Bayshore Nursing & Rehab

F0658: Resident Assessment and Care Planning

Assessment & care planning

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected May 22, 2026

F0689: Quality of Life and Care

Quality of life & care

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected May 22, 2026

F0600: Freedom from Abuse, Neglect, and Exploitation

Abuse, neglect & exploitation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected May 22, 2026

F0657: Resident Assessment and Care Planning

Assessment & care planning

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected May 22, 2026

F0686: Quality of Life and Care

Quality of life & care

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected Nov 12, 2025

F0689: Quality of Life and Care

Quality of life & care

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected Nov 12, 2025

F0727: Nursing and Physician Services

Nursing & physician services

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected Nov 12, 2025

F0812: Nutrition and Dietary

Nutrition & dietary

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected Nov 12, 2025

F0851: Administration

Administration

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Corrected Nov 12, 2025

F0867: Administration

Administration

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected Nov 12, 2025

F0880: Infection Control

Infection control

Provide and implement an infection prevention and control program.

Corrected Nov 12, 2025

F0881: Infection Control

Infection control

Implement a program that monitors antibiotic use.

Corrected Nov 12, 2025

F0887: Infection Control

Infection control

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected Nov 12, 2025

F0925: Environmental

Environment

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected Nov 12, 2025

F0946: Administration

Administration

Provide training in compliance and ethics.

Corrected Nov 12, 2025

F0949: Administration

Administration

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Corrected Nov 12, 2025

F0582: Resident Rights

Resident rights

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected Nov 12, 2025

F0585: Resident Rights

Resident rights

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected Nov 12, 2025

F0641: Resident Assessment and Care Planning

Assessment & care planning

Ensure each resident receives an accurate assessment.

Corrected Nov 12, 2025

F0656: Resident Assessment and Care Planning

Assessment & care planning

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected Nov 12, 2025

F0679: Quality of Life and Care

Quality of life & care

Provide activities to meet all resident's needs.

Corrected Nov 12, 2025

F0730: Nursing and Physician Services

Nursing & physician services

Observe each nurse aide's job performance and give regular training.

Corrected Nov 12, 2025

F0756: Pharmacy Service

Pharmacy services

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected Nov 12, 2025

F0761: Pharmacy Service

Pharmacy services

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected Nov 12, 2025

F0883: Infection Control

Infection control

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected Nov 12, 2025

F0552: Resident Rights

Resident rights

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected Nov 12, 2025

F0576: Resident Rights

Resident rights

Ensure residents have reasonable access to and privacy in their use of communication methods.

Corrected Nov 12, 2025

F0584: Resident Rights

Resident rights

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected Nov 12, 2025

F0605: Freedom from Abuse, Neglect, and Exploitation

Abuse, neglect & exploitation

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected Nov 12, 2025

F0609: Freedom from Abuse, Neglect, and Exploitation

Abuse, neglect & exploitation

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected Nov 12, 2025

F0610: Freedom from Abuse, Neglect, and Exploitation

Abuse, neglect & exploitation

Respond appropriately to all alleged violations.

Corrected Nov 12, 2025

F0628: Resident Rights

Resident rights

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected Nov 12, 2025

F0645: Resident Assessment and Care Planning

Assessment & care planning

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected Nov 12, 2025

F0677: Quality of Life and Care

Quality of life & care

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected Nov 12, 2025

F0699: Quality of Life and Care

Quality of life & care

Provide care or services that was trauma informed and/or culturally competent.

Corrected Nov 12, 2025

F0790: Quality of Life and Care

Quality of life & care

Provide routine and 24-hour emergency dental care for each resident.

Corrected Nov 12, 2025

F0842: Resident Assessment and Care Planning

Assessment & care planning

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected Nov 12, 2025

F0947: Nursing and Physician Services

Nursing & physician services

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected Nov 12, 2025

F0577: Resident Rights

Resident rights

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected Nov 12, 2025

F0700: Quality of Life and Care

Quality of life & care

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Corrected Nov 12, 2025

F0835: Administration

Administration

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected Nov 12, 2025

F0841: Nursing and Physician Services

Nursing & physician services

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

Corrected Nov 12, 2025

F0684: Quality of Life and Care

Quality of life & care

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected Nov 12, 2025

F0558: Resident Rights

Resident rights

Reasonably accommodate the needs and preferences of each resident.

Corrected Aug 26, 2025

F0689: Quality of Life and Care

Quality of life & care

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected Nov 14, 2025

F0600: Freedom from Abuse, Neglect, and Exploitation

Abuse, neglect & exploitation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected Aug 26, 2025

F0609: Freedom from Abuse, Neglect, and Exploitation

Abuse, neglect & exploitation

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected Aug 26, 2025

F0732: Nursing and Physician Services

Nursing & physician services

Post nurse staffing information every day.

