Brown CTY Comm Treatment CTR-Bayshore Village

In the surveyor’s words

From the most serious findings on record at Brown CTY Comm Treatment CTR-Bayshore Village, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Dec 11, 2024

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 61 residents residing in the facility. The facility did not cool pre-cooked leftover food with an approved cooling method. Findings include: The 2022 Federal Food and Drug Administration (FDA) Food Code documents at section ,d+[DATE].14 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S ,d+[DATE].14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a… […]

• No harm, potential for more than minimal, patternF641Aug 30, 2023

  Based on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments were accurate for 7 Residents (R) (R16, R8, R1, R2, R14, R20 and R53) of 20 sampled residents. R16's Quarterly MDS assessment, dated 8/1/23, did not contain a Brief Interview for Mental Status (BIMS) assessment (used to determine level of cognition). A progress note, dated 8/8/23, indicated R16 had mild cognitive impairment. In addition, the MDS inaccurately indicated R16 had a physical restraint. […]

• No harm, potential for more than minimal, patternF812Sep 8, 2022

  Based on observation, staff interview, and record review, the facility did not ensure food was prepared, stored, and served under sanitary conditions. Outdated and undated products were stored for 5 Residents (R) (R15, R27, R35, R54, and R157) of 60 residents. Staff did not date or did not discard food and beverages after seven days of constitution or opening for community use beverages and R15, R27, R35, R54, and R157's individually labeled items. Kitchenette ovens had baked food debris, in varying amounts, in the interior of oven. Findings include: On 9/6/22 at 8:36 AM, Surveyor interviewed Dietary Manager (DM)-I who indicated the facility used the Food and Drug Administration (FDA) Food Code as its standard of practice. […]

• No harm, potential for more than minimal, isolatedF644Mar 4, 2026

  Based on staff interview and record review, the facility did not ensure a Pre-admission Screening and Resident Review (PASRR) Level I Screen was updated to initiate a PASRR Level II Screen for 1 resident (R) (R6) of 17 sampled residents.Since R6's PASRR Level 1 Screen on 2/14/02, R6 was prescribed antipsychotic medication and had a significant change in status. The facility did not update R6's PASRR Level I Screen and submit for Level II reevaluation.Findings include:From 3/2/26 to 3/4/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including schizophrenia, unspecified dementia, insomnia, and anxiety disorder. […]

• No harm, potential for more than minimal, isolatedF689Mar 4, 2026

  Based on observation, staff interview, and record review, the facility did not ensure 15-minute checks were consistently completed for 1 resident (R) (R54) of 2 sampled residents.R54 was at risk for elopement. R54's care plan contained an intervention for staff to complete 15-minute checks at all times (dated 2/10/26). Between 2/10/26 and 3/3/26, R54's 15-minute checks were not consistently completed.Findings include: The facility's Elopement/Absent Without Leave (AWOL) policy, revised 12/2024, indicates: It is the policy of the facility to provide specific strategies for healthcare personnel in the event a consumer attempts to leave the facility .without notifying appropriate healthcare personnel of his/her intentions to do so. […]