Bay Harbor Post Acute Healthcare Center
Inspection Findings
F-Tag F0550
F 0550
knocking or announcing herself.
Level of Harm - Minimal harm or potential for actual harm
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.
Residents Affected - Few
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.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0565
F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
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 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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0585
F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
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.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0607
F 0607
ombudsman.
Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0609
F 0609 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some
#2 had been administered insulin in the area of the noted discoloration. The Report indicated it was submitted to the SSA on 06/20/2025 at 6:50 PM.
An email correspondence dated 10/10/2025 at 4:22 PM with the SSA revealed the initial report regarding Resident #2's allegation was received on 06/20/2025 at 6:52 PM and no final report was received.
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.
- 5. 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
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0610
F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some
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 REDACTED] revealed the resident had no verbal indicators or emotional distress/anxiety.
- 3. Registered Nurse (RN) #20's timecard sheet revealed their last date worked was on 09/29/2025 and
- 4. Record review revealed the RDO placed the Administrator and DON on administrative leave on
- 5. Record review revealed the facility obtained statements from RN #20 and Housekeeper #28 of their
- 6. Record review revealed social services staff met with Resident #33 on 10/11/2025 and identified the
- 7. Record review revealed Resident #33's representative was made aware of the abuse allegation on
- 8. Record review revealed the RDO notified the Medical Director of the allegation of physical abuse for
- 9. Record review revealed Local Law Enforcement were notified of Resident #33's allegation of sexual
- 10. Record review revealed the facility notified the SSA of Resident #41's physical abuse allegation on
- 11. Record review revealed Medical Directors were notified of the allegations of abuse on 10/11/2025.
- 12. Record review revealed the facility notified the Ombudsman of the allegations of abuse Resident #41
- 13. Record review revealed Resident #33's trauma assessment completed on 10/11/2025 identified past
Housekeeper #28's last date worked was on 10/11/2025.
10/11/2025.
witness accounts of the allegations against them.
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.
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.
Resident #41 and sexual abuse for Resident #33.
abuse allegation and Resident #41's allegation of physical abuse allegation on 10/10/2025 and 10/09/2025, respectively.
10/09/2025 and Resident #33's allegation of sexual abuse on 10/09/2025.
and Resident #33 on 10/12/2025.
sexual abuse and Resident #41's trauma assessment completed on 10/11/2025 [NAME]
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0826
F 0826 Level of Harm - Minimal harm or potential for actual harm
the Interim Director of Nursing (Int. DON) stated she would expect residents to receive therapy services as ordered and for therapy staff to communicate with nursing staff about any refusals of therapy services or if
the resident was out of the facility. 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.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Report, included a focus area initiated 10/08/2025, that indicated the resident was resistive to care related to dementia and refused medications, tube feedings, and showers. Interventions directed staff to encourage as much participation/interaction by the resident as possible during care activities. A Maryland Department of Health Office of Health Care Quality Facility Reported Incident Follow-Up Investigation Report Form, dated 02/02/2025, revealed Resident #30's family member had a concern related to the resident not receiving showers. The report revealed Unit Manager (UM) #18 was interviewed and stated Resident #30 often refused showers. 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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Harbor Post Acute Healthcare Center
200 Civic Avenue Salisbury, MD 21804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0880
F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
hygiene, and donned clean gloves before starting the procedure. GNA #46 used soap and washcloths from
the basin of water to wash the resident's perineal area and cleaned the catheter/insertion site from the urethral meatus outward. GNA #46 placed the used washcloths into the trash bag. GNA #46 placed washcloths into the basin of plain water and used them to rinse the resident's perineal area and catheter/insertion site. GNA #46 disposed of the washcloth in the trash bag and dried the areas using a clean towel. Still wearing the same gloves, GNA #46 placed a clean brief on Resident #44, assisted the resident with putting on pants, brushed the resident's hair, handed the resident a cane, and assisted the resident out of bed. GNA #46 rinsed out the resident's basins, dried them with a paper towel, placed the resident's personal items into the basin, and placed them back into the resident's closet while still wearing
the same pair of gloves. GNA #46 then removed the gloves and gown and exited the room. 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.
Event ID:
Facility ID:
If continuation sheet
BAY HARBOR POST ACUTE HEALTHCARE CENTER in SALISBURY, MD inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SALISBURY, MD, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BAY HARBOR POST ACUTE HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.