Bayshore Residence and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Bayshore Residence and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jun 27, 2024

  Based on observation, interview, and document review, the facility failed to ensure residents were free from mental and emotional abuse for 4 of 4 residents (R1, R2, R3, R4) when nursing assistant (NA)-A took humiliating photographs of residents and video recordings of residents which NA-A then posted on Snapchat (social media). In addition, the facility failed to ensure residents were free from physical abuse when NA-A physically abused R1 when assisting R1 into bed. NA-A also video taped this abuse and posted on Snapchat. These actions had the potential to cause serious psychosocial and physical harm to residents. This deficient practice resulted in an immediate jeopardy (IJ). […]

• Immediate jeopardy, isolatedF578May 28, 2024

  Based on interview and document review, the facility failed to ensure a resident's advance directives were accurately and consistently documented in the resident's electronic health record (EHR) banner, Provider Order for Life Sustaining Treatment (POLST) and physician orders to ensure the residents wishes would be followed in the event of a cardiac arrest. This resulted in an immediate jeopardy for 1 of 34 residents (R86) who's code status was not accurately documented and was reviewed for advanced directives. The immediate jeopardy (IJ) began on [DATE], at R86's first care conference. The care conference identified R86 and family member (FM)-A as being in attendance. Section C Nursing included the following: Resident continues to be a full code. […]

• Immediate jeopardy, isolatedF689Apr 20, 2024

  Based on interview and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) who was at risk for elopement. This resulted in an immediate jeopardy (IJ) for R1 when he eloped from the facility, was not identified as missing for 1.25 hours and found 2 miles away from the facility. The IJ began on 4/15/24 at 6:37 a.m. when nursing assistant (NA)-A saw R1 outside of the facility on the sidewalk in front of the building, mistook him for a visitor, and cleared the wanderguard door alarm without searching for a missing resident. The administrator and director of nursing (DON) were informed of the IJ on 4/18/24 at 4:30 p.m. The facility had implemented corrective action on 4/16/24, prior to the start of the survey and was therefore Past Noncompliance. […]

• Immediate jeopardy, isolatedF600Mar 9, 2023

  Based on observation, interview, and document review, the facility failed to protect a resident from sexual abuse and failed to implement protective measures to prevent ongoing abuse for 1 of 1 resident (R1) reviewed for abuse. This deficient practice resulted in an immediate jeopardy (IJ) when R3 was discovered sitting on top of R1 in the bed and pulling her pants down while R2 was standing next to the bed with their pants down below their knees. Further, the facility failed to implement protective measures, assess for ability to consent, and notify R1's physician of the incident. The IJ began on 2/17/23, when family member (FM)-A reported to registered nurse (RN)-C R1's R2 and R3 were found in R1's room. R3 was sitting on top of R1's legs, in her bed, pulling her pants down. […]

• Immediate jeopardy, isolatedF760Apr 15, 2022

  Based on interview and document review, the facility failed to develop a system to ensure medications were correctly transcribed for 1 of 3 residents (R1). This resulted in an Immediate Jeopardy (IJ) situation for R1 when her [MEDICATION(S)] (diuretic) was inadvertently discontinued which resulted in R1 not receiving diuretic medication for 11 days, and subsequently hospitalized with heart failure. The immediate jeopardy began on 3/24/22, when R1's [MEDICATION(S)] had been incorrectly discontinued. On 4/4/22, R1 was sent to the emergency department (ED) with low oxygen saturation levels (68% on room air) and difficulty breathing. R1 was admitted to the hospital and was given intravenous (IV) [MEDICATION(S)] (diuretic). […]