Nursing Home News — Page 21

The inspection, conducted November 19, 2025, identified the lapse under a category covering resident assessment and care planning deficiencies.

The inspection report does not describe the resident by name, age, or diagnosis.

The problem was not that nobody knew the standard.

Federal inspectors classified the lapse as causing actual harm.

Federal inspectors cited Bay Crest, located at 3750 Garnet Street, for failing to complete proper admission assessments for newly arriving residents.

Inspectors classified the violation as causing minimal harm or the potential for actual harm, and noted that a few residents were affected.

The committee exists to catch failures before they repeat.

That detail matters because nursing homes use a standardized assessment tool, the Minimum Data Set, to track exactly these kinds of safety risks.

"Oh my God I didn't even notice it," LPN-E told the surveyor.

The resident understood exactly what was happening.

The protocol itself was not complicated.

Pressure ulcers, sometimes called bedsores, develop when sustained pressure cuts off blood flow to skin and underlying tissue.