Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bay Ridge Healthcare Center during CMS and state inspections, most recent first.
A resident with COPD, acute respiratory failure with hypoxia, sepsis, and other serious diagnoses developed confusion, delusions, pallor, and worsening oxygenation while on O2 and ordered BiPAP. Staff observed the resident was not using BiPAP, was difficult to arouse, and had an O2 sat of 84%, but the RN did not notify the MD immediately and continued monitoring. The MD was not contacted until the resident became minimally responsive with an O2 sat of 80%, after which the resident was transferred to the hospital, admitted to ICU with respiratory distress and hypotension, and later died after CPR was stopped at the daughter’s request.
A resident with COPD, acute respiratory failure with hypoxia, and other serious diagnoses developed altered mental status and worsening respiratory status with low O2 sats. Staff noted confusion, pallor, mouth breathing, and an O2 sat of 84%, but did not obtain timely vital signs, did not give the ordered PRN breathing treatment, and delayed notifying the MD for several hours before the resident was sent to the hospital by EMS.
A resident with DM, hemiplegia after CVA, bipolar disorder, and a cognitive communication deficit was discharged home with an order to send scheduled meds (excluding narcotics), but the discharge medication list signed by the DON and the responsible party did not include the resident’s ordered insulins (Humalog and insulin glargine), which remained active at the time of discharge and were documented on the MAR and care plan. The DON reported she gathered medications from the med aide’s cart, assumed these were all current meds, and overlooked the insulin stored separately in the nurse’s cart, while the assigned LVN stated the DON had taken responsibility for discharge medications and that insulin should be sent home with discharged residents. The Regional Senior Administrator stated that only narcotics are typically not sent home, insulin usually is, and there was no written discharge policy beyond a facility guide instructing staff to send all medications except discontinued meds and narcotics and to obtain verification signatures.
Two residents did not have complete documentation on their MARs and TARs for ordered medications and treatments, with blank entries and no explanations provided by nursing staff. This failure to document as required was confirmed by staff interviews and was not in accordance with facility policy.
A resident with cognitive impairment and multiple comorbidities experienced an unwitnessed fall resulting in a hematoma and skin tear. The incident was not investigated or reported to the state agency within the required timeframe, despite facility policy and regulatory requirements. The administrator and DON confirmed the lapse in timely reporting and investigation.
A resident with multiple chronic conditions did not have proper documentation for a scheduled dose of Diclofenac topical gel, as the MAR showed a blank entry with no explanation provided. Nursing staff confirmed that all medication administration or omissions should be documented, and facility policy required this as well. The lack of documentation resulted in uncertainty about whether the medication was given as ordered.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised after another resident propped open a door to smoke, bypassing the wander guard system. The resident was found outside by local police and returned to the facility without injury. Staff interviews and documentation confirmed that inadequate supervision and failure to secure doors led to the incident.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. One resident's hospice care plan lacked focus and interventions, another's dialysis treatment was not included in their care plan, and a third resident's care plan inaccurately documented the side affected by a stroke. These oversights were confirmed through record reviews and staff interviews.
A facility failed to coordinate assessments with the PASARR program, resulting in a resident with intellectual disability and mood disorder not receiving required specialized services like PT, OT, and ST. The PASARR form was initially rejected due to errors, and despite instructions to resubmit by a deadline, the facility did not comply. Interviews revealed confusion among staff about responsibilities for form submission.
The facility failed to provide sufficient dietary staffing for breakfast, leading to the ordering of kolaches and donuts for residents. The absence of dietary staff on the morning in question was due to the suspension of the Dietary Manager and the no-show of a scheduled dietary aide, who later quit. Residents reported receiving enough food, and the issue was addressed the following day. The facility's staffing policy was not adhered to, resulting in a deficiency.
Two residents with specific dietary needs were not provided with a pureed diet as ordered due to the absence of dietary staff. Improvised meals, including oatmeal, were served, which were not properly prepared to meet the residents' dietary requirements, potentially putting them at risk for aspiration. Staff interviews revealed a lack of communication and understanding of the residents' dietary needs.
