Bay Pointe Nursing Pavilion

In the surveyor’s words

From the most serious findings on record at Bay Pointe Nursing Pavilion, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Jul 10, 2026

  Based on observation and interviews, the facility failed to ensure hand hygiene was offered to residents before dining, staff performed hand hygiene during meal tray passing, and infection control standards of practice were followed in the kitchen. Findings included:On 7/7/26 at 9:25 a.m., an observation of the dish machine area revealed Staff O, Dietary Aide and Staff P, Dietary Aide, operating the dish machine. Both staff were observed with painted, artificial fingernails approximately one half inch to one inch long. Staff P was observed scraping dirty kitchenware before loading the items into the dish machine. […]

• No harm, potential for more than minimal, patternF645Jul 10, 2026

  Based on record review and interviews, the facility failed to update required Level I Preadmission Screening and Resident Review (PASARR) information and failed to complete Level II PASRR evaluations when needed. This failure affected four (Residents #17, #4, #6, and #80) out of 21 residents sampled. As a result, these residents did not receive required assessments to determine whether they needed specialized mental health services. Findings include: Record review showed Resident #17 was first admitted on [DATE] with several mental health diagnoses, including Brief Psychotic Disorder, Major Depressive Disorder (recurrent, moderate), and Generalized Anxiety Disorder. […]

• No harm, potential for more than minimal, patternF761Jul 10, 2026

  Based on observations, interviews, and record review, the facility failed to ensure medications were stored according to professional standards for three of six medication carts reviewed and failed to ensure medications were not stored at the bedside. This deficient practice created the potential for medication contamination, diversion, and unsafe administration. Findings include: On [DATE] at 10:00 a.m., an observation of Resident #24 showed a medication cup containing two pills—one peach colored and one red—left on the resident's bedside table. On [DATE] at 8:50 a.m., an observation of the 100 Hall medication cart showed a container of bleach kill wipes stored directly next to resident medication cards in the bottom drawer with no divider separating the chemicals from the medications. […]

• No harm, potential for more than minimal, patternF755Apr 8, 2026

  Based on observations, record reviews and interviews the facility failed to ensure shift to shift controlled substance logs were complete and accurate for five hall logs (100, 300, 400, 500, and 600) out of six controlled substance logs reviewed. Findings included: On 4/8/26 at 9:12 a.m. during an observation, interview and narcotic count verification of the 400 Hall even cart with Staff A, Licensed Practical Nurse (LPN), the controlled substance key exchange audit (CSKEA)form used to document controlled medications and medication cart key exchange was noted blank. There were no signatures by the off going or oncoming nurse. Staff A, LPN said controlled medications were counted at the beginning of the shift and stated she did not sign the form. […]

• No harm, potential for more than minimal, patternF725Mar 12, 2025

  Based on review of facility records, staff and resident interviews, the facility failed to ensure sufficient staffing to meet the needs of the residents as evidenced by, 1. Resident interviews on untimely call light response for five residents (#11, #14, #15, #10 and #16) of 8 residents sampled, 2. Unresolved grievances related to call light response times for one resident (#11) of five residents reviewed for grievances. Findings included: On 3/10/25 at 2:20 p.m., an interview was conducted with Resident #11 who stated, depending on who's working the call light response varies. […]