Bayberry Skilled Nursing & Healthcare Center

In the surveyor’s words

From the most serious findings on record at Bayberry Skilled Nursing & Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 8, 2026

  Based on observation, interview and record review, for one of two sampled residents (Resident 6) who were reviewed for accidents, the facility failed to ensure two staff were present and bed rails were provided during incontinent care (providing support for individuals who cannot control their bladder or bowels) when Certified Nursing Assistant (CNA) 2 let go of Resident 6, with no bed rail to hold onto. Resident 6 fell out of bed and sustained fracture of the surgical neck of the left humerus with fracture line extension to the greater tuberosity (left shoulder fracture).During a review of Resident 6's admission Record (AR) dated 1/5/26, the AR indicated Resident 6 was admitted to the facility in November 2025 with multiple diagnoses that included hemiplegia (paralysis that affects only… […]

• No harm, potential for more than minimal, widespreadF812Jun 28, 2024

  Based on observation, interview, and facility document review, the facility failed to ensure food was stored and prepared in a safe and sanitary environment when: 1. Kitchen Floors were not clean and maintained in good condition; 2. Chicken was not thawed safely; 3. The ice machine was not clean and was not cleaned according to manufacturer's instructions; 4. A can opener was not clean; and 5. Cutting boards were not clean and were in poor condition These failures had the potential to result in contamination of food, food preparation equipment, and utensils used for food, leading to food borne illness and/or food related illness for 80 residents who received food from the kitchen out of a census of 80. 1. […]

• No harm, potential for more than minimal, widespreadF813Jun 28, 2024

  Based on observation, interview, and record review, the facility failed to ensure: 1. Family members could bring in food for residents. 2. Residents had a location to safely store perishable food. 3. A policy described the safe storage of food brought in by family members. This failure had the potential to result in foodborne illness from unsafe food storage, decreased food intake, and did not create a homelike environment for 80 residents who took food by mouth out of a census of 80. Findings: During an interview on 6/24/24 at 11:21 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated that the facility did not have any refrigerators to store resident food in, and perishable foods were thrown away. During an interview on 6/24/24 at 11:25 a.m. […]

• No harm, potential for more than minimal, patternF600Jul 16, 2026

  Based on observation, interview, and record review, the facility failed to ensure six of 15 sampled residents (Resident 2, Resident 3, Resident 4, Resident 6, Resident 7 and Resident 8) were free from physical abuse when: 1. Resident 1 pushed and punched Resident 2;2. Resident 3 spat on Resident 4, after Resident 4 called Resident 3 a racial slur;3. Resident 5 punched Resident 6 four times;4. Resident 7 and Resident 8 hit each other. This failure had the potential to result in physical, mental and emotional harm for Resident 2, Resident 3, Resident 4, Resident 6, Resident 7 and Resident 8. 1. […]

• No harm, potential for more than minimal, patternF641Jan 8, 2026

  Based on observation, interview, and record review, the facility failed to ensure accurate coding of the Minimum Data Set (MDS, a resident assessment tool to drive resident care plan) for four of seven sampled residents (Resident 42, 49, 52, and 64) when residents' tobacco use was incorrectly coded as No on the MDS despite evidence of tobacco use. This failure resulted in an inaccurate reflection of the residents' smoking status and had the potential to affect the development and implantation of resident-centered care plans.During a review of the admission Records (ARs) for Resident 42, 49, 52, and 64, printed on 1/7/25, the records indicated that these residents were admitted to the facility on [DATE], 12/3/25, 5/16/24, and 11/7/24, respectively.During observations on 1/6/26 and 1/7/26 at… […]