Inspection Reports for
Bayside Healthcare Center
3201 WALL BLVD, GRETNA, LA, 70056
Back to Facility Profile6 Reports
Inspection Report — Sep 17, 2025
Annual Inspection CMS
Date: Sep 17, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare regulations and standards at Bayside Healthcare Center.
Findings
The facility was found deficient in multiple areas including improper labeling of enteral feeding supplies for Resident #4, failure to assess smoking status for Resident #38, inadequate infection prevention and control practices involving Residents #18 and #96, and failure to maintain an environment free from flies affecting multiple residents.
Deficiencies (4)
Failure to ensure enteral feeding bag, free water flush bag, and syringe were properly labeled according to professional standards for Resident #4.
Failure to assess a resident's smoking status to determine need for supervision or assistance for smoking for Resident #38.
Failure to implement enhanced barrier precautions for Resident #96 with midline catheter, failure to clean glucometers properly, and failure to perform proper hand hygiene during wound care for Resident #18.
Failure to maintain an environment free from flies affecting multiple residents including Residents #18, #21, #27, #34, #37, #45, #50, #60, #61, #64, #67, and #96.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 12
Glucometers reviewed: 2
Residents reviewed for infection control: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Acknowledged enteral feeding labeling deficiencies and infection control issues |
| S1 Administrator | Administrator | Acknowledged enteral feeding labeling deficiencies and infection control issues |
| S8 Activities Director | Activities Director | Noted Resident #38 liked to sit outside to smoke |
| S9 Licensed Practical Nurse | Licensed Practical Nurse | Documented Resident #38 as a smoker |
| S10 Minimum Data Set Coordinator | MDS Coordinator | Indicated smoking status should be assessed upon admission and quarterly |
| S5 Assistant Director of Nursing | Assistant Director of Nursing | Indicated Resident #38 should have had smoking assessment |
| S4 Licensed Practical Nurse | Licensed Practical Nurse | Performed midline catheter care without enhanced barrier precautions |
| S3 Wound Care Nurse | Wound Care Nurse | Failed to perform hand hygiene and change gloves during wound care for Resident #18 |
| S12 Dietary Manager | Dietary Manager | Confirmed presence of flies in kitchen |
Inspection Report — Oct 16, 2024
Complaint Investigation CMS
Date: Oct 16, 2024
Visit Reason
The inspection was conducted to investigate complaints related to resident privacy during catheter care, failure to timely report and investigate alleged resident-to-resident abuse, failure to complete required PASARR Level II evaluations for residents with mental health diagnoses, and deficiencies in infection prevention and control practices.
Complaint Details
The complaint investigation was triggered by concerns about resident privacy during catheter care, failure to report and investigate resident-to-resident abuse, failure to complete PASARR Level II evaluations for residents with mental illness, and infection control deficiencies. The facility was found to have multiple failures in these areas, including not reporting abuse incidents to the State Survey Agency and not conducting required investigations.
Findings
The facility failed to ensure resident privacy during catheter care, timely reporting and thorough investigation of resident abuse allegations, completion of required PASARR Level II evaluations for residents with mental illness, and maintenance of an effective infection control program including proper glove use and wound care. Additionally, the facility lacked a system for monitoring antibiotic use and resistance patterns.
Deficiencies (9)
Failed to ensure privacy was provided for Resident #32 during catheter care as the door and privacy curtain remained open.
Failed to timely report alleged resident-to-resident verbal and/or physical abuse incidents involving Residents #2 and #440 to the State Survey Agency.
Failed to thoroughly investigate alleged resident-to-resident abuse incidents involving Residents #2 and #440.
Failed to refer Resident #60 for a required Level II PASARR evaluation following new mental health diagnoses.
Failed to complete a Level II PASARR evaluation for Resident #9 despite diagnoses of Major Depressive Disorder and PTSD.
Failed to include infection causing organisms in the facility's infection control surveillance documentation.
