Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Bayberry Commons during CMS and state inspections, most recent first.
Pharmacy consultant recommendations for medication regimen irregularities were not addressed by the attending physician for three residents, including those with back pain, Alzheimer's disease, and dementia. Recommendations included clarifying medication orders and adding appropriate diagnoses, but there was no evidence of physician review or action until surveyors brought the issues to the facility's attention.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with dementia and major depressive disorder did not receive an increased dose of sertraline as recommended by psychiatric services and approved by the provider, because the facility placed the order on hold pending POA consent. After an initial attempt to contact the POA, there was no further documented effort to obtain consent, and the provider was unaware the medication change had not been implemented.
A resident with a history of dysphagia had a change in physician's diet orders from aspiration precautions to a regular diet with thin liquids. Despite this, the TAR continued to be signed off as if aspiration precautions were still in place. Staff interviews confirmed that the outdated order was no longer active, but documentation was not updated accordingly, resulting in inaccurate medical records.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the plan was not prepared, reviewed, and revised by a team of health professionals as required.
A facility failed to notify a resident's physician of significant changes in the resident's condition, including lethargy and unresponsiveness, over several days. The resident, with a history of heart disease and reduced mobility, showed signs of deterioration, such as refusal of medication and meals, and was intermittently unarousable. Despite these changes, the physician was not notified until several days later, and vital signs were not documented. The resident was eventually hospitalized with respiratory failure, pneumonia, and a UTI, and later transferred to hospice care.
A resident with heart disease and other conditions did not receive several prescribed medications over three days. The facility's policy requires notifying the physician when medications are missed, but there was no evidence of such notification. The DNS acknowledged the lack of documentation, and the physician was unaware of the missed doses.
A facility failed to protect a resident from sexual abuse, as two residents with severe cognitive impairments were found engaging in sexual acts multiple times. Despite initial separation and 15-minute checks, the facility did not effectively monitor or intervene, leading to repeated incidents. Staff interviews confirmed the lack of consistent documentation and interventions, and the facility's leadership acknowledged the deficiency.
A facility failed to provide proper respiratory care for a resident with congestive heart failure and shortness of breath. Despite the resident's need for continuous oxygen therapy, there was no physician's order specifying the required oxygen flow and method. The deficiency was identified after the resident was hospitalized due to breathing difficulties, and staff interviews confirmed the lack of necessary documentation and orders.
A facility failed to maintain accurate medical records for a resident receiving oxygen therapy. Despite hospital records indicating the resident was on 3L of oxygen, the facility only had an order for 1L as needed. Progress notes showed varying oxygen levels, but these were not documented in the Medication Administration Record. Staff interviews revealed inconsistencies in documentation, with the DON unable to provide complete records.
A resident identified as a high fall risk was not provided with hip protectors, as required by their care plan, leading to a fall and a right femur fracture. The resident, who had severe cognitive impairment, was ambulating with staff when they tripped. An LPN noted the protectors were unavailable due to being soiled, and there was no documentation of the resident refusing them. The DON could not provide evidence that the protectors were offered or refused.
A resident with a history of falls was found to have two alarms engaged while in a wheelchair, which were not easily removable, indicating potential restraint use. The facility failed to provide evidence of assessments or ongoing evaluations for the alarms' necessity and effects. Staff interviews revealed a lack of awareness about any assessments, and the administration could not demonstrate that the alarms were the least restrictive intervention.
The facility failed to conduct comprehensive assessments for five residents and a Significant Change in Status Assessment (SCSA) for a resident admitted to hospice. Comprehensive assessments, which include the Minimum Data Set (MDS) and Care Area Assessment (CAA) process, were incomplete due to missing CAA documentation. Additionally, the required SCSA was not completed for a resident after admission to hospice services, as confirmed by the ADNS.
The facility failed to ensure accurate MDS assessments for several residents, leading to discrepancies in their medical records. A resident with repeated falls was inaccurately documented as using alarms less than daily, while another resident with nicotine dependence was incorrectly noted as not using tobacco. Additionally, a resident with a history of MRSA was still coded as having an active MDRO, and a resident with urine retention was inaccurately documented as having an indwelling catheter. The MDS Coordinator acknowledged these inaccuracies, and the administration could not provide evidence of accurate assessments.
