Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bayberry Skilled Nursing & Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and Alzheimer's disease was physically abused by a CNA during a shower. The CNA forcefully turned the resident, causing injury, removed the resident's clothing despite protests, and was observed smacking the resident's hand and pulling their hair. The incident resulted in the resident experiencing pain, as documented in progress notes.
The facility failed to maintain a safe and sanitary environment for food storage and preparation, with issues including broken kitchen floors, improper thawing of chicken, and unclean food preparation equipment. Observations revealed insects under loose tiles, incorrect labeling of thawed chicken, and residue on the ice machine, can opener, and cutting boards. Staff interviews confirmed these deficiencies and the lack of adherence to facility policies.
The facility failed to provide a policy or storage for perishable food brought by family members, leading to the disposal of such food if not consumed immediately. Interviews with staff, including a CNA, LVN, ADON, and DON, confirmed the absence of refrigerators for resident food storage. The facility's policy did not address safe storage practices, potentially impacting 80 residents who consumed food orally.
The facility failed to provide pureed vegetables according to the menu for residents on pureed diets, affecting four residents. Pureed carrots were prepared without seasoning, resulting in a flavorless and gummy texture, unlike the well-seasoned regular carrots. The Dietary Supervisor confirmed that the facility's recipes required the regular textured carrots to be pureed, but this was not followed.
A multi-dose vial of Tuberculin PPD was found unlabeled and undated in the medication room refrigerator. A nurse acknowledged the vial could have been opened months ago and should have had an open date label. The pharmacy expiration reference list and FDA product information indicated that opened vials should be discarded after 30 days due to potential oxidation and degradation affecting potency.
A resident with dysphagia was given vanilla wafers instead of a suitable dessert for their Soft & Bite-Sized and Renal diet, risking choking. The facility's Dietary Manual and menu spreadsheet lacked proper IDDSI standards, leading to this oversight.
The facility failed to maintain a freezer in good working order, resulting in food not being kept frozen solid. Observations revealed that the temperature of the freezer was too high, causing items like supplement shakes and pie crusts to be soft and improperly frozen. The Dietary Supervisor confirmed the issue, noting that the health shakes had an incorrect consistency. The facility's policy requires freezers to keep food frozen solid.
Resident Physically Abused During Shower by CNA
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) physically abused a resident with severe cognitive impairment and Alzheimer's disease. The resident, who had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment, was subjected to forceful handling during a shower. Multiple staff interviews confirmed that the CNA forcefully turned the resident while on a shower chair, causing the resident's arm to hit the wall, and forcefully removed the resident's clothing despite the resident verbally protesting. Witnesses also observed the CNA smacking the resident's hand and pulling the resident's hair after the resident pinched the CNA's hand. Progress notes documented that the resident experienced new pain in the left shoulder and showed signs of pain following the incident. The facility's policy clearly states that residents have the right to be free from abuse, including physical abuse. The actions of the CNA, as observed and reported by other staff and documented in the resident's records, resulted in the resident experiencing physical abuse and pain.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food storage and preparation, as evidenced by several observations and interviews. The kitchen floors were found to be in poor condition, with broken and missing tiles, leading to an uneven surface. Insects were discovered under loose tiles, and there was a significant build-up of black and brown residue under the warewashing sink. The Maintenance Supervisor acknowledged the floor's poor condition and the Administrator admitted that the kitchen floors were not an active part of the facility's Performance Improvement Project, despite receiving bids to fix the floor. The facility also failed to ensure safe thawing practices for chicken. A pan of raw chicken was observed in the refrigerator with incorrect labeling, and the Dietary Supervisor confirmed that the label did not reflect the actual date the chicken was placed in the refrigerator. The chicken was thawed under running water without proper temperature control, and there was no documentation of critical control points to ensure safe thawing. The Dietary Supervisor instructed the staff to discard the improperly thawed chicken. Additionally, the facility did not maintain cleanliness of food preparation equipment. The ice machine was not cleaned according to the manufacturer's instructions, with dark residue found on sensors inside the machine. The can opener and cutting boards were also found to be unclean, with residue and particles present. The facility's policies and procedures for cleaning these items were not followed, as evidenced by the observations and interviews with staff.