A resident in a LTC facility reported feeling threatened by a statement made by the Activities Director (AD), "snitches get stitches and end up in ditches." The resident, who was cognitively intact, felt targeted by the AD, who allegedly excluded her from outings and made derogatory comments. Interviews revealed a pattern of inappropriate behavior by the AD, including taunting the resident after an accidental incident and making derogatory remarks during activities. The facility's administration was unaware of these issues until a care plan meeting, despite having policies to prevent abuse.
A long-term care facility failed to report an alleged verbal abuse incident involving a resident and the Activities Director (AD). The resident felt threatened by a comment made by the AD, "Snitches get stitches and end up in ditches," which was overheard in the smoking area. The incident was not reported immediately by CNA B, who overheard the comment, due to fear of confrontation. The facility's policies on abuse reporting were not followed, leading to a deficiency in addressing the incident.
A resident was threatened by a CNA's significant other, who entered the facility with a gun after a verbal altercation over the phone. The CNA allowed the significant other into the resident's room, where he brandished the weapon. The incident highlighted a failure in the facility's abuse prevention and emergency procedures.
A CNA at an LTC facility allowed her armed significant other into the building, leading to a confrontation with a resident. The incident began during wound care when the CNA's phone rang, resulting in a heated exchange between the resident and the significant other. The significant other entered the facility, allegedly brandishing a gun, and confronted the resident. Staff interviews revealed a lack of training on emergency procedures for workplace aggression.
The facility failed to maintain an infection prevention and control program by not sanitizing blood pressure equipment used for multiple residents. Medication Aide A used the same blood pressure machine on three residents without sanitizing it between uses, despite being trained on infection control protocols. The Director of Nursing confirmed that this practice exposed residents to a higher risk of cross-contamination and infection.
Delayed Physician Notification for Resident With Respiratory Decline
Penalty
Summary
The facility failed to consult the resident’s physician immediately when a resident experienced a significant change in condition. The resident had a history that included acute gastric ulcer with perforation, UTI, acute respiratory failure with hypoxia, sepsis, atelectasis, and COPD/emphysema, and was ordered to use BiPAP nightly and 3 liters of oxygen by nasal cannula. The resident’s care plan included monitoring for difficulty breathing on exertion and for signs of acute respiratory insufficiency such as anxiety, confusion, and restlessness. On the morning of the event, staff observed the resident to be confused, mumbling, delusional, pale, and yellowish. A CNA reported the resident did not have the BiPAP on and was talking to herself, and the CNA did not feel it was safe to feed breakfast. An MA notified the RN that she was not comfortable giving morning medications because the resident was “out of it,” and the RN instructed the MA to hold the medications. The RN later assessed the resident and noted deep mouth breathing while the nasal cannula was in place. The DON and RN obtained an oxygen saturation of 84%, but the RN did not notify the physician at that time and instead continued to monitor the resident. The resident’s condition continued to worsen. The RN later could not obtain an oxygen saturation reading, tried two pulse oximeters, and reported that the resident changed from talking and mumbling to stopping talking with a change in color. The physician was not notified until 12:30 p.m., when the resident was minimally responsive and had an oxygen saturation of 80% on nasal cannula, altered mental status, delusions, and refusal of breakfast and lunch. The physician ordered transfer to the hospital, and the resident was sent by EMS at about 1:00 p.m. The resident was admitted to ICU with respiratory distress and hypotension, later became pulseless during ICU evaluation, CPR was performed for about 20 minutes, and resuscitation was stopped at the daughter’s request. The resident was pronounced deceased at 8:53 p.m. on the same day.