A facility failed to maintain an infection prevention and control program for a resident with MRSA colonization. The resident's care plan aimed to prevent MRSA spread, but the facility did not conduct timely MRSA screenings or maintain required precautions. Observations confirmed the absence of necessary precautions, and staff could not provide evidence of an effective infection control program.
A resident on anticoagulant medication experienced an unwitnessed fall with a head strike and a subsequent headache. The NP was notified of the fall but not the headache, and gave a verbal order for neurological assessments and vital signs every shift for 72 hours. This order was not transcribed or executed, leading to a deficiency in care.
A resident with dysphagia was not provided food in a form suitable for their mechanical soft diet, receiving whole sausage links and bacon instead. Staff, including a nurse and cook, acknowledged the error, and the Assistant Director of Nursing Services confirmed the oversight.
Failure to Address Pharmacist-Identified Medication Irregularities
Penalty
Summary
The facility failed to ensure that drug regimen review (MRR) irregularities identified by the consultant pharmacist were addressed by the attending physician for three residents. For one resident with lower back pain and a spinal compression fracture, a pharmacy recommendation to specify the application area for a lidocaine patch was not acted upon. In another case, a resident with Alzheimer's disease had pharmacy recommendations regarding the administration of Miralax and clarification of vitamin D therapy, which were not addressed despite repeated notes from the consultant pharmacist. A third resident with dementia, vitamin D deficiency, and folate deficiency anemia had recommendations to add appropriate diagnoses for several medications, but these were also not addressed. Record review and staff interviews confirmed that there was no evidence the MRR irregularity recommendations were reviewed or acted upon by the physician for these residents, and the Director of Nursing Services was unable to provide documentation of follow-up. The facility's policy requires monitoring of consultant pharmacy services and timely response to identified irregularities, but this was not followed in these cases until the issues were identified by surveyors.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Implement Psychiatric Medication Recommendation Due to Incomplete Consent Process
Penalty
Summary
A deficiency was identified when the facility failed to implement a psychiatric recommendation for a resident with dementia and major depressive disorder. The psychiatric provider recommended an increase in sertraline to 50 mg daily due to inappropriate behaviors, and this recommendation was approved by the resident's provider. However, the facility placed the new order on hold pending consent from the resident's Power of Attorney (POA). Documentation shows that a call was made to the POA to obtain consent, and a message was left, but there was no further evidence of additional attempts to contact the POA or obtain consent after that date. Interviews with staff confirmed that the facility's process requires obtaining and documenting consent from the resident representative before implementing changes to psychotropic medications. The LPN and DON both indicated that documentation of attempts to obtain consent should be present in the progress notes, but no such documentation was found after the initial attempt. The resident's provider was unaware that the medication increase had not been implemented and believed the resident was already receiving the higher dose.