Lack of Food Storage Policy for Resident Meals Brought by Family
Penalty
Summary
The facility failed to ensure that family members could bring in food for residents and that there was a location to safely store perishable food. Interviews with staff, including a Certified Nursing Assistant (CNA), a Licensed Vocational Nurse (LVN), the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed that the facility did not have refrigerators available for storing resident food. As a result, perishable foods brought in by family members were discarded if not consumed immediately. The DON confirmed that family members were informed not to bring food into the facility due to the lack of storage options. A review of the facility's policy titled 'Food Brought by Family/Visitors' indicated that family members should notify nursing staff of their intention to bring food, and the Clinical Dietitian or a Nurse Supervisor should ensure the food aligns with the resident's diet plan. However, the policy did not provide guidelines for the safe storage of food brought in by family members. This lack of a clear policy and storage solution had the potential to result in foodborne illness and decreased food intake, affecting all 80 residents who consumed food orally.
Failure to Provide Properly Seasoned Pureed Vegetables
Penalty
Summary
The facility failed to provide pureed vegetables according to the menu for residents receiving pureed diets, which affected four out of five residents on such diets. During an observation in the kitchen, it was noted that pureed carrots were prepared without seasoning, resulting in a flavorless and gummy texture. The Dietary Supervisor (DS) confirmed that the pureed carrots lacked flavor and had an unpleasant texture compared to the well-seasoned regular carrots. Interviews revealed that the cook, identified as C1, prepared the regular textured carrots with seasoning but did not add any seasoning to the pureed carrots. The DS confirmed that the facility's recipes required the regular textured carrots to be pureed rather than preparing a separate batch for the pureed texture. The facility's policy on standardized recipes indicated that these should be used when preparing menu items, but this was not followed for the pureed carrots.
Improper Labeling of Tuberculin PPD Vial
Penalty
Summary
The facility failed to ensure proper labeling of biologicals, specifically a multi-dose vial of Tuberculin Purified Protein Derivative (PPD), which was found unlabeled and undated in the medication room refrigerator. During an observation and interview, a Registered Nurse acknowledged that the vial could have been opened months ago and should have had an open date label. Further review with the Infection Preventionist revealed that the pharmacy expiration reference list indicated that opened tuberculin test vials should be discarded after 30 days. The Tuberculin PPD product information from the FDA also stated that vials in use for more than 30 days should be discarded due to possible oxidation and degradation affecting potency. This oversight had the potential to lead to residents receiving false test results due to reduced potency of the Tuberculin PPD.
Inappropriate Food Texture Provided to Resident with Dysphagia
Penalty
Summary
The facility failed to provide the appropriate texture of food prescribed for a resident diagnosed with oropharyngeal phase dysphagia, a condition affecting swallowing. The resident was assessed by a Speech Language Pathologist (SLP) and prescribed a Soft & Bite-Sized diet with Mildly Thick Liquids, along with a Renal diet. During a tray-line food service observation, it was noted that the kitchen staff placed vanilla wafers, broken into bite-sized pieces, on the resident's tray, which was not suitable for the prescribed diet. The Dietary Supervisor initially was unsure if the wafers were appropriate and later confirmed with the SLP that they were not suitable for the resident's diet. The SLP explained that vanilla wafers should be soaked in milk to soften them for a Soft & Bite-Sized diet, but milk was not appropriate for the Renal diet. The resident was edentulous, meaning they had no teeth, which increased the risk of choking on the wafers. The facility's Dietary Manual indicated that dry cookies were to be avoided for residents on a Soft & Bite-Sized diet. The menu spreadsheet used in the kitchen did not include the IDDSI standards for the Renal diet, contributing to the oversight.
Freezer Malfunction Leads to Improper Food Storage
Penalty
Summary
The facility failed to maintain all equipment in good working order, specifically one of three freezers, which did not keep food frozen solid. During an observation, the temperature of freezer 1 was recorded at 19 degrees Fahrenheit, and items inside, such as supplement shakes and pie crusts, were found to be soft and not frozen solid. In a subsequent observation and interview with the Dietary Supervisor, it was noted that several uncooked pie dough crusts and angel food cakes were also soft to the touch. The health shakes stored in the freezer had an inappropriate gooey consistency with ice build-up, indicating they were not properly frozen. The facility's policy on food storage, dated 2017, requires that all freezer units be kept in good working condition and that frozen foods be maintained at a temperature to keep them frozen solid.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Concord
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Pass Healthcare Center | 1.2 mi | — | 6 | 0 |
| Concord Post Acute | 1.5 mi | — | 4 | 0 |
| Diablo Valley Post Acute | 1.7 mi | — | 11 | 0 |
| Legacy Post Acute Care | 2.9 mi | — | 2 | 0 |
| Pleasant Hill Post Acute | 3.2 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.