Delayed assessment and treatment for respiratory decline and altered mental status
Penalty
Summary
The facility failed to ensure a resident with emphysema/COPD, acute respiratory failure with hypoxia, sepsis, and other recent serious diagnoses received treatment and care in accordance with orders, the care plan, and the resident’s condition. The resident had an order for BiPAP nightly with 3 liters of oxygen by nasal cannula and an order for ipratropium-albuterol inhalation solution every 6 hours as needed for shortness of breath. The care plan directed staff to monitor for difficulty breathing on exertion and signs of acute respiratory insufficiency, including anxiety, confusion, and restlessness. On the morning of the event, an RN observed the resident around 6:30 a.m. and noted unusual mumbling and delusional behavior, pale and yellowish color, and breathing through the mouth while wearing nasal cannula oxygen at 4 LPM. The RN continued rounds and later assessed the resident after a medication aide expressed concern. The RN and DON obtained an oxygen saturation of 84%, but the DON stated this was the resident’s baseline and instructed staff to place the BiPAP on the resident and continue monitoring. The resident was not given the ordered PRN breathing treatment when respiratory issues were present, and no vital signs were documented for that day. The resident’s condition continued to worsen over several hours. Around 11:00 a.m., the RN reassessed the resident and could not obtain an oxygen saturation reading despite trying two pulse oximeters, while the resident’s color and responsiveness declined. The physician was not notified until about 12:30 p.m., when the RN reported the resident was less responsive and had a low oxygen level; the physician then ordered transfer to the hospital. The resident left by EMS at about 1:00 p.m. The physician stated he was not aware of the other changes in condition and that the risk of not receiving appropriate assessment sooner was catastrophic. Hospital staff reported the resident arrived with shortness of breath, hypoxia, and low blood pressure, was intubated, lost pulse shortly after, and later died.
Failure to Accurately Reconcile and Send Insulin at Discharge
Penalty
Summary
The facility failed to ensure that a discharged resident’s summary included an accurate reconciliation of all pre-discharge and post-discharge medications. The resident, an adult male with hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, bipolar disorder, type 2 diabetes mellitus, and a cognitive communication deficit, was discharged home to his sister, who was his POA. A physician’s order dated the day prior to discharge directed that the resident may discharge home with his sister with scheduled medications, no narcotics, and all other belongings. Progress notes confirmed the discharge home, and the discharge summary referenced the MAR for drug therapy. Record review showed that at the time of discharge, the resident had active orders for two types of insulin: Humalog (insulin lispro) 5 units subcutaneously twice daily, and insulin glargine 30 units subcutaneously twice daily, both ordered for diabetes management. The resident’s care plan identified diabetes mellitus as a focus and listed insulin glargine as a medication the resident was receiving, with interventions to monitor and document side effects and effectiveness of diabetic medications. However, the document titled “Medications Released on Leave of Absence,” which was saved in the electronic record as the discharge medication list and signed by the DON and the responsible party, did not list insulin as a medication sent home with the resident. Interviews revealed that the DON, who worked the shift of the discharge, gathered the resident’s scheduled medications (excluding narcotics) and had the responsible party sign the discharge medication list, stating she did not think the resident had insulin prescribed and that if he had, she would have sent it home. LVN A, the nurse assigned to the resident on the day of discharge, stated that the DON said she would handle the discharge medications and that insulin should be sent home with a resident being discharged, along with other scheduled medications except narcotics. In a subsequent interview, the DON acknowledged that the resident did have active insulin orders at discharge, that the insulin should have gone home, and that she overlooked it because the insulin was stored separately in the nurse’s medication cart while the medications handed to her came from the medication aide’s cart. The Regional Senior Administrator stated that, to her understanding, narcotics are the only medications not sent home at discharge, insulin usually goes home with residents, and there was no written policy specifying nurses’ actions for discharging a resident, though discharge processes were covered during nurse orientation. The facility guide for planned discharge documentation instructed staff to send medications, except discontinued medications and/or narcotics, with the resident or responsible party and to obtain verification signatures for medications received upon discharge.
