene was contrary to the facility's expectations and had the potential to affect all residents receiving meal services. In the dining room, culinary services aides were observed improperly handling drinking cups by the rim while serving beverages to residents. This practice was noted on several occasions, and one aide was also seen touching her face and ear without cleaning her hands before serving drinks. Despite having received training on the correct way to handle cups, the aides did not consistently apply this knowledge, increasing the risk of contamination. Additionally, the facility did not adequately monitor the chemical sanitization solution used in the dishwasher. Observations revealed that the sanitizing solution was consistently below the required concentration levels, and the staff were not performing proper testing as per the facility's policy. The culinary services director admitted to not conducting periodic checks to ensure compliance with the policy, and the logs showed discrepancies in recorded temperatures and sanitization levels. This oversight in maintaining proper sanitization standards could compromise the cleanliness of dishes used by residents.
Failure to Implement Antibiotic Review Process
Penalty
Summary
The facility failed to implement a process for antibiotic review to determine the efficacy and resident outcomes for four residents, which had the potential to affect all 34 residents living in the facility. The deficiency was identified through interviews and document reviews, revealing that the facility did not document outcomes for residents prescribed antibiotics, including susceptibility, signs/symptoms of infection, any prolonged treatment, side effects, and/or changes in antibiotics. Resident 12, diagnosed with quadriplegia and neurogenic bowel, was treated for a catheter-associated urinary tract infection with ciprofloxacin, but no outcomes were documented to assess the treatment's efficacy. Similarly, Resident 27, with a history of recurrent UTIs, was treated with Macrobid and later switched to Keflex due to aggressive behavior, yet no outcomes were recorded. Resident 1, with chronic kidney disease and a history of UTIs, was treated multiple times with different antibiotics, but again, no outcomes were documented. Resident 31, diagnosed with a cough, was treated for an upper respiratory infection with azithromycin, but the facility failed to document the treatment's efficacy. The infection preventionist and DON acknowledged the lack of documented outcomes and stated that it is expected for nursing staff to monitor signs/symptoms of infection and notify the provider and family of the resident's condition. The consulting pharmacist emphasized the importance of addressing urine culture results to ensure effective treatment. The facility's antibiotic stewardship policy outlined responsibilities for tracking and reporting antibiotic use, but these procedures were not followed, leading to the deficiency.
Resident's Recliner Removed Without Consent
Penalty
Summary
The facility failed to honor a resident's rights and choices by removing his personal recliner from his room without his consent. The resident, who had intact cognition and was diagnosed with heart failure, kidney failure, and edema, relied on his recliner for comfort and to elevate his legs as per physician's orders. Despite expressing his need for the recliner and his discomfort sleeping in a bed, the recliner was taken away for cleaning due to a urine odor without the resident's permission. This action left the resident sleeping in his wheelchair, unable to elevate his legs as required. Interviews with the Director of Nursing (DON), Social Services Director (SSD), and the facility administrator revealed a lack of communication and planning regarding the removal and return of the recliner. The DON admitted to removing the recliner without seeking the resident's consent and was uncertain about the cleaning process and timeline for its return. The SSD acknowledged the importance of the recliner to the resident and stated that permission should have been obtained before its removal. The administrator confirmed the decision to remove the recliner was made without verifying if the resident's consent was obtained. A policy on resident rights and personal property was requested but not provided.
Inaccurate MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to ensure that a resident's status was accurately identified in the Minimum Data Set (MDS) assessment. The resident, who was receiving hospice care due to end-stage kidney disease, was not correctly documented as receiving hospice services in the MDS. The resident's face sheet indicated hospice as the primary payer, and the hospice plan of care confirmed the start of hospice services. However, the MDS section for special treatments and programs did not include hospice care services, and the prognosis section incorrectly indicated no life expectancy of less than six months. The registered nurse responsible for the MDS confirmed the omission, and the director of nursing acknowledged that the MDS should have been completed accurately to reflect hospice services. The facility administrator stated that the facility followed the Resident Assessment Instrument (RAI) Manual but did not have a specific MDS policy.
