Deficiency Records for Bay View Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Bay View Nursing and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-10 | 2024-02-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-14 | 2023-10-16 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-09-14 | 2023-10-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-09-14 | 2023-10-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-14 | 2023-10-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-14 | 2023-10-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-09-14 | 2023-10-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-14 | 2023-10-16 | 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 | 2023-09-14 | 2023-10-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-09-14 | 2023-10-16 | N |
| Provide or obtain dental services for each resident. | Health | 2023-09-14 | 2023-10-16 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-09-14 | 2023-10-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-14 | 2023-10-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-14 | 2023-10-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-14 | 2023-10-16 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-14 | 2023-10-16 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-09-14 | 2023-10-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-09-14 | 2023-10-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-13 | 2023-10-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-13 | 2023-10-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-13 | 2023-10-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-13 | 2023-10-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-13 | 2023-10-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-09-13 | 2023-10-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-13 | 2023-10-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-13 | 2023-10-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-13 | 2023-10-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-13 | 2023-10-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-13 | 2023-10-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-13 | 2023-10-16 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-11-23 | 2023-02-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-22 | 2023-01-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-22 | 2023-01-18 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-12-22 | 2023-01-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-23 | 2022-12-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-23 | 2022-12-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-19 | 2022-10-26 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-19 | 2022-10-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-19 | 2022-10-26 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-09-19 | 2022-10-26 | Y |
| 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. | Health | 2022-09-19 | 2022-10-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-19 | 2022-10-26 | Y |
| Report COVID19 data to residents and families. | Health | 2022-09-19 | 2022-10-26 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-19 | 2022-10-26 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-19 | 2022-10-26 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-11 | 2022-08-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-06 | 2022-06-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-26 | 2022-06-07 | Y |
| 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 | 2022-03-17 | 2022-04-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-17 | 2022-04-27 | 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 | 2022-03-17 | 2022-04-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-17 | 2022-04-27 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-17 | 2022-04-27 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2022-03-17 | 2022-04-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-16 | 2022-04-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-16 | 2022-04-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-16 | 2022-04-25 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-04 | 2022-04-22 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-03-17 | 2022-04-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-16 | 2022-04-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-16 | 2022-04-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-16 | 2022-04-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-03-16 | 2022-04-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-16 | 2022-04-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-16 | 2022-03-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-16 | 2022-03-16 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-12-13 | 2022-01-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-16 | 2022-01-11 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-16 | 2022-01-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-04 | 2022-01-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-04 | 2022-01-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-08 | 2022-01-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-08 | 2022-01-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-08 | 2022-01-11 | Y |
| 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 | 2021-10-08 | 2022-01-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-08 | 2022-01-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-06 | 2021-04-26 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-30 | 2020-03-17 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-01-30 | 2020-03-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-01-30 | 2020-03-17 | N |
| 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. | Health | 2020-01-30 | 2020-03-17 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2020-01-30 | 2020-03-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-30 | 2020-03-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-01-30 | 2020-03-17 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-01-30 | 2020-03-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-01-30 | 2020-03-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-30 | 2020-03-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-29 | 2020-03-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-29 | 2020-03-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-29 | 2020-03-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-29 | 2020-03-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-29 | 2020-03-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-29 | 2020-03-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-29 | 2020-03-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-29 | 2020-03-17 | N |