Corrected Aug 26, 2025

F0692: Quality of Life and Care

Quality of life & care

Provide enough food/fluids to maintain a resident's health.

Corrected Nov 14, 2025

F0801: Nutrition and Dietary

Nutrition & dietary

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected Aug 25, 2025

F0940: Administration

Administration

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Corrected Aug 25, 2025

F0941: Administration

Administration

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Corrected Aug 25, 2025

F0942: Resident Rights

Resident rights

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Corrected Aug 25, 2025

F0943: Freedom from Abuse, Neglect, and Exploitation

Abuse, neglect & exploitation

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Corrected Aug 25, 2025

F0944: Administration

Administration

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Corrected Aug 25, 2025

F0945: Infection Control

Infection control

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Corrected Aug 25, 2025

F0946: Administration

Administration

Provide training in compliance and ethics.

Corrected Aug 25, 2025

F0947: Nursing and Physician Services

Nursing & physician services

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Corrected Aug 25, 2025

F0609: Freedom from Abuse, Neglect, and Exploitation

Abuse, neglect & exploitation

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected Aug 25, 2025

F0610: Freedom from Abuse, Neglect, and Exploitation

Abuse, neglect & exploitation

Respond appropriately to all alleged violations.

Corrected Aug 25, 2025

F0684: Quality of Life and Care

Quality of life & care

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected Sep 29, 2025

F0697: Quality of Life and Care

Quality of life & care

Provide safe, appropriate pain management for a resident who requires such services.

Corrected Aug 25, 2025

F0755: Pharmacy Service

Pharmacy services

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected Aug 25, 2025

F0690: Quality of Life and Care

Quality of life & care

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected Jun 27, 2025

F0880: Infection Control

Infection control

Provide and implement an infection prevention and control program.

Corrected Jun 27, 2025

F0561: Resident Rights

Resident rights

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected Jun 27, 2025

F0584: Resident Rights

Resident rights

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected Jun 27, 2025

F0641: Resident Assessment and Care Planning

Assessment & care planning

Ensure each resident receives an accurate assessment.

Corrected Jun 27, 2025

F0655: Resident Assessment and Care Planning

Assessment & care planning

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected Jun 27, 2025

F0657: Resident Assessment and Care Planning

Assessment & care planning

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected Jun 27, 2025

F0684: Quality of Life and Care

Quality of life & care

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected Jun 27, 2025

F0695: Quality of Life and Care

Quality of life & care

Provide safe and appropriate respiratory care for a resident when needed.

Corrected Jun 27, 2025

F0580: Resident Rights

Resident rights

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected Feb 27, 2025

F0585: Resident Rights

Resident rights

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected Feb 27, 2025

F0755: Pharmacy Service

Pharmacy services

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected Feb 27, 2025

F0759: Pharmacy Service

Pharmacy services

Ensure medication error rates are not 5 percent or greater.

Corrected Feb 27, 2025

F0584: Resident Rights

Resident rights

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected Feb 27, 2025

F0554: Resident Rights

Resident rights

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected Feb 27, 2025

F0925: Environmental

Environment

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected Dec 2, 2024

F0600: Freedom from Abuse, Neglect, and Exploitation

Abuse, neglect & exploitation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected Dec 2, 2024

Payment denial

Medicare/Medicaid payment denial issued following a survey deficiency.

F0584: Resident Rights

Resident rights

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected Feb 27, 2025

F0814: Nutrition and Dietary

Nutrition & dietary

Dispose of garbage and refuse properly.

Corrected Dec 2, 2024

F0837: Administration

Administration

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Corrected Aug 15, 2024

F0908: Environmental

Environment

Keep all essential equipment working safely.

Corrected Jul 25, 2024

F0584: Resident Rights

Resident rights

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected Jul 25, 2024

F0558: Resident Rights

Resident rights

Reasonably accommodate the needs and preferences of each resident.

Corrected Jul 25, 2024

F0578: Resident Rights

Resident rights

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected Jul 25, 2024

F0607: Freedom from Abuse, Neglect, and Exploitation

Abuse, neglect & exploitation

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected Jul 25, 2024

F0656: Resident Assessment and Care Planning

Assessment & care planning

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected Jul 25, 2024

F0689: Quality of Life and Care

Quality of life & care

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected Jul 25, 2024

F0692: Quality of Life and Care

Quality of life & care

Provide enough food/fluids to maintain a resident's health.

