Resident 69 told inspectors on January 29 that he had stopped asking to get out of bed because he was "afraid the nursing staff would tell him why he is trying/wanting to get up." He said staff would always tell him "he is supposed to be in bed and he felt he did not have the freedom to do the things he wanted to do."
The 69-year-old man was admitted to Bay Crest Care Center with a history of falls, confusion, and poor safety judgment. His care plan required one to two person assistance during transfers and bed mobility.
His fall pattern began December 18, 2024, and accelerated through January. On January 2, 2025, at midnight, he fell and sustained dry blood to his forehead, complained of blurry vision and dizziness, and was transferred to a hospital emergency room. He returned the same day with a diagnosis of head abrasion due to fall.
Three days later, the interdisciplinary team met and documented risk factors including "confusion, impaired balance, unsteady gait, poor safety awareness, not calling for assistance and falls within the last 30 days." The team recommended a sitter to assist and supervise Resident 69.
The recommendation was ignored.
On January 7 at 7:07 a.m., his roommate witnessed another fall. Resident 69 was found with a cut on his head. The licensed nurse again recommended a sitter. The interdisciplinary team repeated their recommendation for constant supervision.
Two days later, on January 9, he fell again. This time, a nursing assistant found him on the floor with a cut on his left eyebrow. His oxygen saturation dropped to 88 percent.
After the third fall in a week, his primary care physician ordered him transferred to the hospital for evaluation due to dizziness and seeing floaters. Emergency department notes documented "visual issues lights flashing with three episodes of falling over the past week." He was admitted with an impression of "unsteady gait and repeated falls."
When he returned to the facility on January 20, nursing staff documented that he remained at high risk for falls due to "history of falls in the last 6 months (five falls), disorientation/confusion, poor safety judgement, requiring assistance during toileting and a prescribed cardiac medication."
Six days later, on January 26, Licensed Vocational Nurse 2 observed him coming out of his room with his feet crossed, resulting in another fall on his buttocks in the hallway.
During the inspection, surveyors observed Resident 69 in his room on January 27, 28, and 29 with no sitter present. On January 27 at 2 p.m., he told inspectors he was "tired of watching television, and just wanted to take a nap because the nursing staff did not offer to get him out of bed."
At 4 p.m. that same day, he said he had asked nursing staff to help him get out of bed to sit in his wheelchair, "but the nursing staff did not help him."
The next morning, January 28, he told inspectors he wanted to get up "but the nursing staff told him to stay in bed." He said he wanted to sit in his wheelchair "to go outside and talk to other people."
By January 29, his frustration was evident. At 10:04 a.m., he told inspectors "he would love to get out of bed but decided not to ask anymore because he was afraid the nursing staff would tell him why he is trying/wanting to get up." He worried "he was always in bed and he might get weaker."
Licensed Vocational Nurse 2 acknowledged to inspectors that Resident 69 "had fallen five times within the past two months" and was "unsteady during walking and had episodes of getting out of bed without asking for assistance." She admitted she did not conduct fall risk reassessments or document post-fall assessments after each incident, despite facility policy requiring such evaluations.
Registered Nurse Supervisor 2 confirmed that no fall risk reassessments were documented after any of the five falls. The care plan had not been revised since December 19, 2024, and did not include the interdisciplinary team's recommendations for close monitoring, frequent visual checks, and a sitter.
The supervisor explained that on January 7, Resident 69 was moved to another room with a sitter who was watching two rooms. When he returned from the hospital on January 20, he was placed in a room with no sitter.
Certified Nursing Assistant 5 told inspectors he received instructions during shift huddles to "keep an eye on Resident 69 because of his fall risk" and tried to check on him every two hours. But he said "it was hard to do because he takes a lot of time with the other residents."
The facility's fall management policy, revised March 28, 2024, states that residents will be assessed for fall risk "to determine the residents' risk thereby providing the residents with appropriate interventions, based on their individualized care plan, to reduce the risk and minimize injury."
Director of Nursing Services told inspectors that "all residents at the facility are considered high risk for fall" and that "falls and injuries due to a fall are avoidable and preventable."
The facility also failed to maintain basic hygiene standards. Five residents had untrimmed fingernails with dark brown deposits underneath. Resident 6 showed inspectors her fingernails and said "she did not like the way her fingernails looked because they were long, unclean and no one in the facility has been provided nail care to her."
Resident 69 was similarly affected, stating "he was not happy about how his fingernails look because they were untrimmed and have dark brown deposits underneath his fingernails." He said "the nursing staff of the facility should be able to do their job by cleaning his fingernails."
Certified Nursing Assistant 1 acknowledged that CNAs are supposed to perform nail care after each resident's bath or shower, explaining that residents "could accidentally scratch themselves and cause an injury to their skin if their fingernails are not trimmed and could cause them to be exposed to infection if their fingernails are unclean."
The facility's fingernail care policy states that "trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin."
Medication errors compounded the care problems. A registered nurse was observed crushing three medications together for one resident, violating the facility's policy that states "crushing each medication separately and administering each with food is considered best practice."
During one medication pass, a registered nurse supervisor failed to provide prescribed thickened liquids to a resident with dysphagia who takes crushed medications mixed in applesauce. The resident "cleared his throat, coughed vigorously and observed whitish/yellowish secretions came out of his mouth."
The supervisor admitted she "did not have a liquid thickener in the medication cart ready to be used during medication pass" but acknowledged "it was important for the residents to be provided liquids prescribed to drink during medication pass to ensure the residents take their medications with no difficulty."
Staff training records revealed systemic failures. Four of five employee files reviewed were missing required training on abuse, dementia, infection control, LGBTQ issues, behavioral health, resident rights, and communication.
The Director of Staff Development told inspectors he received only one day of training when hired and "never saw the consultant again." He said he "cannot provide any proof that the required trainings are being done" and that "staff don't show up" for in-services. He admitted he "does not follow up with the staff and he did not let the Administrator know the staff were not showing up."
Twenty-two of the facility's 36 resident rooms failed to meet the 80 square feet per resident requirement for multiple occupancy rooms. The administrator admitted she "did not know she had to reapply for the room waiver every year."
One resident in an undersized room told inspectors "the room is very small and the staff have to reach over my stuff to get gloves."
The administrator acknowledged to inspectors that she "could improve on the facility's QAPI program and that she has not been as diligent as she should have been." The quality assurance failures resulted in repeat deficiencies from the previous year's inspection in resident rights, care planning, pharmacy services, quality improvement, and infection control.
As Resident 69 lay in bed on January 29, looking toward the hallway with a "bored expression on his face," he remained without the sitter that interdisciplinary teams had recommended after each of his five falls in two months.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bay Crest Care Center from 2025-01-31 including all violations, facility responses, and corrective action plans.