Certified Nursing Assistant used gloves stored in her uniform pocket during catheter care for Resident #32.
Staff provided wound care to Resident #12 in a non-sanitary manner as the nurse's long hair touched her gloves during wound care.
Failed to maintain a system for provision of feedback reports on antibiotic usage and antibiotic resistance patterns.
Report Facts
Residents affected: 1
Residents affected: 2
Residents reviewed for PASARR: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5Wound Care Nurse | Wound Care Nurse | Named in privacy deficiency for Resident #32 catheter care |
| S2Director of Nursing/Infection Preventionist | Director of Nursing/Infection Preventionist | Interviewed regarding privacy, abuse reporting, infection control, and antibiotic monitoring deficiencies |
| S1Administrator | Administrator | Interviewed regarding abuse incident reporting and investigation |
| S4Social Worker | Social Worker | Interviewed regarding PASARR Level II evaluation deficiencies for Residents #9 and #60 |
| S7CNA | Certified Nursing Assistant | Observed using gloves stored in uniform pocket during catheter care for Resident #32 |
| S5LPN | Licensed Practical Nurse | Observed providing wound care with hair touching gloves for Resident #12 |
| S6MDS Nurse | MDS Nurse | Interviewed regarding abuse incidents involving Resident #440 |
Inspection Report — Jul 15, 2024
Routine CMS
Date: Jul 15, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control protocols, specifically focusing on hand hygiene practices during incontinence care.
Findings
The facility failed to ensure that Certified Nursing Assistants performed proper hand hygiene during incontinence care for two observed CNAs, affecting one sampled resident and one random resident. Observations and interviews confirmed lapses in hand hygiene before and after glove removal.
Deficiencies (1)
Failure to ensure Certified Nursing Assistants performed hand hygiene during incontinence care for two CNAs observed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 CNA | Certified Nursing Assistant | Named in hand hygiene deficiency during incontinence care |
| S4 CNA | Certified Nursing Assistant | Named in hand hygiene deficiency during incontinence care |
| S2 Director of Nursing | Director of Nursing | Provided interview confirming hand hygiene expectations and deficiencies |
Inspection Report — Dec 7, 2023
Routine CMS
Date: Dec 7, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality, medication administration, medication storage security, water temperature safety, medication error rates, food quality, infection control, and record-keeping in a nursing facility.
Findings
The facility was found deficient in multiple areas including medication administration documentation and timing, medication storage security, water temperature exceeding safe limits in bathrooms, medication error rate exceeding 5%, expired nutritional supplements and juices available for residents, unclean kitchen equipment, food served at unsafe temperatures, incomplete medical and medication records, and inadequate infection control practices such as improper ice scoop storage and failure to perform hand hygiene between residents during medication administration.
Deficiencies (10)
Failure to document medication administration timely and properly for multiple residents, including Resident #13 and Resident #19.
Medications and medication carts were not stored securely; medication cart Y was found unlocked and unattended.
Water temperature in four bathrooms exceeded 120 degrees Fahrenheit, posing a risk of burns.
Medication error rate was 7.69%, exceeding the acceptable 5% threshold, including wrong dose and late administration.
Food served was often cold, unpalatable, and inconsistent in texture, with resident complaints documented.
Kitchen equipment such as steam table pans and oven were not properly cleaned; some pans had residue and were stored wet.
Expired nutritional supplements (Glucerna) and juices were found on medication carts and in medication storage room.
Incomplete documentation of antipsychotic side effects monitoring, behavior monitoring, medication administration, and supplement administration for multiple residents.
Ice scoop stored improperly in ice chest with standing water, increasing infection risk.
Licensed Practical Nurse failed to perform hand hygiene between administering medications to different residents.
