Bayberry Commons

In the surveyor’s words

From the most serious findings on record at Bayberry Commons, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Dec 19, 2024

  Based on record review and staff and resident interview, it has been determined that the facility failed to ensure that residents are free from sexual abuse, for 1 of 2 residents reviewed, Resident ID #1. Findings are as follows: Review a facility reported incident submitted to the Rhode Island Department of Health on 12/13/2024, revealed that Resident ID #1 and Resident ID #2 were found in a room where they appeared to be engaging in an act that was sexual in nature. Review of a policy titled Abuse prohibition last reviewed on 12/4/2024, states in part, It is the policy of this facility to ensure that all residents are treated with respect and dignity and that all residents are free from abuse, mistreatment, neglect and or misappropriation of their personal property .Residents have the… […]

• Actual harm, isolatedF580Feb 20, 2025

  Based on record review and staff interview, it has been determined that the facility failed to immediately consult with the resident's physician and notify them when there is a significant change in the resident's condition, for 1 of 1 resident reviewed who experienced a change in condition, Resident ID #2. Findings are as follows: Review of a facility policy titled Medication Administration Safety Program (MASP)- Physician Notification states in part, .When a regularly scheduled dose of medication is not administered due to resident refusal, unavailability, resident condition or absence from the facility, the physician should be notified . […]

• Actual harm, isolatedF689Aug 5, 2024

  Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive assistance devices to prevent accidents for 1 of 2 residents reviewed who utilize hip protectors, Resident ID #1. Findings are as follows: Review of the facility reported incident submitted to the Rhode Island Department of Health on 8/1/2024 states in part, Resident was ambulating with staff in the hallway. [S/he] tripped, lost [his/her] balance and fell to the floor .[S/he] was transferred to [hospital's] emergency department and subsequently admitted with a diagnosis of R [right] femur fracture. […]

• No harm, potential for more than minimal, patternF756Jul 18, 2025

  Based on record review and staff interview, it has been determined that the facility failed to ensure a resident's drug regimen was reviewed and acted upon by the attending physician, when irregularities were identified during the monthly Pharmacist Medication Regimen Review (MRR) for 3 of 5 residents reviewed, Resident ID #s 10, 92, and 107.Findings are as follows:Record review of a facility policy titled, CONTINUOUS QUALITY IMPROVEMENT OF THE MEDICATION USE PROCESS last revised January of 2023, states in part, The care center is responsible for monitoring the quality of the entire medication use process including, the.outcomes of consultant pharmacy services.1. […]

• No harm, potential for more than minimal, patternF880Jul 18, 2025

  Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, for 3 of 3 residents reviewed for transmission-based precautions (TBP) Resident ID #s 3, 91, and 105.Findings are as follows:Review of a facility policy titled, Guidelines for Management of MDROs [Multi-Drug Resistant Organism] states in part, .CONTACT PRECAUTIONS - In addition to Standard Precaution, Contact precautions or the equivalent used with specific individuals known or suspected to be infected or colonized with epidemiologically important micro-organisms that can be transmitted by direct contract with the individual or indirect contact with… […]