Incomplete Documentation of Medication and Treatment Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two of five residents reviewed. For one resident, the Medication Administration Record (MAR) for October did not reflect documentation that Diclofenac Sodium External Gel 1% was administered as ordered three times a day. Specifically, there was a blank entry for the 5:00 pm administration on one date, and no documentation in the nurse's progress notes explaining why the treatment was not provided or documented. For another resident, the Treatment Administration Record (TAR) for October did not show documentation that an Accu-Chek blood glucose check was performed as ordered in the evening. The TAR contained blank entries for the required Accu-Chek, and there was no corresponding nurse's note to explain the omission. Both residents had complex medical histories, including conditions such as anemia, heart failure, diabetes, and cognitive impairment, and were dependent on staff for various aspects of care. Interviews with nursing staff confirmed that there should be no blanks on the MARs or TARs, and that all treatments and medications administered or not administered must be documented, including reasons for any omissions. The facility's policy also requires that all services, medications, and treatments be objectively, completely, and accurately documented in the resident's medical record by licensed personnel.
Failure to Timely Investigate and Report Injury of Unknown Source
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the State Survey Agency as required. Specifically, an incident involving an unwitnessed fall resulted in a resident sustaining a hematoma to the forehead and a skin tear to the eyebrow. The incident was not investigated or reported within the required 2-hour or 24-hour timeframes for reporting and investigating abuse and neglect, as outlined in both federal regulations and the facility's own abuse prohibition policy. The resident involved was an elderly female with multiple diagnoses, including hypertension, diabetes, malnutrition, schizophrenia, anxiety disorder, depression, muscle weakness, and dysphagia. She was cognitively impaired, requiring varying levels of assistance with daily activities and was always incontinent. On the day of the incident, the resident was found on the floor by an LPN, bleeding from a head injury. The nurse provided immediate care, notified the physician and DON, called 911, and the resident was transported to the hospital. The resident returned the same day with no further acute findings. Despite the facility's policy requiring prompt investigation and reporting of such incidents, the administrator acknowledged that the incident was neither investigated nor reported to the state agency within the required timeframe. Interviews with the administrator and DON confirmed that the process for reporting was not followed, and the administrator accepted responsibility for the oversight. The facility's policy clearly outlines the need for timely investigation and reporting, which was not adhered to in this case.
Medication Administration Documentation Deficiency
Penalty
Summary
A deficiency occurred when a resident did not receive medication as ordered, and the facility failed to ensure accurate documentation on the Medication Administration Record (MAR). Specifically, the MAR for October showed a blank entry for the administration of Diclofenac Sodium External Gel 1% for pain, with no documentation indicating whether the medication was given or the reason for omission. Review of the nurse's progress notes for the same date revealed no explanation for the missing documentation. The resident involved was an adult male with multiple diagnoses, including anemia, heart failure, hyperlipidemia, hemiplegia/hemiparesis, depression, malnutrition, morbid obesity, chronic diastolic heart failure, and osteoarthritis. His initial Minimum Data Set (MDS) indicated intact cognitive skills for decision-making and varying levels of assistance required for daily activities. At the time of observation, the resident was alert, oriented, and able to communicate his needs, and he reported receiving pain medication when requested. Interviews with nursing staff confirmed that there should be no blanks on the MARs or Treatment Administration Records (TARs), and that any medication not administered should be documented with a reason. The facility's policy also required staff to document administration or reasons for omission. The lack of documentation made it unclear whether the medication was administered as ordered, constituting a medication error and a failure to meet pharmaceutical service requirements.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and did not provide adequate supervision to prevent accidents for one resident with severe cognitive impairment. The resident, a male with diagnoses including anoxic brain damage, schizoaffective disorder, and anxiety disorder, was assessed as having a severe cognitive deficit and was known to wander, requiring a wander guard for safety. Despite these precautions, the resident was able to leave the facility unsupervised when another resident propped open a door to smoke, allowing the resident to exit undetected. On the night of the incident, the resident was last observed in bed at 10:15 PM, but by 11:05 PM, he was found outside the facility and was returned by local police after being discovered across the street. The resident was wearing his wander guard at the time, but the door being propped open bypassed the intended security measures. The facility's records indicate that the resident was outside the facility for approximately 20 minutes before being returned, and no injuries were noted upon assessment. Interviews with staff and review of facility documentation confirmed that the door was propped open by another resident, which directly led to the elopement. The facility's elopement policy required staff to ensure resident safety and monitor doors, but this was not effectively implemented, resulting in the resident's unsupervised exit. The deficiency was identified as past non-compliance at the Immediate Jeopardy level, as the failure to supervise and secure the environment exposed residents to significant safety hazards.