Deficiency Records for Bay View Rehabilitation Hospital, LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Bay View Rehabilitation Hospital, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-17 | 2023-05-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-08 | 2022-10-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-24 | 2021-07-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-24 | 2021-07-27 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-06-24 | 2021-07-27 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-06-24 | 2021-07-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-24 | 2021-07-27 | N |
| 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. | Health | 2021-06-24 | 2021-07-27 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-06-24 | 2021-07-27 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-06-24 | 2021-07-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-24 | 2021-07-27 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-06-24 | 2021-07-27 | N |
| Dispose of garbage and refuse properly. | Health | 2021-06-24 | 2021-07-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-24 | 2021-07-27 | N |
| Keep all essential equipment working safely. | Health | 2021-06-24 | 2021-07-27 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-07-01 | 2021-07-26 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-07-01 | 2021-07-26 | N |
| Use approved construction type or materials. | Fire Safety | 2021-07-01 | 2021-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-01 | 2021-07-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-01 | 2021-07-26 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-07-01 | 2021-07-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-06-04 | 2019-07-01 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-06-04 | 2019-07-01 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-04 | 2019-07-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-04 | 2019-07-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-04 | 2019-07-01 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-06-04 | 2019-07-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-04 | 2019-07-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-06-04 | 2019-07-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-04 | 2019-07-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-04 | 2019-07-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-06-04 | 2019-07-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-04 | 2019-07-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-04 | 2019-07-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-04 | 2019-07-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-03-29 | 2019-04-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-03-29 | 2019-04-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-03-29 | 2019-04-29 | N |
| 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. | Health | 2019-03-29 | 2019-04-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-29 | 2019-04-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-29 | 2019-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-29 | 2019-04-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Develop a communication plan. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-06-14 | 2018-07-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-26 | 2018-05-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-04-26 | 2018-05-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-04-26 | 2018-05-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-04-26 | 2018-05-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-26 | 2018-05-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-26 | 2018-05-26 | N |
