Bayshire Riverwalk Post-Acute

In the surveyor’s words

From the most serious findings on record at Bayshire Riverwalk Post-Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 2, 2026

  Based on observation, interview, and record review, the facility failed to:1. Follow the physical therapy (type of treatment that helps regain normal movement and ease pain after an injury, surgery, or a medical condition that limits the ability to function) recommendation for non-weight bearing status (limiting the amount of weight or pressure placed on a specific limb) on right upper extremity (RUE) for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA 1) instructed Resident 1 to hold onto the grab bars with both hands while in the shower room.2. Ensure Resident 1 was sitting in the shower chair while being undressed in the shower room for one of three sampled residents (Resident 1).3. […]

• Actual harm, isolatedF600Dec 8, 2025

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse (any intentional act causing injury or trauma to another person through bodily contact) when Certified Nursing Assistant (CNA) 1 hit Resident 1 on the right side of his face while CNA 1 and CNA 2 were changing Resident 1's adult brief. This failure resulted in Resident 1 crying and having redness on his face.Findings:During a review of the SOC-341 (Report of Suspected Dependent Adult/Elder Abuse), dated 8/26/25, the SOC-341 indicated, A CNA (2) stated another CNA (1) slapped a resident (Resident 1) in the face while providing care.During a review of Resident 1's Summary of the Incident (SI), documented by Administrator, dated 8/31/25, the SI… […]

• Actual harm, isolatedF689Dec 4, 2025

  Based on observation, interview, and record review, the facility failed to ensure the temperature was taken for a cup of soup prior to serving it to one of three sampled residents (Resident 1) after being heated up, by the nursing staff, in the microwave. This failure resulted in Resident 1 sustaining a second degree burn (damages the epidermis (surface of the skin)) and dermis (thick layer of living tissue below the epidermis containing blood vessels, nerve endings, sweat glands, hair follicles and other structures) layers of the skin and is characterized by blistering, deep redness, swelling, and intense pain) to his left-hand pointer finger.Findings:During a review of Resident 81's admission Record (AR), the AR indicated Resident 81 was admitted on [DATE] and had diagnoses of acquired… […]

• Actual harm, isolatedF655Feb 15, 2023

  Based on observation, interview, and record review, the facility failed to develop a baseline care plan for falls within 48 hours of admission for one of three sampled residents (Resident 1) with a history of falls that included the necessary information for staff to ensure the safety and well-being of Resident 1. This failure resulted in Resident 1 falling, breaking her right hip and transfer to a local hospital for surgical repair. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated, the facility admitted Resident 1 on 10/23/22. […]

• Actual harm, isolatedF689Sep 8, 2022

  Based on observation, interview, and record review, the facility failed to maintain a safe environment for one of four sampled residents ' (Resident 1) when: 1. Resident 1 ' s left wheelchair brake would not lock. 2. A care plan (helps nurses and other care team members organize aspects of resident care according to a timeline) for transfer and toileting was not followed and a non-compliance care plan was not initiated. 3. The policy and procedure for Falling Star Program (a star is placed at the entrance of the door and/or over the resident ' s bed indicating the resident is at risk for falls) was not implemented. 4. […]