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in meeting their medical, nursing, and psychosocial needs. For one resident receiving hospice care, the care plan lacked focus, goals, or interventions, despite the resident's significant medical conditions, including hemiplegia, chronic obstructive pulmonary disease, and dementia. The absence of a detailed hospice care plan was noted during a record review and an observation where the resident was non-responsive. Another resident, who required dialysis three times a week, did not have a care plan addressing this critical treatment. The resident's medical history included end-stage renal disease, diabetes, and vascular dementia. Despite the resident's regular dialysis schedule, the care plan failed to include any focus, goals, or interventions related to dialysis, as confirmed by record reviews and interviews with the resident and staff. A third resident's care plan inaccurately documented the side affected by a cerebral vascular accident. The care plan stated left-sided weakness, while multiple sources, including therapy notes, physician progress notes, and staff interviews, confirmed right-sided weakness. This discrepancy highlighted the facility's failure to maintain accurate and updated care plans, potentially impacting the resident's care and rehabilitation efforts.
Failure to Coordinate PASARR Assessments and Provide Specialized Services
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program, specifically for a resident with intellectual disability and mood disorder. The facility did not incorporate the recommendations from the PASARR Level II determination into the resident's assessment, care planning, and transitions of care. This resulted in the resident not receiving specialized services such as physical therapy (PT), occupational therapy (OT), and speech therapy (ST) as required. The PASARR form for these services was initially submitted but rejected due to incorrect therapy services being listed and a missing doctor signature. Despite being notified of the need to resubmit the form by a specific deadline, the facility failed to do so, leading to a lack of specialized services for the resident. Interviews with facility staff revealed a lack of clarity and responsibility regarding the submission of PASARR forms. The Rehab Director was unaware of who submitted the initial form and was waiting for approval from the MDS Coordinator to enter the resident's information for specialized services. The MDS Coordinator, who had recently started in her role, stated that the corporate office handled PASARR information and was unsure why the forms were not completed. The PASARR Unit Program Specialist had instructed the facility to submit the necessary forms by specific deadlines, but these instructions were not followed, resulting in the resident not receiving the required Medicaid services.
Insufficient Dietary Staffing Leads to Breakfast Disruption
Penalty
Summary
The facility failed to provide sufficient dietary staffing for breakfast on March 29, 2024, which could place residents at risk of not receiving meals at designated mealtimes and a diminished quality of life. On the morning of March 29, 2024, there was no dietary staff present to prepare breakfast, leading to the facility ordering kolaches and donuts for the residents. This situation arose because the Dietary Manager was on suspension, and the scheduled dietary aide, Dietary Aide B, did not show up for work and subsequently quit without notifying management. Interviews with residents revealed that they were served kolaches and donuts for breakfast on the day in question. One resident, who was the Resident Counsel President, noted that it was an isolated incident and that the issue was corrected the following day. Another resident mentioned that they were able to eat the food without difficulty and that it was enough for them. The absence of dietary staff was confirmed by multiple staff members, including the CNA, ADON, and DON, who were notified of the situation early in the morning and took steps to order breakfast for the residents. The Dietary Manager, who was responsible for making the dietary aide schedule, was suspended on March 28, 2024, and did not inform management of the staffing issue. The Administrator realized the scheduling conflict late in the afternoon on March 28, 2024, and attempted to address it by contacting the Dietary Manager, who assured her that staff would be in place. However, the dietary aide scheduled for the morning shift, Dietary Aide B, was a no call/no show and was later terminated. The facility's policy on staffing, revised in October 2017, states that sufficient numbers of staff with the necessary skills and competency should be provided to meet resident needs, which was not adhered to in this instance.