Report Facts
Medication error rate: 7.69
Water temperature: 125
Water temperature: 127
Water temperature: 126
Medication administration opportunities: 26
Medication errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4 Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Named in medication administration documentation omissions and failure to perform hand hygiene. |
| S2 Director of Nursing | Director of Nursing (DON) | Provided statements regarding medication administration, supervision, and infection control. |
| S3 Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Responsible for ensuring nursing staff perform duties and for medication cart security. |
| S5 Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Named in medication administration timing errors and expired supplement observations. |
| S9 Maintenance Supervisor | Maintenance Supervisor (MS) | Measured water temperatures and acknowledged unsafe hot water temperatures. |
| S6 Dietary Manager | Dietary Manager | Acknowledged food complaints, unclean kitchen equipment, and expired nutritional supplements. |
| S10 Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Confirmed improper ice scoop storage. |
| S1 Administrator | Administrator | Acknowledged food temperature and water temperature issues, and missing documentation. |
Inspection Report — Dec 4, 2023
Annual Inspection CMS
Date: Dec 4, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including water temperature safety, medication administration accuracy, medication security, infection control, and overall facility safety.
Findings
The facility was found to have water temperatures exceeding 120 degrees Fahrenheit in 4 of 7 bathrooms, a medication error rate of 7.69% exceeding the 5% threshold, unlocked medication carts, and lapses in infection control practices including improper ice scoop storage and failure of a nurse to perform hand hygiene between medication administrations.
Deficiencies (5)
Water accessible to residents exceeded 120 degrees Fahrenheit in 4 bathrooms.
Medication error rate was 7.69%, exceeding the 5% threshold.
Medications were not maintained in a secure manner; medication cart was unlocked and unattended.
Resident's ice supply was not maintained according to infection control practices; ice scoop was sitting in clear liquid.
Licensed Practical Nurse failed to perform hand hygiene between administering medications to separate residents.
Report Facts
Medication error rate: 7.69
Medication administration opportunities: 26
Medication errors: 2
Bathrooms with water temperature exceeding 120°F: 4
Water temperature readings: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4 LPN | Licensed Practical Nurse | Administered wrong medication dose and failed to perform hand hygiene between medication administrations. |
| S5 LPN | Licensed Practical Nurse | Administered medication outside scheduled time. |
| S9 MS | Maintenance Supervisor | Measured water temperatures and acknowledged thermometer calibration issue. |
| S2 DON | Director of Nursing | Acknowledged medication errors and hand hygiene deficiencies. |
| S3 ADON | Assistant Director of Nursing | Stated medication cart should be locked at all times. |
| S1 Administrator | Administrator | Acknowledged bathroom sink water temperatures were too hot and potential for harm. |
| S10 CNA | Certified Nursing Assistant | Confirmed ice scoop was improperly stored in liquid. |
Inspection Report — Aug 2, 2023
Complaint Investigation CMS
Date: Aug 2, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to allow residents unrestricted visitation, contrary to CMS guidelines and state regulations.
Complaint Details
The complaint investigation found that visitation was restricted by appointment only, with limited visiting hours and locations, affecting multiple residents and their families. Residents and family members reported being unable to visit freely or at any time as required by CMS guidance.
Findings
The facility restricted visitation by requiring appointments, limiting visiting hours, and restricting visitors to certain areas, which affected multiple residents. Several staff and residents confirmed visitation limitations despite CMS guidance allowing unrestricted visitation.
Deficiencies (1)
Failed to allow residents unrestricted visitation, requiring appointments and limiting visiting hours and locations.
Report Facts
Residents affected: 90
Sampled residents with visitation issues: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Posted visitation notice and provided statements about staff knowledge of visitation rules |
| S7 Receptionist | Receptionist | Provided information on visitation start and end times |
| S3 Certified Nursing Assistant Supervisor | CNA Supervisor | Stated visitation requires appointments |
| S4 Certified Nursing Assistant | CNA | Described visitation locations and times |
| S5 Certified Nursing Assistant | CNA | Stated family members must have appointments to visit |
| S2 Registered Nurse Supervisor | Registered Nurse Supervisor | Described visitation policies and times |
| S6 Licensed Practical Nurse | LPN | Uncertain about visitation policy and times |
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