A list of the most recent deficiencies for Bayview Manor. 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 the wrongful use of the resident's belongings or money. | Health | 2023-11-21 | 2024-01-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-21 | 2024-01-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-21 | 2024-01-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-21 | 2024-01-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-21 | 2024-01-19 | Y |
| 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. | Health | 2023-10-24 | 2023-12-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-24 | 2023-12-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-13 | 2023-10-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-13 | 2023-10-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-13 | 2023-10-15 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-02-02 | 2023-04-17 | 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 | 2023-02-02 | 2023-04-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-02-02 | 2023-04-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-02 | 2023-04-17 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-02-02 | 2023-04-17 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-02-02 | 2023-04-17 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-02-02 | 2023-04-17 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-02-02 | 2023-04-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-02 | 2023-04-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-02 | 2023-04-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-02 | 2023-04-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-02 | 2023-04-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-02 | 2023-04-17 | 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 | 2023-02-02 | 2023-04-17 | N |
| 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 | 2023-02-02 | 2023-04-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-02 | 2023-04-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-02 | 2023-04-17 | N |
| Respond appropriately to all alleged violations. | Health | 2023-02-02 | 2023-04-17 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Establish methods for sharing information. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-02 | 2023-03-09 | N |
| Respond appropriately to all alleged violations. | Health | 2022-08-18 | 2022-10-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-18 | 2022-10-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-18 | 2022-10-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-15 | 2022-04-25 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-01-03 | 2022-02-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-03 | 2022-02-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-11-25 | 2020-01-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-11-25 | 2020-01-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-25 | 2020-01-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-25 | 2020-01-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-11-25 | 2020-01-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-25 | 2020-01-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-25 | 2020-01-20 | 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 | 2019-11-25 | 2020-01-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-25 | 2020-01-20 | N |
| 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 | 2019-11-25 | 2020-01-20 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-11-25 | 2020-01-20 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-11-25 | 2020-01-20 | 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 | 2019-11-25 | 2020-01-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-25 | 2020-01-20 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-11-25 | 2020-01-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-11-26 | 2019-12-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-08-27 | 2018-11-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-08-27 | 2018-11-07 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-08-27 | 2018-10-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-08-27 | 2018-10-25 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-08-27 | 2018-10-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-08-27 | 2018-10-16 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-08-27 | 2018-10-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-27 | 2018-10-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-08-27 | 2018-10-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-27 | 2018-10-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-08-27 | 2018-10-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-08-27 | 2018-10-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-08-22 | 2018-10-05 | N |
| Respond appropriately to all alleged violations. | Health | 2018-08-22 | 2018-10-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-22 | 2018-10-05 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-08-22 | 2018-10-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-22 | 2018-10-05 | 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 | 2018-08-22 | 2018-10-05 | 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 | 2018-08-22 | 2018-10-05 | 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 | 2018-08-22 | 2018-10-05 | N |
| 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 | 2018-08-22 | 2018-10-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-22 | 2018-10-05 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-08-27 | 2018-09-11 | N |