Failure to Accurately Document and Update Medical Records for Diet Orders
Penalty
Summary
The facility failed to maintain accurate medical records and documentation in accordance with professional standards for a resident with a physician's order for aspiration precautions. The resident, who had diagnoses including Alzheimer's disease and a history of dysphagia, was readmitted with an order for aspiration precautions such as head of bed elevation, staff assistance during meals, oral care after eating, nectar thick fluids, and a puree diet. Subsequently, a new physician's order was issued for a regular house diet with thin liquids. Despite this change, the Treatment Administration Record (TAR) continued to reflect that aspiration precautions were being implemented and signed off as completed three times daily, even after the new diet order was in place. Surveyor observation revealed the resident eating alone with thin liquids and a regular diet, contrary to the previous aspiration precautions. Interviews with staff confirmed that the order for aspiration precautions was no longer active, yet documentation on the TAR indicated otherwise. One LPN acknowledged signing off on the aspiration precautions without verifying the current diet order, and the Director of Nursing Services stated that staff are expected to document accurately. This discrepancy between actual care provided and documentation led to the deficiency.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to immediately consult with the resident's physician and notify them when there was a significant change in the resident's condition. This deficiency was identified for a resident who experienced a change in condition, including lethargy and unresponsiveness, over several days. The resident, admitted with diagnoses such as heart disease and reduced mobility, showed signs of deterioration, including refusal of medication and meals, and was intermittently unarousable. Despite these changes, there was no evidence that the physician was notified until several days later. The resident's condition continued to decline, with progress notes indicating poor fluid intake, difficulty with ambulation, and unresponsiveness to verbal stimuli. Vital signs were not documented for several days following the change in condition. The resident was eventually found to have fallen, with a significant drop in oxygen saturation, and was transferred to the hospital where they were diagnosed with hypercapnic respiratory failure, pneumonia, and a urinary tract infection. The facility's records failed to show that the physician was informed of the missed medications or the resident's deteriorating condition in a timely manner. Interviews with staff revealed that there was an expectation for the physician to be notified of such changes, but this did not occur. The Director of Nursing Services acknowledged the lack of appropriate documentation and physician notification. The resident was later transferred to hospice care following the hospital admission and passed away shortly thereafter. The facility did not have a specific policy for notifying physicians of a change in condition, contributing to the deficiency.
Failure to Notify Physician of Missed Medications
Penalty
Summary
The facility failed to meet professional standards of quality by not following physician's orders for a resident who refused medications. The resident, admitted in November 2024 with diagnoses including heart disease, acute pulmonary edema, and reduced mobility, did not receive several prescribed medications on specific dates in February 2025. These medications included Aspirin, Furosemide, Gentle Iron, Metoprolol Succinate Extended Release, Polyethylene Glycol, Warfarin, Melatonin, Simvastatin, Trazodone, and Zyprexa. The facility's Medication Administration Record (MAR) showed these medications were not administered on February 2nd, 3rd, and 4th, 2025. The facility's policy requires physician notification when a medication is not administered due to resident refusal or other reasons. However, the record review failed to show evidence that the physician was notified of the missed medications. Interviews with the Director of Nursing Services (DNS) and the resident's physician confirmed that the physician was not informed within the expected timeframe. The DNS acknowledged the lack of appropriate documentation in the resident's medical record, and the physician indicated he was not aware of the missed medications.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by multiple incidents involving two residents with severe cognitive impairments. Resident ID #1, who has dementia and a BIMS score indicating severe cognitive impairment, was found in compromising situations with Resident ID #2, who also has dementia and was unable to complete a BIMS assessment due to cognitive limitations. Both residents were observed engaging in sexual acts, despite their inability to consent due to their cognitive conditions. The incidents occurred on a secured unit, where staff initially separated the residents after observing inappropriate behavior. However, the residents were later found in similar situations multiple times, indicating a lack of effective monitoring and intervention. The facility's policy on abuse prohibition requires an evaluation of a resident's capacity to consent to sexual activity, which was not adequately addressed in this case. The 15-minute checks implemented after the initial incident were not consistently documented, and no new interventions were put in place after subsequent incidents. Staff interviews revealed that the residents were separated after each incident, but the measures taken were insufficient to prevent further occurrences. The facility's failure to document the 15-minute checks and implement effective interventions contributed to the ongoing risk of abuse. The Director of Nursing Services and the Administrator acknowledged the repeated incidents and the lack of evidence that the facility kept Resident ID #1 free from sexual abuse.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who required oxygen therapy. The resident, who had diagnoses including congestive heart failure and shortness of breath, was readmitted to the facility in June 2024. Despite the resident's need for continuous oxygen therapy, the facility did not have a physician's order for continuous oxygen, which is required to specify the liter flow and method of administration. The resident was documented as receiving oxygen on several occasions, but there was no evidence of a physician's order for continuous oxygen therapy. The deficiency was identified following a community-reported complaint that the resident was transported to the hospital due to breathing difficulties. Interviews with facility staff, including a Licensed Practical Nurse, a Registered Nurse, and the Director of Nursing Services, confirmed the absence of a physician's order for continuous oxygen. The Director of Nursing Services acknowledged the need for such an order and the requirement to document the resident's oxygen saturation level every shift, but could not explain why the order was not in place.
