Bay Harbor Post Acute Healthcare Center
BAY HARBOR POST ACUTE HEALTHCARE CENTER in SALISBURY, MD — inspection on October 17, 2025.
Found 10 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 10/07/2025 at 8:38 AM, when informed that she entered the room without knocking or announcing herself, GNA #48 stated, The door was open.
She indicated that staff did not have to knock before entering a resident's room if the door was already open.
During an interview on 10/17/2025 at 1:21 PM, the Regional Director of Operations (RDO) stated it was his expectation that staff make themselves known before entering a room.
Ideally, that meant knocking before entering, but announcing themselves before entering was also acceptable.
During an interview on 10/17/2025 at 2:40 PM, the Regional Nurse Consultant (RNC) confirmed staff should knock before entering. It was not a facility expectation for staff to enter the room without knocking just because the door was open.
During an interview on 10/17/2025 at 2:45 PM, Unit Manager #18 stated that staff should knock before entering. It was not facility expectation for staff to enter the room without knocking just because the door was open.
She stated that staff would not enter their neighbor's home without knocking, and the residents' rooms were their homes.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 10/17/2025 at 1:21 PM, the Regional Director of Operations (RDO) stated that call lights should be answered timely and as soon as possible.
There was no specific threshold for the number of minutes the facility targeted. If there was a pattern in the grievances, the facility should be taking a different approach based on what was working and not working. He stated it would be hard to answer what the facility was doing to address grievances because he was not the Administrator. He was not sure if the concerns referenced Resident Council Minutes had been addressed in the Quality Assurance and Performance Improvement (QAPI) committee but stated he would search for any related Performance Improvement Plan (PIP). No documentation regarding QAPI was provided by the end of the survey.
During an interview on 10/17/2025 at 1:49 PM, the Regional Nurse Consultant (RNC) stated the call light should be answered as soon as possible.
She did not know what the threshold was for call lights changing from solid to flashing.
She also did not indicate if there was a certain timeframe targeted by the facility in terms of how quickly call lights were responded to.
She could not speak to the grievances or Resident Council process as she was not the Director of Nursing (DON).
She did state the facility's grievance policy should be followed.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
SUMMARY STATEMENT OF DEFICIENCIES
During an observation on 10/08/2025 at 12:00 PM, Resident #35's call light was noted to be on and flashing. An interview with Resident #35 at this time revealed the resident had requested acetaminophen and had been waiting since 11:00 AM.
During an interview on 10/08/2025 at 12:05 PM, Geriatric Nurse Aide (GNA) #24 stated a call light should not be turned off until the resident's need was met.
During a phone interview on 10/15/2025 at 3:11 PM, GNA #50 stated that staff tried to answer call lights as fast as they could, but sometimes there were three or four lights going off simultaneously.
She indicated the GNAs tried to work as best as they could, but things would be faster or quicker if they had more staffing.
During an interview on 10/17/2025 at 1:21 PM, the Regional Director of Operations (RDO) stated that call lights should be answered timely and as soon as possible.
There was no specific threshold for the number of minutes the facility targeted. If there was a pattern in the grievances, the facility should be taking a different approach based on what was working and not working. He stated it would be hard to answer what the facility was doing to address grievances because he was not the Administrator. He was not sure if the concerns referenced in the grievances had been addressed in the Quality Assurance and Performance Improvement (QAPI) committee but stated he would search for any related Performance Improvement Plan (PIP). No documentation regarding QAPI was provided by the end of the survey.
During an interview on 10/17/2025 at 1:49 PM, the Regional Nurse Consultant (RNC) stated the call light should be answered as soon as possible.
She did not know what the threshold was for call lights changing from solid to flashing.
She also did not indicate whether there was a certain timeframe targeted by the facility in terms of how quickly call lights should be answered.
She stated she could not speak to the grievances, as she was not the Director of Nursing (DON) but stated the facility's grievance policy should be followed.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
SUMMARY STATEMENT OF DEFICIENCIES
observed with another resident in Resident #16's bed, the residents were fighting over Resident #16's pillow, and Resident #16 was observed with a wound on their right forearm.
During an interview on 10/15/2025 at 3:28 PM, Licensed Practical Nurse (LPN) #62 stated she observed the altercation between Resident #16 and Resident #49 (on 05/10/2025).