Failure to Provide Pureed Diet as Ordered
Penalty
Summary
The facility failed to ensure that two residents received food prepared in a form designed to meet their individual needs, specifically a pureed diet as ordered by their physicians. This deficiency was identified during a review of the residents' records and interviews with staff. Both residents had medical conditions that necessitated a pureed diet to prevent risks such as choking and aspiration. Despite these requirements, the facility did not provide the appropriate diet on a specific day when there was no dietary staff available to prepare meals. On the morning of the incident, the facility's dietary staff did not show up, leading to a situation where breakfast had to be ordered from outside. The staff ordered kolaches and donuts for the residents, but these were not suitable for those on a pureed diet. The CNA and other staff members improvised by preparing oatmeal, which they believed was of a pureed consistency, for the residents requiring a pureed diet. However, the dietician later clarified that oatmeal in its regular form is not considered pureed and should be blended to achieve the correct consistency. Interviews with various staff members, including the CNA, Nurse, ADON, and Dietary Manager, revealed a lack of communication and understanding regarding the dietary needs of the residents on a pureed diet. The Dietary Manager was on suspension and did not inform the management about the absence of dietary staff. Consequently, the residents on a pureed diet were served oatmeal, which was not appropriately prepared to meet their dietary requirements, potentially putting them at risk for aspiration and other complications.
Verbal Abuse by Activities Director
Penalty
Summary
The facility failed to protect a resident from verbal abuse by the Activities Director (AD). The incident involved a resident who reported feeling threatened by a statement made by the AD, "snitches get stitches and end up in ditches," during a care plan meeting attended by the Director of Nursing (DON), Administrator, and the resident's family. The resident, who was cognitively intact, expressed that the AD had not liked her since her admission and had made excuses to exclude her from outings. The resident felt the comment was directed at her, contributing to her sense of being targeted by the AD. Interviews with staff and other residents revealed a pattern of inappropriate behavior by the AD. A Licensed Vocational Nurse (LVN) witnessed an incident where the resident accidentally ran over a Certified Nursing Assistant's (CNA) foot with her wheelchair, which the AD later used to taunt the resident. Another resident corroborated the claim that the AD made the threatening statement in the smoking area, although it was not directed at anyone specifically. The AD denied making the statement and claimed the residents were targeting her due to previous incidents. Further interviews highlighted additional concerns about the AD's conduct. A CNA reported hearing the AD make derogatory comments during a bingo game, calling residents ungrateful. The CNA admitted she did not report the incident due to fear of confrontation. The facility's administration was unaware of these issues until the care plan meeting, despite having policies in place to prevent abuse and neglect. The facility's grievance log showed no prior complaints about the AD, indicating a lack of reporting or awareness of the ongoing issues.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The report details a failure in a long-term care facility to report an alleged incident of verbal abuse involving a resident and the Activities Director (AD). The incident involved a resident who felt threatened by a comment made by the AD, "Snitches get stitches and end up in ditches," which was overheard by the resident and another resident in the smoking area. The resident, who was cognitively intact, expressed feeling stressed and threatened by the comment, which was perceived as directed towards her after she had reported issues with the AD to the Director of Nursing (DON). The facility's Social Worker (SW) and other staff were unaware of the incident until it was brought up during a care plan meeting by the resident's family. The report further reveals that the Certified Nursing Assistant (CNA) B, who overheard the AD's inappropriate comments during a bingo game, failed to report the incident to the Administrator, as required by the facility's abuse reporting policy. CNA B admitted to being in shock and wanting to avoid confrontation, despite knowing the proper reporting procedure. The AD was also accused of making derogatory comments about the residents' appreciation of bingo prizes and was involved in a separate incident where a resident accidentally ran over a CNA's foot with her wheelchair. The facility's grievance log showed no prior complaints about the AD, and the AD denied making the threatening comment, suggesting that the residents had a vendetta against her. The facility's policies on abuse prohibition and resident rights emphasize the importance of reporting and addressing abuse, neglect, and mistreatment, but the failure to report the incident promptly and the lack of documentation of grievances indicate a deficiency in adhering to these policies.