Corrected Jul 25, 2024

F0761: Pharmacy Service

Pharmacy services

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected Jul 25, 2024

F0919: Environmental

Environment

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected Jul 25, 2024

F0880: Infection Control

Infection control

Provide and implement an infection prevention and control program.

Corrected Jul 25, 2024

F0814: Nutrition and Dietary

Nutrition & dietary

Dispose of garbage and refuse properly.

Corrected Jul 25, 2024

F0584: Resident Rights

Resident rights

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected Jun 16, 2024

F0655: Resident Assessment and Care Planning

Assessment & care planning

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected Jun 16, 2024

F0880: Infection Control

Infection control

Provide and implement an infection prevention and control program.

Corrected Jun 16, 2024

F0925: Environmental

Environment

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected Nov 7, 2023

F0584: Resident Rights

Resident rights

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected Nov 7, 2023

F0585: Resident Rights

Resident rights

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected Nov 7, 2023

F0609: Freedom from Abuse, Neglect, and Exploitation

Abuse, neglect & exploitation

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected Nov 7, 2023

F0806: Nutrition and Dietary

Nutrition & dietary

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected Nov 7, 2023

F0689: Quality of Life and Care

Quality of life & care

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected Nov 7, 2023

F0801: Nutrition and Dietary

Nutrition & dietary

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected Nov 7, 2023

F0805: Nutrition and Dietary

Nutrition & dietary

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected Nov 7, 2023

F0657: Resident Assessment and Care Planning

Assessment & care planning

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected Aug 22, 2023

F0684: Quality of Life and Care

Quality of life & care

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected Aug 22, 2023

F0600: Freedom from Abuse, Neglect, and Exploitation

Abuse, neglect & exploitation

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected Aug 22, 2023

F0689: Quality of Life and Care

Quality of life & care

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected Aug 22, 2023

F0744: Quality of Life and Care

Quality of life & care

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected Aug 22, 2023

F0867: Administration

Administration

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected Aug 22, 2023

F0610: Freedom from Abuse, Neglect, and Exploitation

Abuse, neglect & exploitation

Respond appropriately to all alleged violations.

Corrected Aug 22, 2023

F0609: Freedom from Abuse, Neglect, and Exploitation

Abuse, neglect & exploitation

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected Aug 22, 2023

F0656: Resident Assessment and Care Planning

Assessment & care planning

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected Aug 22, 2023

F0679: Quality of Life and Care

Quality of life & care

Provide activities to meet all resident's needs.

Corrected Aug 22, 2023

F0745: Quality of Life and Care

Quality of life & care

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Corrected Aug 22, 2023

F0758: Pharmacy Service

Pharmacy services

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected Aug 22, 2023

F0689: Quality of Life and Care

Quality of life & care

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected Jul 24, 2023

F0760: Pharmacy Service

Pharmacy services

Ensure that residents are free from significant medication errors.

Corrected Jun 13, 2023

F0584: Resident Rights

Resident rights

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected May 17, 2023

F0623: Resident Rights

Resident rights

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected May 17, 2023

F0625: Resident Rights

Resident rights

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected May 17, 2023

F0800: Nutrition and Dietary

Nutrition & dietary

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Corrected May 17, 2023

F0812: Nutrition and Dietary

Nutrition & dietary

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected May 17, 2023

F0656: Resident Assessment and Care Planning

Assessment & care planning

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected May 17, 2023

F0677: Quality of Life and Care

Quality of life & care

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected May 17, 2023

F0684: Quality of Life and Care

Quality of life & care

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected May 17, 2023

F0692: Quality of Life and Care

Quality of life & care

Provide enough food/fluids to maintain a resident's health.

Corrected May 17, 2023

F0695: Quality of Life and Care

Quality of life & care

Provide safe and appropriate respiratory care for a resident when needed.

Corrected May 17, 2023

F0698: Quality of Life and Care

Quality of life & care

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected Jun 13, 2023

F0755: Pharmacy Service

Pharmacy services

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected May 17, 2023

F0756: Pharmacy Service

Pharmacy services

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected May 17, 2023

F0757: Pharmacy Service

Pharmacy services

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected Jun 13, 2023

F0758: Pharmacy Service

Pharmacy services

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected May 17, 2023

F0759: Pharmacy Service

Pharmacy services

Ensure medication error rates are not 5 percent or greater.

Corrected May 17, 2023

F0761: Pharmacy Service

Pharmacy services

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected May 17, 2023

F0804: Nutrition and Dietary

Nutrition & dietary

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected May 17, 2023

F0814: Nutrition and Dietary

Nutrition & dietary

Dispose of garbage and refuse properly.

Corrected May 17, 2023

F0882: Infection Control

Infection control

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected May 17, 2023