Bay Harbor Post Acute Healthcare Center

In the surveyor’s words

From the most serious findings on record at Bay Harbor Post Acute Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF609Oct 17, 2025

  Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure four (Resident #41, Resident #11, Resident #22, and Resident #33) of 23 residents reviewed for abuse were reported/timely reported to the Administrator and State Survey Agency (SSA) and failed to ensure the results of investigations were submitted to the SSA/submitted within five working days of the incident for four (Resident #11, #2, 22, and 34 of 23 reviewed for abuse. Specifically, the failed to report/timely report the following: 1. Resident #41 reported Registered Nurse (RN) #20 physically abused the resident on 09/13/2025. Staff reported the incident to the Director of Nursing (DON); however, the DON failed to report the allegation to the SSA.2. […]

• Immediate jeopardy, patternF610Oct 17, 2025

  Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure 4 (Residents #41, #11, #33, and #34) of 23 residents reviewed for abuse had thorough investigations completed. Specifically, the facility failed to conduct thorough investigations regarding the following:1. Resident #41 reported Registered Nurse (RN) #20 physically abused the resident on 09/13/2025. Staff reported the incident to the Director of Nursing (DON); however, the DON failed to conduct a thorough investigation and failed to suspend RN #20 placing Resident #41 and additional residents at risk for abuse.2. Resident #11 reported that Housekeeper #28 pushed them. […]

• Actual harm, isolatedF760Apr 17, 2026

  Based on medical record review and interviews, it was determined that the facility staff failed to enter medication orders into a resident's electronic health record (EHR). This deficient practice was evidenced in 1 (R #238) of 5 resident records reviewed for medication administration during the recertification survey. The deficient practice resulted in harm to R#238.The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 3/13/2026. […]

• Actual harm, isolatedF689Feb 28, 2024

  Based upon medical record review, facility documentation review and staff interview it was determined that facility staff failed to safely secure a resident during a Hoyer Lift transfer resulting in the resident's subsequent injury and a hospital emergency visit. This was evident for 1 of 1 residents reviewed (Resident #50) during the Complaint survey investigation. The findings included: On 2/22/24 at 1:30 PM a review of Resident #50's Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 6/9/22 was conducted. The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident and to modify the care plan based on the resident's status. […]

• No harm, potential for more than minimal, widespreadF812Jan 17, 2025

  3) On [DATE] at approximately 9:25 AM, the Surveyor observed the Medication room at nursing station #1. There were 2 small black refrigerators sitting one on top of the other in the medication room. The inside of the bottom refrigerator door and interior shelves were dirty, covered with multiple areas of brown dried food stains and sticky cream-colored stains. The Surveyor observed a clear cup of cream-colored pudding covered with plastic wrap and labeled ,d+[DATE]. 4) On [DATE] at approximately 9:50 AM, the Surveyor observed the Clean Utility room. There was a Standard size refrigerator located in the corner of the room. Licensed Practical Nurse (LPN) #5 informed the Surveyor that was where resident stored personal foods. […]