Bay View Rehabilitation Hospital, LLC

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received dialysis consistent with professional standards of practice, the comprehensive person-centered care plans, and residents' goals and preferences when Resident 1 had refused and missed dialysis treatment six times within the last six months (since January). There was no care plan for the refusals of dialysis for Resident 1 and no notification of the Medical Doctor (MD) four out of the six times that dialysis treatment was refused and no notification of Responsible Party (RP) five times. These failures placed Resident 1 at increased risk for complications including high potassium build up which can lead to heart problems, heart attack, and death. [...]

Inspectors wroteBased on interview and record review, for one sampled resident (Resident 1), the facility failed to provide Resident 1's Responsible party (RP) copies of the requested medical records within the required timeframe according to the faxed requests on 2/4/26. This failure resulted in a delay in obtaining Resident 1's medical records for the RP/family's desired purpose. A review of Resident 1's admission record (AR) indicated that Resident 1 was admitted to the facility originally on 1/27/17 and readmitted [DATE]. During a telephone interview on 7/7/26 at 5:20 p.m. with RP, RP expressed concern that it took a while for the facility to send them Resident 1's medical records to start the process of moving Resident 1 to a facility closer to the family's home. During an interview on 7/9/26 at 3:15 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 2 was provided a room and bed in a timely manner when he spent around 12 hours sitting in their wheelchair in the hallway from around 12 midnight until 1:30 p.m. This failure had the potential for increased risk of Resident 2 developing pressure ulcers; deep vein thrombosis ( DVT- a serious medical condition that occurs when a blood clot forms in a deep vein, usually in the leg or thigh), muscle stiffness and contractures (an involuntary, persistent shortening of muscle fibers), and skin problems such as pressure ulcers. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to protect two of ten sampled residents (Resident 2 and Resident 3), and one visitor (Visitor 1, family member of Resident 7), from abuse when:Resident 1 fondled the genitals of Resident 2 on 5/24/26. Resident 1 hit the arm of Resident 3 on 6/4/26. The facility relocated Resident 1 to the same unit as Resident 2 after an alleged sexual assault by Resident 1 to Resident 2 on 6/5/26. The facility placed Resident 1 in a room with two vulnerable residents (Resident 9 and Resident 10) on 6/10/26. Additionally, R1 displayed physical aggression towards an unrelated Visitor on 6/4/26. This failure resulted in emotional harm to Resident 2, Resident 3 after Resident 1 abused them and had the potential to render physical and/or emotional harm to Resident 9 and Resident 10 and other vulnerable residents in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, investigate, and report one sexual assault allegation within two hours of incident notification and one abuse allegation within 24 hours of incident notification to the California Department of Public Health (CDPH), and the Ombudsman for two of ten sampled residents (Resident 2 and Resident 3). This failure resulted in one allegation of physical abuse and one allegation of sexual abuse going uninvestigated and unreported resulting in emotional harm to Resident 2 and Resident 3, in addition to the potential for physical and/or emotional harm to other vulnerable residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's order for interventions/treatment for one of three sampled residents (Resident 1) pressure injury to sacrococcyx (tailbone). This failure resulted in slow healing of Resident 1's pressure injury and had the potential for infection. During a review of Resident 1's admission record, dated 4/10/26, the admission record indicated Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), dated 1/30/26, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 11. A score of 11 indicated Resident 1 had moderate cognitive impairment. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure resident-directed care for one of three sampled residents, (Resident 1), when Resident 1 attended a medical appointment without physician ordered x-rays. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident and/or responsible party (RP or legal guardian) for one of one sampled resident (Resident 1) received a written notification about the room change when Resident 1 was moved to another room. This failure violated Resident 1 and Resident 1's RP ' s rights to receive written notice of the room change, including the reason for the change, before the resident's room in the facility was changed.

Inspectors wroteBased observation, interview, and record review, the facility failed to provide a comfortable and safe room temperature for three of 158 sampled residents (Residents 1, 2, and 3) when the room temperature for these residents was less than 71 degrees for over six hours. This failure resulted in an unhomelike environment and placed Resident 1, 2, and 3 at risk for loss of body heat and hypothermia (body's temperature drops dangerously low, usually due to prolonged exposure to cold temperatures).

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to complete a Level I preadmission screening and resident review (PASARR) for residents that remained in the facility on the 31st day of admission to the facility for two (Resident 116 and Resident 152) of six sampled residents reviewed for PASARR. The facility further failed to ensure a Level I Screening was accurate for one (Resident 96) of six sampled residents reviewed for PASARR.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure a significant change in status assessment (SCSA) Minimum Data Set (MDS) assessment was completed for one (Resident 78) of one sampled resident reviewed for hospice.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for six (Residents 13, 17, 60, 116, 148, and 157) of 32 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a comprehensive care plan was developed for one (Resident 148) of two sampled residents reviewed for mood/behavior.

