A list of the most recent deficiencies for The Lilac at Bayview. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-21 | 2023-10-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-21 | 2023-10-06 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-21 | 2023-10-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-18 | 2023-06-18 | 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 | 2023-05-18 | 2023-06-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-18 | 2023-06-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-18 | 2023-06-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-18 | 2023-06-18 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-05-18 | 2023-06-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-18 | 2023-06-18 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-05-17 | 2023-06-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-17 | 2023-06-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-17 | 2023-06-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-17 | 2023-06-18 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-05-17 | 2023-06-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-06 | 2022-05-26 | Y |
| 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. | Health | 2021-09-16 | 2021-10-21 | N |
| Keep all essential equipment working safely. | Health | 2021-09-16 | 2021-10-21 | N |
| 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. | Health | 2021-07-23 | 2021-08-27 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-07-23 | 2021-08-27 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-07-23 | 2021-08-27 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-07-23 | 2021-08-27 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-11 | 2019-11-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-11 | 2019-11-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-11 | 2019-11-04 | N |