Resident Threatened by Armed Visitor Due to CNA's Actions
Penalty
Summary
The facility failed to protect a resident from abuse when a CNA allowed her significant other to enter the facility and verbally abuse the resident. The significant other, who was armed with a gun, threatened the resident in his room. This incident occurred while the CNA was assisting a nurse with wound care for the resident. The resident, who had a history of paraplegia and other medical conditions, was subjected to verbal abuse and threats, causing a potential risk of harm. The incident began when the CNA's phone rang during wound care, and despite being advised not to answer, she eventually did. The significant other was heard yelling and using abusive language towards the CNA, which was then relayed to the resident. The situation escalated when the CNA put the call on speakerphone, leading to a verbal altercation between the resident and the significant other. The CNA then allowed her significant other into the facility, where he confronted the resident in person, brandishing a gun. The facility's administration was informed of the incident, and it was reported that the police were called to escort the CNA and her significant other off the premises. Interviews with staff revealed a lack of awareness of emergency procedures for workplace aggression and violence. The facility's policies on abuse prohibition and emergency procedures were not effectively implemented, leading to this serious breach of resident safety.
CNA Allows Armed Significant Other into Facility, Endangering Resident
Penalty
Summary
The facility failed to ensure a safe environment for a resident when a CNA allowed her significant other, who was armed with a pistol, to enter the facility's locked building and access the resident's room. The incident began when the CNA was assisting a nurse with wound care for the resident, and her phone kept ringing. Despite being told not to answer, the CNA eventually took the call, which led to a heated exchange between the resident and the CNA's significant other over the phone. The significant other then came to the facility, and the CNA let him in through a locked door, leading him to the resident's room where he allegedly brandished a gun. The resident involved was a male with a history of significant medical conditions, including paraplegia and a pressure ulcer, requiring substantial assistance with daily activities. During the incident, the resident and the CNA's significant other exchanged vulgarities, and the significant other reportedly pointed a gun at the resident. Another resident was present in the room but left when asked by the resident involved. The situation escalated to the point where the police were called, and the CNA and her significant other were escorted off the property. Interviews with facility staff revealed a lack of awareness and training regarding the facility's emergency procedures for workplace aggression and violence. Some staff members were unsure of the steps to take in such situations, and there was confusion about the training they had received. The facility's policy on workplace aggression and violence was not effectively communicated or implemented, contributing to the severity of the incident.
Failure to Sanitize Blood Pressure Equipment
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by the improper sanitization of blood pressure equipment used for multiple residents. Specifically, Medication Aide A was observed using the same blood pressure machine on three different residents (Residents #1, #2, and #3) without sanitizing it between uses. This practice was observed on 12/28/2023 during the morning hours. Medication Aide A admitted to forgetting to sanitize the equipment due to not having a sanitizing wipe on her cart, despite being trained on infection control protocols. The Director of Nursing confirmed that this practice exposed residents to a higher risk of cross-contamination and infection, and reiterated that all equipment used for multiple residents must be disinfected between uses. The facility's policy, dated 3/2023, also mandates the cleaning and disinfection of resident-care equipment according to CDC recommendations. Resident #1, a female with multiple diagnoses including hypertension and dementia, had her blood pressure checked first. Resident #2, also a female with multiple diagnoses including hypertension and chronic kidney disease, had her blood pressure checked next with the same unsanitized machine. Finally, Resident #3, a female with diagnoses including hypertension and respiratory failure, had her blood pressure checked with the same machine without it being sanitized. This failure to sanitize the equipment could place residents at risk of exposure to infections.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near La Porte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sylan Shores Health And Wellness | 4.4 mi | ★★★★★ | 1 | 0 |
| Mont Belvieu Rehabilitation & Healthcare Center | 6.8 mi | ★★★★★ | 9 | 0 |
| Rollingbrook Rehabilitation And Healthcare Center | 6.9 mi | ★★★★★ | 4 | 0 |
| St James House Of Baytown | 7.2 mi | ★★★★★ | 3 | 0 |
| Focused Care At Allenbrook | 7.4 mi | ★★★★★ | 3 | 0 |
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