Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Baywood Crossing Rehabilitation & Healthcare Cente during CMS and state inspections, most recent first.
Failure to Obtain Consent for Antidepressant Medication: A resident with intact cognition and her own responsible party status was prescribed and given Mirtazapine for adjustment disorder with mixed anxiety and depressed mood, but the EHR did not contain a signed consent for the antidepressant. The ADON confirmed the medication was administered without the required consent, and the facility policy stated antidepressant consents must be obtained and recorded in the EHR.
The facility had incomplete and inaccurate resident records for multiple residents. One resident admitted with a femur fracture had no physician progress notes in the chart even though the physician said he saw the resident and discussed care with the PA, and the record also lacked required antidepressant monitoring notes. Several residents with wounds or pressure injuries had missing TAR entries for ordered wound treatments, while staff said wound care was usually done by the wound care nurse, with weekend or covering nurses responsible when she was unavailable.
A resident with a history of stroke and hemiplegia experienced dental pain and a broken tooth, which was documented by an LVN. Despite the pain affecting the resident's eating, there was no timely follow-up by the social worker or other staff, and the resident's family eventually filed a grievance. The resident did not receive dental treatment until about a month after the initial complaint, highlighting a failure in communication and timely response to dental emergencies.
The facility failed to obtain a signed consent for the antipsychotic medication Quetiapine fumarate (Seroquel) administered to a resident with severe cognitive impairments. Despite the facility's policy requiring informed consent, the medication was given without it, placing the resident at risk.
The facility failed to conduct accurate assessments of residents' oral dental and vision needs. Several residents were not properly assessed for their dental conditions, despite having significant issues such as missing teeth and the need for dentures. One resident also had vision problems that were not accurately documented. The MDS coordinator admitted to being unsure of how to code these assessments, leading to inaccuracies.
The facility failed to create comprehensive care plans for three residents requiring assistance with ADLs, despite their severe cognitive impairments and multiple diagnoses. Observations and interviews confirmed the need for staff assistance, but no care plans were documented, posing a risk of improper care.
A resident with dementia and other conditions was administered Quetiapine fumarate (Seroquel) without the facility obtaining a signed consent. Interviews with the DON and ADON confirmed the lapse in following the facility's protocol for informed consent.
The facility failed to ensure accurate PASRR screening for a resident with multiple mental health disorders, including bipolar disorder and major depressive disorder. Despite severe cognitive impairment and active diagnoses, the PASRR Level 1 Screening incorrectly indicated no evidence of mental illness. The MDS Coordinator admitted the oversight.
A resident with significant dental issues was not assisted with a dental service consult despite evident need. The resident was told he had to pay for the visit out of pocket, but it was later found that his insurance covered routine dental care. The facility's policy on referrals was not followed, leading to the deficiency.
Failure to Obtain Consent for Antidepressant Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed in advance of care and treatment by not obtaining a signed consent for Mirtazapine, an antidepressant medication. Resident #1 was a female admitted with a diagnosis including fracture of the unspecified part of the neck of the left femur, and her face sheet identified her as her own responsible party. Her admission MDS showed a BIMS score of 15, indicating intact cognition, and her discharge MDS showed she had taken an antidepressant in the last 7 days. Physician orders showed Mirtazapine 7.5 mg by mouth at bedtime, started for adjustment disorder with mixed anxiety and depressed mood, and the February 2026 MAR showed the medication was administered on multiple days, including one dose signed by MA A. Review of the electronic medical record did not reveal a consent for Mirtazapine. During interview, the ADON stated Mirtazapine should have had a consent, confirmed the medication was given without one in the record, and said consent was supposed to be obtained from the resident or responsible party before proceeding. The facility policy for psychotropic medication use stated antidepressant medication consents would be obtained and recorded in the EHR.
