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 10/17/2025 at 1:21 PM, the Regional Director of Operations (RDO) stated it
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.
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Bay Harbor Post Acute Healthcare Center 200 Civic Avenue Salisbury, MD 21804
10/17/2025 at 1:49 PM, the Regional Nurse Consultant (RNC) stated the call light should be answered
how quickly call lights were responded to.
She could not speak to the grievances or Resident Council
should be followed.
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Bay Harbor Post Acute Healthcare Center 200 Civic Avenue Salisbury, MD 21804
Based on continued observations, staff did not provide the
During an observation on 10/08/2025 at 12:00 PM, Resident #35's call light was noted to be on and
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.
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Bay Harbor Post Acute Healthcare Center 200 Civic Avenue Salisbury, MD 21804
05/10/2025).
She stated Resident #49 was arguing with Resident #16 about the pillow, and she
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Bay Harbor Post Acute Healthcare Center 200 Civic Avenue Salisbury, MD 21804
During an interview on 10/15/2025 at 9:52 AM, the RDO stated a thorough investigation of abuse
well as staff on the unit to get an understanding of what happened during the alleged time frame.
The RDO confirmed there were no statements in the report file from Resident #11 or Housekeeper #28.
Specifically, he stated that they were confident everything from the facility investigation had been turned over.
The resident who made the allegation should also have a statement.
The RDO said those interviews were part of their policy and protocol.
The Regional Nurse Consultant was also present during the expectations interview, and she confirmed the expectations communicated by the RDO.
She also added that it was part of the facility process to notify the Ombudsman of abuse allegations.
- An admission Record revealed the facility admitted Resident #30 on 02/20/2023.
According to the admission Record, the resident had a medical history that included diagnoses of aphagia following cerebral infarction, dysphagia, oral phase, and vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
A Maryland Department of Health Office of Health Care Quality Facility Reported Incident Initial Report Form revealed an allegation of neglect was filed by the facility on 01/29/2025 at 2:30 PM by the facility's Director of Nursing (DON).
The Report Form revealed an allegation was made by a family member of Resident #30 involving neglect of care and services on 01/29/2025 at 1:30 PM.
The Report Form revealed a notification to law enforcement was not made.
During an interview on 10/15/2025 at 10:50 AM, the Interim DON (Int. DON) stated allegations of neglect should be reported to law enforcement, and she would expect staff to follow the facility policy as far as reporting was concerned.
- Review of Initial Reports revealed the following:
- An Initial Report dated 06/04/2025 at 3:40 PM for Resident #22 indicated an allegation of verbal abuse was not reported to other agencies. - An Initial Report dated 04/03/2025 at 11:15 AM for Resident #24 indicated an allegation of an injury of unknown origin was not reported to other agencies.
An Initial Report dated 02/17/2025 at 3:18 PM for Resident #34 indicated an allegation of verbal abuse was not reported to other agencies.
An Initial Report dated 03/12/2025 at 10:30 AM for Resident #35 indicated an allegation of verbal abuse was not reported to other agencies.
During an interview on 10/08/2025 at 9:05 AM, the Regional Director of Operations/Interim Administrator (RDO) stated he expected staff to follow their policy and report all allegations to all agencies as required.
During an interview on 10/16/2025 at 3:04 PM, the Regional Nurse Consultant/Interim Director of Nursing (Inter. DON) stated she expected the staff to report allegations to the police and the ombudsman.
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Bay Harbor Post Acute Healthcare Center 200 Civic Avenue Salisbury, MD 21804
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
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Bay Harbor Post Acute Healthcare Center 200 Civic Avenue Salisbury, MD 21804
and Housekeeper #28's last date worked was on 10/11/2025.
jeopardy to resident health or 4.
Record review revealed the RDO placed the Administrator and DON on administrative leave on safety 10/11/2025.
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]
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Bay Harbor Post Acute Healthcare Center 200 Civic Avenue Salisbury, MD 21804
PM, the Regional Director of Operation (RDO) stated he would expect residents to receive therapy
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Bay Harbor Post Acute Healthcare Center 200 Civic Avenue Salisbury, MD 21804
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.
215067 10/17/2025
Bay Harbor Post Acute Healthcare Center 200 Civic Avenue Salisbury, MD 21804
During an interview on 10/17/2025 at 4:33 PM, the Interim Director of Nursing
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.