Inspectors wroteBased on interview and record review, the facility failed to prevent medical device related pressure injury (injury to the skin and underlying tissues that results from prolonged pressure on the skin) from developing for one of one sampled resident (Resident 1) when Resident 1 ' s nephrostomy tube (a thin catheter that drains urine from the kidney into a bag) pressed onto Resident 1 ' s upper back skin. This failure resulted in Resident 1 developing pressure injury to the left upper back.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure to immediately report alleged abuse allegations to the facility Administrator and to California Department of Public Health (CDPH) within 2 hours, for one of three sampled residents (Resident 1), when Resident 1 alleged Certified Nursing Assistant 1 (CNA 1) slapped them in the face. This failure had the potential to cause a delay in investigations and affect physical and psychological well-being of Resident 1. A review of Resident 1's admission Record printed 7/27/24, indicated Resident 1 was admitted to the facility in 2020 with multiple diagnosis including: Major Depressive Disorder, Single Episode (a serious mood disorder that can affect how a person feels, thinks, and behaves). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect residents in the facility from physical abuse when Certified Nursing Assistant 1 (CNA1) deliberately poked one resident (Resident 1) in the right cheek, smacked Resident 1 in the hand and then forced Resident 1 down in her wheelchair causing Resident 1 to cry out. The facility failed to protect 16 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16) assigned to CNA1, from possible physical abuse when the Administrator (ADM) returned CNA1 to direct care duty before completion of a thorough abuse investigation, including interviewing all witnesses. CNA1 was permitted to have access to Resident 1 and continued to work with other vulnerable residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep one of three residents (Resident 1) free from physical abuse when Certified Nursing Assistant 1 (CNA1) deliberately poked Resident 1 in the right cheek, smacked Resident 1 in the hand and then forced Resident 1 down in her wheelchair causing her to cry out. This abuse resulted in Resident 1 crying out in pain, hyperventilating (breathing rapidly) and visibly shaking, and had the potential to instill fear in Resident 1 which could result in psychosocial harm. This abuse also had the potential to result in further physical abuse towards Resident 1 and/or other vulnerable residents under CNA1 ' s care. (Cross Reference F610)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and functional environment for residents and staff when: 1. Sliding doors in multiple residents' rooms did not have a working lock. 2. Screen doors in all resident's rooms did not have locks. This failure had the potential to result in residents and staff being unsafe from neighborhood crimes such as theft and physical assault because of unlocked doors.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure to immediately report an alleged abuse allegation to the California Department of Public Health (CDPH) within two hours, for two of three sampled residents (Resident 1 and 2), when Resident 1 and Resident 3 allegedly hit each other, and Resident 2 alleged Certified Nursing Assistant 1 (CNA 1) hit him on the side of his stomach. These failures had the potential to cause a delay in investigations and affect physical and psychological well-being of residents.

Inspectors wroteThe facility failed to ensure the competency of the Dietary Manager (DM) when: 1. the DM did not ensure the cleanliness and maintenence of equipment in the kitchen (Cross-reference F812 and F908); and 2. the DM did not adequately oversee the safe cooling of meat. This failure to maintain equipment and a clean kitchen environment had the potential to result in cross-contamination of food and lead to foodborne illness for 129 residents who received food from the kitchen out of a facility census of 141.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the competency of Food and Nutrition Services staff when: 1. Dietary [NAME] 1 (DC1) did not correctly date thawing chicken stored in a refrigerator; and 2. DC1 and Dietary [NAME] 2 (DC2) did not follow standardized recipes when preparing food. The failure to ensure staff competency for food related tasks had the potential to cause contamination of food resulting in food borne illness; provide food for residents which did not meet the nutrients according to the planned menu resulting in nutritional related medical issues; and provide food to residents with an inappropriate texture for medical needs resulting in choking or death for 129 residents who received food from the kitchen out of a census of 141.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food safely when: 1. A dirty food tray was placed on a clean food preparation table, and an open cart containing dirty trays was left in a hallway. 2. 2 racks of clean food covers were stored beside the handwashing sink at a distance where splash from the sink could easily reach the clean covers. 3. Electric fan in the food preparation area was dirty. 4. Baking pans were stored dirty and sticky in an area for clean utensils. 5. A rack beside the stove where pots and pans were stored was sticky and dirty. 6. The big mixer stored ready to use was sticky. 7. Drawers were lined with colored tape, which made the storage surface rough with crevices, and not easily cleanable. 8. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure nursing staff were knowledgeable about safely storing food for residents brought in by family and visitors. This failure had the potential for residents to not receive food from family and visitors leading to a decrease in food intake and weight loss for 129 residents who ate food by mouth out of a facility census of 141.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to store food-related garbage in a dumpster with a tight-fitting lid. This failure had the potential to attract pest to the facility and lead to pest related spread of disease to 141 residents out of a census of 141.