Incomplete resident records and missing physician visit documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for five residents reviewed. The report states that antidepressant monitoring documentation was inaccurate and/or incomplete for one resident, wound care documentation was inaccurate and/or incomplete for five residents, and one resident was not seen by a physician during the admission period at the facility. The deficiency was identified through observation, interview, and record review. For one resident admitted with a left femur fracture and later discharged from the facility, the record showed the attending physician was listed as the primary physician, with a PA and NP also involved in care. The chart contained progress notes written by the PA and NP, but the Administrator stated there were no progress notes written by the physician. The physician stated he and the PA both saw residents during the first 72 hours and discussed them, but he did not have a way to attest to the notes and said he had been having the PA write the notes referring to him. The Administrator acknowledged that the physician had to do the initial visit and said if the physician did not do the initial visit, a diagnosis could be missed. For the same resident, the record showed antidepressant medication monitoring orders requiring documentation every shift and a progress note if side effects were observed, but the February MAR contained Y entries for monitoring and the progress notes did not include notes for the documented monitoring dates. The resident also had wound orders for the left buttock and coccyx, but the TAR showed missing documentation on multiple dates for those wound treatments. The report also documented missing wound treatment entries for four other residents with pressure injuries or wounds, including missing TAR documentation for ordered treatments to the buttocks, heels, feet, sacrum, and other wound sites. Staff interviews confirmed that wound care was generally performed by the wound care nurse on weekdays, with the weekend supervisor or other nurses covering when needed, but the missing documentation remained unexplained in several instances.
Failure to Provide Timely Dental Care for Resident with Dental Pain
Penalty
Summary
The facility failed to assist a resident in obtaining timely routine and emergency dental care after dental pain was documented. The resident, a 59-year-old male with hemiplegia and hemiparesis following a stroke, was noted to have dental pain and a broken tooth in early July, as documented by an LVN in the electronic medical record. The LVN left a message with the resident's responsible party and noted to inform Social Services, but there were no progress notes from the social worker regarding dental care for the resident during June or July. The resident continued to experience dental pain, avoided eating, and his roommate confirmed the pain and its impact on eating habits. The issue persisted until mid-August, when the resident's family filed a grievance with the facility, expressing concern about the lack of dental care and the need for an appointment. The family was informed that the contracted dentist only visited quarterly and could not provide unscheduled visits, and they were advised to seek outside dental care if needed. The resident eventually received dental care, including an extraction and plans for further treatment, but this occurred about a month after the initial complaint of pain. Interviews with the resident, his family, and his roommate confirmed the delay and the impact on the resident's well-being, including reduced food intake due to pain. Staff interviews revealed a lack of communication and follow-through regarding the resident's dental pain. The social worker stated that dental pain should be treated as an emergency, especially if it affects eating, but was not aware of the resident's issue until the family grievance. The DON confirmed that dental referrals go through the social worker, and the administrator acknowledged that action was only taken after the family raised the issue. Facility policy required provision of routine and 24-hour emergency dental services, but this was not followed in the resident's case.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to inform residents in advance of the risks and benefits of proposed care and treatment, specifically for one resident who was administered the antipsychotic medication Quetiapine fumarate (Seroquel) without obtaining a signed consent. Resident #3, an elderly male with diagnoses including unspecified dementia, anxiety disorder, encephalopathy, and major depressive disorder, was unable to complete the Brief Interview for Mental Status (BIMS) and had severely impaired daily decision-making skills. Despite these conditions, the facility did not have a current consent for the antipsychotic medication treatment, which was actively being administered to the resident. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that the facility's protocol required obtaining informed consent before administering or changing the dosage of antipsychotic medications. However, the ADON admitted that the facility did not have a current consent for Resident #3 and was in the process of obtaining it from the resident's Power of Attorney (POA). The facility's policy, last revised in January 2023, mandates that informed consent be documented on a specific form prior to the administration of such medications. This lapse in protocol placed residents at risk of receiving treatments without informed consent.
Inaccurate Resident Assessments for Oral Dental and Vision Needs
Penalty
Summary
The facility failed to conduct comprehensive and accurate assessments of residents' functional capacities, specifically regarding their oral dental needs and vision. Resident #8, who had severe cognitive impairment, was not accurately assessed for oral dental concerns despite having no teeth and no dentures. Similarly, Resident #26, who was moderately impaired cognitively, was also not accurately assessed for oral dental concerns, even though her care plan indicated she was edentulous and wore dentures. Both residents were observed to be on mechanically altered diets and assisted with their meals, indicating potential issues with chewing and oral health that were not properly documented in their assessments. Resident #76, who had moderate cognitive impairment, was not accurately assessed for his vision and oral dental needs. His care plan indicated he had missing teeth and chose not to wear dentures, yet his MDS assessment did not reflect these issues. During an interview, Resident #76 expressed the need to see a dentist and mentioned significant tooth loss, which was not documented in his assessment. Additionally, he reported vision problems and the need for bifocal eyeglasses, which were also not accurately reflected in his MDS assessment. Resident #97, who had intact cognition, was also not accurately assessed for oral dental needs. Her care plan indicated she was edentulous and wore dentures, but her MDS assessment did not reflect any oral dental concerns. The MDS coordinator admitted to being new to the position and unsure of how to code the residents' oral dental assessments, leading to inaccuracies. The facility's social worker also failed to follow up on insurance coverage for dental care and eyeglasses for Resident #76, further contributing to the deficiencies in resident assessments.