Failure to Maintain Accurate Oxygen Therapy Records
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for a resident receiving oxygen therapy. The resident, who was readmitted to the facility with diagnoses including congestive heart failure and shortness of breath, was documented in hospital records as being on 3 liters of oxygen at baseline. However, the facility's records only showed a physician's order for oxygen at 1 liter via nasal cannula as needed, with no evidence of an order for continuous oxygen therapy. Progress notes indicated the resident was receiving varying levels of oxygen on multiple dates, but these were not documented in the Medication Administration Record. Interviews with staff revealed inconsistencies in the documentation of the resident's oxygen therapy. A Licensed Practical Nurse confirmed that the resident utilized oxygen continuously, receiving between 1-3 liters. The Director of Nursing Services acknowledged the expectation for staff to document oxygen administration and the resident's oxygen saturation level every shift, but was unable to provide evidence of complete and accurate records. This lack of documentation and adherence to professional standards led to the deficiency finding.
Failure to Provide Hip Protectors Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident, identified as a high fall risk, was provided with hip protectors as an intervention to prevent accidents. The resident, who had severe cognitive impairment and a history of falls, was ambulating with staff assistance when they tripped and fell, resulting in a right femur fracture. A physician's order was in place to encourage the use of hip protectors at all times, except during personal care, but the resident was not wearing them at the time of the fall. The incident report and staff interviews revealed that the hip protectors were marked as unavailable by an LPN on the shift when the fall occurred. The LPN could not recall if the resident was wearing the protectors and acknowledged that they were not provided due to being soiled. The Director of Nursing Services was unable to provide evidence that the hip protectors were offered or refused by the resident, and there was no documentation in the progress notes indicating that the resident declined to wear them. This oversight led to the resident sustaining a broken hip.
Failure to Assess and Document Use of Alarms as Restraints
Penalty
Summary
The facility failed to ensure that residents are free from physical restraints that are not required to treat medical symptoms, specifically in the case of a resident who was using two alarms as a fall intervention. The resident, who was admitted in September 2021 with diagnoses including difficulty walking and repeated falls, was found to have two alarms engaged while sitting in a wheelchair. These alarms were intended to prevent the resident from getting out of the chair, and the resident expressed dislike for them. The alarms were not easily removable by the resident, indicating a potential restraint situation. The facility did not provide evidence of an assessment for the use of these alarms or any ongoing evaluation of their necessity and potential adverse effects. Interviews with staff revealed a lack of awareness regarding any assessments performed for the alarms' use. The Administrator and Assistant Director of Nursing acknowledged the use of the alarms but could not demonstrate that they did not restrict the resident's movement or that they were the least restrictive intervention. This lack of documentation and assessment led to the deficiency noted by the surveyors.
Failure to Conduct Comprehensive and Significant Change Assessments
Penalty
Summary
The facility failed to conduct comprehensive assessments using the Resident Assessment Instrument (RAI) for five out of six residents reviewed. These assessments are required to include both the Minimum Data Set (MDS) and the Care Area Assessment (CAA) process, as well as care planning. The MDS is a preliminary assessment that identifies potential resident problems, while the CAA process provides further assessment of triggered areas. For residents with IDs 7, 25, 39, 53, and 89, the facility did not complete the necessary CAA documentation, which should include information on complicating factors, risks, and any referrals for the care areas. The Minimum Data Set Coordinator acknowledged the absence of CAA notes for these residents during a surveyor interview. Additionally, the facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who was admitted to hospice services, indicating a significant change in health status. According to the MDS 3.0 Resident Assessment Instrument Manual, an SCSA is required when a resident elects the hospice benefit. The record review for this resident, identified as Resident ID #50, did not reveal evidence of a completed SCSA after the resident's admission to hospice services. The Assistant Director of Nursing Services (ADNS) confirmed during an interview that a significant change assessment should have been completed. These deficiencies highlight the facility's failure to adhere to the required assessment protocols, which are crucial for identifying and addressing the needs of residents. The lack of comprehensive assessments and significant change assessments can impede the development of individualized care plans aimed at promoting residents' highest practicable level of functioning.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate assessments for several residents, leading to discrepancies in their medical records. Resident ID #8, who was readmitted with a diagnosis of repeated falls, was inaccurately assessed in the Minimum Data Set (MDS) as using bed and chair alarms less than daily, despite a physician's order indicating daily use. Similarly, Resident ID #19, diagnosed with nicotine dependence, was incorrectly documented as not using tobacco in the MDS, although the care plan indicated the resident was an independent smoker. Further inaccuracies were found with Resident ID #25, who was admitted with a diagnosis of MRSA. Despite two consecutive negative MRSA screenings, the resident was still coded as having an active MDRO in the MDS. Additionally, Resident ID #56, admitted with urine retention, was inaccurately documented as having an indwelling catheter in two MDS assessments, even though the catheter had been removed. The MDS Coordinator acknowledged these inaccuracies, and the facility's administration could not provide evidence of accurate MDS assessments for these residents.