Inspectors wroteBased on record review and interview, the facility failed to follow doctor's orders for two (Resident 88 and Resident 91) of five residents with a feeding tube (medical device used to provide liquid nourishments, fluids and medications by bypassing oral intake) when the staff did not document performing tube site care. This deficient practice may result in an increased risk for skin breakdown at Resident 88 and Resident 91's tube site.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that accommodated the preferences of three unsampled residents: Resident 95, Resident 127 and Resident seven who were on a physician prescribed fortified diet. This failure had the potential for inadequate food intake and altered nutritional status for these three of three residents who were interviewed about their prescribed fortified diet out of a census of 141.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their infection prevention policies and procedures when: 1. Licensed Vocational Nurse (LVN) 4, did not wash hands or use an alcohol-based hand rub after performing blood sugar check using Glucometer (device use to check for blood sugar level using blood sample) for Resident 30. 2. Certified Nursing Assistant (CNA) 5, did not wear proper personal protective equipment (PPE, protective items or garments such as gloves and gown, worn to protect the body or clothing from germs that can cause spread of infection) when feeding Resident 82, who was on droplet and contact precautions (droplet and contact precautions are measures intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the walk-in refrigerator/freezer was maintained when there was grime, and ice build-up on the unit cooler (equipment within the refrigerator to regulate and maintain temperature and air flow), pipes and electrical wires; the unit cooler was missing a part to enclose electrical wires; an electrical box was missing a cover; and a metal floor threshold (for closing a gap between the bottom of the door and the floor so there is a good seal) to the entrance of the freezer was not in good repair. This failure had a potential for the walk-in refrigerator/freezer to malfunction and increase the risk for food contamination for 129 residents who received food from the kitchen out of a census of 141.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the privacy and dignity for two of five sampled residents (Residents 89 and 30) was protected when urinary drainage bags were left uncovered and visible to other residents, as well as visitors. This failure had the potential to negatively affect the emotional well-being of the residents.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure one of 28 sampled residents (Resident 594) received nail care which resulted in Resident 594's nails on both hands being long with black matter underneath them. This failure had the potenial for Resident 594 to scratch himself.

Inspectors wroteBased an interview and record review, the facility failed to provide restorative nursing services (nursing care used to improve or maintain physical function) to one of nine residents (Resident 1). This failure had the potential to result in physical decline and development of contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on record review and interview, the facility failed to provide care for two (Resident 109 and 695) of two Residents that require dialysis (treatment for kidney failure that rids your body of unwanted toxins, waste products and excess fluids by filtering your blood) when the staff did not do an assessment after their dialysis treatments. These deficient practice may result in staff being unaware of any abnormal vital signs that can happen after dialysis treatments.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain a doctors order or determine if one of 38 sampled residents (Resident 160) was able to self-administer medications, when Resident 160 had eye drops at the bedside. This deficient practice had the potential to result in Resident 160 using the eye drops against safe dosing recommendations. It also had the potential to result in the use of the medications by other residents, who could potentially come into the room and obtain them from the drawer where it was stored. According to the Minimum Data Set (MDS, an assessment tool used to guide care) dated 3/5/19, On the Brief Interview for Mental Status (BIMS), Resident 160 scored 15/15 or cognitively intact. Resident 160 was diagnosed with glaucoma (increased pressure in the eye). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure three of 38 sampled residents (Residents 117, 148, and 91) had a call light within reach. This deficient practice has a potential for residents to have unmet needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents had bedside curtains which assured full visual privacy in multiple occupancy rooms. This deficient practice resulted in no visual privacy for residents in eight rooms (302, 305, 306, 360, 362, 363, 364, and 366). in an observation on 3/27/19 between 10:30 a.m. and 2:00 p.m., bed curtains did not provide for complete privacy in rooms 302, 306, 360, 362, 363, 364, and 366. In an interview on 3/27/19 at 9:30 a.m., Licensed Vocational Nurse (LVN) 3 stated the curtain was pulled to give privacy to one resident at a time. In an interview on 3/27/19 at 10:30 a.m., the Director of Nursing (DON) stated she did not realize the curtains were like that and they were possibly in the laundry.

Inspectors wroteBased on observation, interview and record review, for one (Resident 265) of one sampled resident, the facility failed to ensure the oxygen humidifier (a device to that helps the nose from drying out by humidifying administered oxygen) had water in it. This failure had the potential to cause sore, dry, bloody nose.

Inspectors wroteBased on observation, interview and record review, expired medication and equipment was found in a medication room and expired and open dressing supplies were found in two treatment carts. This failure could result in unsuccessfully treatment of residents' medical conditions with ineffective medications and unclean supplies.

Inspectors wroteBased on observations, interviews and record reviews, the staff failed to follow infection control practice when contrary to the facility policy, the treatment nurse brought back unused disposable treatment supplies from Resident 71's room and returned the unused supplies back to the treatment cart for others to use. This deficient practice placed other residents at risk for developing infection form contaminated disposable supplies.