Failure to Develop Comprehensive Care Plans for ADL Assistance
Penalty
Summary
The facility failed to create comprehensive resident-centered care plans with measurable objectives for three residents who required assistance with activities of daily living (ADLs). Resident #17, an 82-year-old female with severe cognitive impairment and multiple diagnoses including dementia and chronic kidney disease, did not have a care plan for ADL assistance. Observations and interviews confirmed that she required staff assistance for toileting, bathing, dressing, and hygiene, but no care plan was in place to address these needs. Similarly, Resident #52, a 77-year-old female with severe cognitive impairment and multiple diagnoses including osteoarthritis and major depressive disorder, also lacked a care plan for ADL assistance despite requiring extensive staff help for transfers, dressing, toileting, hygiene, and supervision for bathing. Observations and interviews corroborated her need for assistance, but no care plan was documented to guide her care. Resident #158, a female with severe cognitive impairment and multiple diagnoses including metabolic encephalopathy and chronic kidney disease, also did not have a care plan for ADL assistance. She required moderate to maximum staff assistance for hygiene, transfers, showers, toileting, and dressing, but no care plan was in place to address these needs. Interviews with the MDS nurse and the Director of Nursing (DON) confirmed that the care plans for these residents were missed, and the lack of accurate care plans posed a risk of improper care. The facility's policy on comprehensive person-centered care plans, which mandates ongoing assessments and revisions as resident conditions change, was not followed in these cases.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to inform residents in advance of the risks and benefits of proposed care and treatment, specifically for one resident who was administered the antipsychotic medication Quetiapine fumarate (Seroquel) without obtaining a signed consent. The resident, an elderly male with diagnoses including unspecified dementia, anxiety disorder, encephalopathy, and major depressive disorder, was unable to complete the Brief Interview for Mental Status (BIMS) and had severely impaired daily decision-making skills. Despite these conditions, the facility did not secure informed consent from the resident or his Power of Attorney (POA) before administering the medication. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that the facility's protocol requires obtaining informed consent prior to administering psychotropic medications. However, the ADON admitted that the facility did not have a current consent for the resident and had not followed up with the POA to obtain it. The facility's policy, last revised in January 2023, mandates obtaining informed consent documented on a specific form, which was not adhered to in this case.
Failure to Ensure Accurate PASRR Screening for Resident with Mental Health Disorders
Penalty
Summary
The facility failed to ensure that individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening. Specifically, the facility did not review Resident #8's PASRR Level 1 assessment for accuracy and did not refer the resident for further assessment for services. Resident #8, a female with multiple diagnoses including bipolar disorder, major depressive disorder, and anxiety disorder, was admitted and readmitted to the facility. Despite having a significant change assessment indicating severe cognitive impairment and active diagnoses of mental illness, the PASRR Level 1 Screening incorrectly indicated no evidence of mental illness. During an interview, the MDS Coordinator admitted responsibility for completing PASRRs and acknowledged that Resident #8 should have been referred for a PASRR evaluation on admission but was overlooked. The failure to refer Resident #8 for a PASRR evaluation could place residents at risk of not receiving needed assessments, individualized care, and specialized services to meet their needs.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide or obtain dental services for a resident who had missing teeth and dental decay. The resident, who was moderately impaired with cognition and had clear speech and vision, was not assisted with a dental service consult despite his evident need. The resident expressed that he needed to see a dentist but was told he had to pay for the visit out of pocket. He had significant dental issues, including almost no teeth in his upper oral cavity and none in his lower oral cavity, which affected his ability to eat properly. The facility's social worker initially stated that the resident had to pay for dental care out of pocket because he was a full vendor. However, upon further investigation, it was found that the resident's insurance did cover routine dental care. The facility's policy on referrals indicated that social services personnel should coordinate resident referrals with outside agencies and document these referrals in the resident's medical record. Despite this policy, the necessary dental care referral was not made in a timely manner for the resident, leading to the deficiency noted in the report.
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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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