Failure to Implement Infection Control for MDRO
Penalty
Summary
The facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections, specifically concerning Multi-drug Resistant Organisms (MDRO). The deficiency was identified for one resident who was readmitted to the facility with a diagnosis of MRSA colonization. The facility's policy required Enhanced Barrier Precautions for residents with MDRO colonization, which includes the use of gowns and gloves during high-contact care activities. However, the facility did not adhere to these precautions for the resident in question. The resident's care plan indicated a goal to prevent the spread of MRSA, yet the facility did not conduct timely MRSA screenings as per their policy. The resident tested positive for MRSA in the nares in 2021, and a subsequent MRSA screen was delayed until 2024, which resulted negative. Despite this, there was no evidence of two consecutive negative MRSA cultures before removing the resident from Contact or Enhanced Barrier Precautions. Observations during the survey confirmed that the resident was not on the required precautions, and the facility staff could not provide evidence of maintaining an effective infection prevention and control program.
Failure to Transcribe and Execute Verbal Orders for Post-Fall Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who was on an anticoagulant medication, experienced an unwitnessed fall with a head strike and subsequently developed a headache. Although the Nurse Practitioner was notified of the fall and aware of the resident's anticoagulant use, she was not informed about the resident's headache. She had given a verbal order for neurological assessments and vital signs to be completed every shift for 72 hours, but this order was not transcribed into the resident's record. Further review revealed that there was no evidence that the neurological assessments and vital signs were completed as per the Nurse Practitioner's verbal order. The Assistant Director of Nursing confirmed the lack of documentation and stated that residents with a head strike while on an anticoagulant should be sent to the emergency room for evaluation. This oversight in communication and documentation led to a deficiency in the care provided to the resident.
Failure to Provide Appropriate Mechanical Soft Diet
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of a resident on a mechanical soft diet. The resident, who was admitted with a diagnosis of dysphagia, experienced difficulty swallowing during a meal, which led to a diet downgrade to mechanical soft as per a physician's order. Despite this, the resident was served inappropriate food items, such as whole sausage links and bacon, which are not suitable for a mechanical soft diet. Surveyor observations and interviews revealed that the resident was served whole sausage links and bacon on separate occasions, which the resident found difficult to eat. Staff members, including a registered nurse and a cook, acknowledged that these food items were not appropriate for the resident's dietary needs. The Assistant Director of Nursing Services also confirmed that the resident should not have received these items and was unable to provide evidence that the food was prepared according to the resident's individual needs.
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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.
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Nursing homes near Pascoag
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crystal Lake Rehabilitation And Care Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Overlook Nursing And Rehabilitation Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Greenville Operations Ri Llc Dba Greenville Skille | 6.8 mi | ★★★★★ | 16 | 1 |
| Cedar Haven Operations Llc Dba Lake Forrest Health | 7 mi | ★★★★★ | 18 | 2 |
| Stillwater Assisted Living And Skilled Nursing Com | 7.8 mi | ★★★★★ | 1 | 0 |
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