Failure to Follow Physician Orders for Leg Elevation
Penalty
Summary
The facility failed to follow physician orders for a resident with edema, specifically regarding the elevation of the resident's legs. The resident, who had diagnoses of heart failure, kidney failure, and edema, was supposed to have their legs elevated to the level of the heart or above for 45-60 minutes every shift, as per physician orders. However, the resident's recliner, which was used for leg elevation, was removed for cleaning, and the resident had been sleeping in a wheelchair without elevating their legs since then. Interviews with the resident, a family member, and staff revealed that the resident had not been provided with an alternative means to elevate their legs, despite the known importance of this intervention for managing edema. Staff interviews indicated a lack of awareness and follow-through regarding the resident's leg elevation orders. Nursing staff, including a nursing assistant, a registered nurse, and a licensed practical nurse, were unsure if the resident's legs had been elevated since the recliner's removal. The Director of Nursing was also unaware of the situation and stated that she would have expected staff to inform her if the resident was unable to elevate their legs. The treatment administration record showed no refusals of leg elevation, contradicting staff statements about the resident's frequent refusals. The facility did not provide a policy on edema when requested, further highlighting the oversight in care management for this resident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to conduct a comprehensive reassessment after a fall incident involving a resident with severe cognitive impairment, chronic obstructive pulmonary disease, muscle weakness, and a history of falls. The resident, who required substantial assistance with transfers and used a wheelchair for mobility, attempted to self-transfer to the bathroom and fell, resulting in a skin tear. Although staff educated the resident on using the call light for assistance, the incident review and analysis were not comprehensively completed, lacking a review of the fall's cause and the implementation of new interventions to prevent future falls. Following a subsequent fall, the facility completed an incident review and analysis, but the intervention of leaving the resident's walker at the bedside was discussed but not implemented or added to the care plan. Observations showed the resident walking in the hall without a walker or staff assistance, and interviews with staff revealed a lack of awareness of interventions beyond the use of gripper socks. The Director of Nursing confirmed that a post-fall assessment and intervention should have been completed and implemented promptly, but this did not occur, highlighting a deficiency in the facility's fall prevention and management practices.
Failure to Follow Catheter Care and Urinalysis Protocols
Penalty
Summary
The facility failed to follow the provider's order for catheter flushes for a resident with an indwelling catheter, increasing the risk of urinary tract infections (UTIs). The resident, who was cognitively intact and dependent on staff for toileting hygiene, had a history of traumatic spinal cord dysfunction, neurogenic bladder, and quadriplegia. The physician's order required flushing and irrigating the catheter every other day with normal saline, but this was not completed five times in September. The resident experienced issues with catheter clogging and leakage, which were not adequately addressed by the staff. Additionally, the facility did not address urinalysis results for two residents reviewed for UTIs. One resident, who was frequently incontinent of urine and had a history of chronic kidney disease, hemiplegia, dementia, and altered mental status, returned from the hospital with a UTI and was prescribed an antibiotic. However, the urine culture results were not reviewed by the facility, and the prescribed medication was not listed in the culture results. The nurse manager confirmed that the urine culture result was scanned into the electronic medical record without being reviewed by a nurse. The facility's failure to review and address urine culture results in a timely manner was confirmed by the consulting pharmacist and the director of nursing. The health information management staff scanned documents into the electronic medical record without ensuring they were signed and dated by nursing, leading to a breakdown in the process. The physician assistant for the resident with the indwelling catheter was not aware of any pending urinalysis results, and the facility did not follow up with the provider within 24 hours as expected.
Failure to Follow Provider's Medication Review Response
Penalty
Summary
The facility failed to ensure that the provider's response to a monthly medication review was followed for a resident reviewed for unnecessary medications. The resident, who had moderate cognitive impairment and diabetes mellitus, was receiving insulin injections. A consultant pharmacist recommended that the physician consider redrawing the resident's A1C and adjusting insulin doses as needed. The physician responded to this recommendation by ordering an A1C test. However, the facility's records lacked documentation that the A1C test was completed as ordered. A licensed practical nurse confirmed that the physician's order for the A1C test was not addressed by the nursing staff. The order was not sent to nursing before being scanned into the electronic medical record by health information management staff. The director of nursing stated that nurse managers were responsible for following up on pharmacy recommendations and provider responses. The director also expected health information management to ensure that orders were signed and dated by nursing before being scanned into the electronic medical record. Despite these expectations, the order from the physician was not completed, and a facility policy was requested but not received.
Deficiency in PPE Use and Wound Care Protocols
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP). Observations revealed that staff did not don PPE, such as gloves and gowns, when transferring the resident from a wheelchair to the bathroom, despite a sign on the resident's door indicating the requirement for PPE during high-contact activities. Staff members, including a trained medication aide and nursing assistants, were seen handling the resident without gloves and gowns, contrary to the facility's EBP policy. Additionally, during wound care for the same resident, staff did not adhere to proper glove use and hand hygiene protocols. A licensed practical nurse (LPN) and a nursing assistant were observed performing wound care without changing gloves or performing hand hygiene between steps, such as after removing the old dressing and before applying a new one. The LPN used the same gloves to handle wound care supplies and apply a new dressing, which is against the facility's wound care treatment procedure. Interviews with staff, including the director of nursing (DON) and the infection preventionist, confirmed a lack of compliance with EBP protocols. The DON acknowledged that staff were not trained to wear gowns and gloves during transfers for residents on EBP, and the infection preventionist stated that staff were expected to change gloves and wash hands during wound care. The facility's policies on EBP and wound care were not followed, leading to deficiencies in infection prevention and control practices.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 49 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gaylord
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society Arlington | 7.5 mi | — | 0 | 0 |
| Glenfields Living With Care | 15.8 mi | ★★★★★ | 0 | 0 |
| Cura Of Le Sueur | 16.6 mi | ★★★★★ | 12 | 0 |
| Benedictine Living Community Of St. Peter | 18.7 mi | ★★★★★ | 8 | 0 |
| Oak Hills Living Center | 21.1 mi | ★★★★★ | 9 | 0 |
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