She stated Resident #49 was arguing with Resident #16 about the pillow, and she observed Resident #49 with his fingernails in Resident #16's arm. LPN #62 stated she attempted to separate the residents and was eventually able to coach Resident #49 out of the room.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
SUMMARY STATEMENT OF DEFICIENCIES
ombudsman.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 10/11/2025 at 6:24 PM, the DON stated she submitted the facility's five-day report but was unable to provide any type of confirmation.
During an interview on 10/11/2025 at 6:24 PM, the RDO revealed they believed there were problems with the way the SSA had them submit final reports, because there was no way to get confirmation that the report was accepted.
- An admission Record indicated the facility admitted Resident #22 on 10/17/2024.
According to the admission Record, the resident had a medical history t
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
been on guard, watchful, or easily startled, and been trying hard to not think about the events. Resident #41's weekly skin check dated 10/09/2025 revealed no new skin impairments were identified, and a social service assessment dated [DATE] revealed the resident had no verbal indicators or emotional distress/anxiety.
- Registered Nurse (RN) #20's timecard sheet revealed their last date worked was on 09/29/2025 and
Housekeeper #28's last date worked was on 10/11/2025.
Record review revealed the RDO placed the Administrator and DON on administrative leave on 10/11/2025.
Record review revealed the facility obtained statements from RN #20 and Housekeeper #28 of their witness accounts of the allegations against them.
Record review revealed social services staff met with Resident #33 on 10/11/2025 and identified the resident as self-isolating and feeling guilty.
Record review revealed social services staff met with Resident #41 on 10/11/2025 and identified no verbal indicators or emotional distress/anxiety during assessment.
Record review revealed Resident #33's representative was made aware of the abuse allegation on 10/11/2025 at 9:56 PM, and Resident #41's representative was made aware of the abuse allegations on 10/09/2025 at 3:15 PM.
Record review revealed the RDO notified the Medical Director of the allegation of physical abuse for Resident #41 and sexual abuse for Resident #33.
Record review revealed Local Law Enforcement were notified of Resident #33's allegation of sexual abuse allegation and Resident #41's allegation of physical abuse allegation on 10/10/2025 and 10/09/2025, respectively.
Record review revealed the facility notified the SSA of Resident #41's physical abuse allegation on 10/09/2025 and Resident #33's allegation of sexual abuse on 10/09/2025.
Record review revealed Medical Directors were notified of the allegations of abuse on 10/11/2025.
Record review revealed the facility notified the Ombudsman of the allegations of abuse Resident #41 and Resident #33 on 10/12/2025.
Record review revealed Resident #33's trauma assessment completed on 10/11/2025 identified past sexual abuse and Resident #41's trauma assessment completed on 10/11/2025 [NAME]
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 10/17/2025 at 5:26 PM, the Regional Director of Operation (RDO) stated he would expect residents to receive therapy services as ordered by the resident's physician.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 10/10/2025 at 11:36 AM, the Director of Nursing (DON) stated she could not locate Resident #30's shower documentation for 01/2025 or 02/2025.
The DON stated resident showers were documented on a paper form during that time, and they were not located in Resident #30's record.
The DON stated that the documentation should be part of the resident's medical record.
During an interview on 10/15/2025 at 10:50 AM, the Interim DON (Int. DON) stated she would expect staff to follow guidelines of the resident's care record and the GNA tasks to see what tasks would require documentation.
The Int. DON stated shower and bathing documentation would be included in the GNA task documentation, and she would expect staff to document using the appropriate coding to signify if the task occurred or did not occur.
During an interview on 10/17/2025 at 5:26 PM, the Regional Director of Operations (RDO) stated he would expect staff to document care the resident received in the resident's medical record.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/17/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 10/16/2025 at 10:31 AM, GNA #46 stated she was not aware of any point during the catheter care procedure at which she should have changed gloves and performed hand hygiene. GNA #46 acknowledged she should have changed her gloves and washed her hands after providing catheter care before touching the resident or the resident's belongings.
During an interview on 10/17/2025 at 12:05 PM, the Infection Preventionist (IP) stated she would occasionally observe staff perform catheter care for residents, but probably not as much as she should.
During an interview on 10/17/2025 at 4:33 PM, the Interim Director of Nursing (Int. DON) stated if a GNA was performing catheter care and cleaning the area around the catheter, she would expect staff to put on gloves and change the gloves after finishing the procedure.
During an interview on 10/17/2025 at 5:26 PM, the Regional Director of Operation (RDO) stated he would expect staff to perform good hand hygiene and follow facility protocols regarding infection control practices.
Facility ID: