Bayview Rehabilitation and Healthcare Center

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure that 1 of 1 residents reviewed was free from significant medication errors. Specifically, on 3/12/2026 at approximately 8:45 PM, a Certified Medication Technician administered clozapine 150 mg and melatonin 3 mg prescribed for another resident to Resident #1 without verifying identity, in violation of facility policy. As a direct result, the resident required emergency transfer and hospitalization due to altered responsiveness, hypothermia, aspiration pneumonia, and tachycardia, subsequently transitioned to comfort care, and expired on 3/18/2026. This system failure created immediate jeopardy, resulting in actual harm, including death.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to have sufficient nursing staff with the necessary competencies and skills to provide the required nursing and related services. Specifically, the facility failed to assure that all persons administering medications conducted and documented 4 out of 4 quarterly evaluations per state requirements for 1 of 1 Certified Medication Technician (CMT) reviewed, Staff A, who administered medications erroneously to Resident ID #1. The resident was transferred to the hospital due to the medication errors and later expired.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that services provided meet professional standards of quality relative to following physician's orders for 1 of 1 resident reviewed with an order for Midodrine (a medication prescribed to increase a person's blood pressure) and an order for a wound treatment, Resident ID #1.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the resident's drug regimen was free from unnecessary medications for 1 of 1 resident reviewed receiving Metoprolol Tartrate (a medication prescribed to treat cardiac conditions and assists in lowering the blood pressure and heart rate), Resident ID #1.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed receiving Warfarin/Coumadin (an anticoagulant medication prescribed to treat and prevent harmful blood clots from forming or growing larger), Resident ID #3.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to following physician's orders for 2 of 2 residents with medications and treatments that were not signed off as administered, Resident ID #s 1 and 6, for 1 of 3 residents observed with a non-pressure related wound, Resident ID #6, and for 1 of 3 residents reviewed with an order for a nutritional supplement, Resident ID #90.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide respiratory care consistent with professional standards of practice relative to 2 of 4 residents reviewed for oxygen use, Resident ID #s 11 and 46.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 3 of 4 residents reviewed for insulin administration, Resident ID #s 1, 2, and 6.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infection, relative to 1 of 2 residents observed during a wound dressing change, Resident ID #2.

Inspectors wroteBased on record review and staff interview, it has been determined the facility failed to maintain medical records on each resident that are complete and accurately documented in accordance with accepted professional standards and practices, for 2 of 6 residents reviewed for pressure injuries (a localized area of the skin and/or underlying soft tissue damage caused by prolonged pressure), Resident ID #s 53 and 114.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to provide a resident the right to participate in the development and implementation of his or her person-centered plan of care and facilitate the inclusion of the resident and/or resident representative for 1 of 3 residents reviewed for care planning meetings, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 3 residents reviewed for constipation, Resident ID #2.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to Covid-19, for 1 of 2 units observed, the Country Unit, affecting Resident ID #s 2, 6, 11, 14, 15, 19, 26, 28, 30, 38, 42, 44, 46, 47, 49, 54, 55, 58, 64, 65, 67, 80, 82, 84, 87, 88, 92, 97, 104, and 109, as the facility failed to have cleaning and disinfecting wipes effective at killing Covid-19 readily accessible to staff and was using Micro-Kill+ Disinfecting, Deodorizing Cleaning Wipes with Alcohol, which are ineffective at killing Covid-19, to clean and disinfect multi-use resident equipment. [...]

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to protect the residents' right to be free from abuse for 1 of 1 resident reviewed for abuse, Resident ID #46.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives and is provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being, for 1 of 3 residents reviewed for behaviors, Resident ID #66.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 2 residents reviewed relative to Post-traumatic stress disorder (PTSD, occurs in some individuals who have encountered a shocking, scary, or dangerous situation) Resident ID #49 and 1 of 1 resident reviewed for wandering, Resident ID #65.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for 1 of 2 residents reviewed for skin abrasions, Resident ID #83.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to complete an annual performance review for every Nursing Assistant (NA), at least once every 12 months, for 3 of 3 NA personnel records reviewed, Staff D, E, and F.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food service safety, relative to the main kitchen and 2 of 2 kitchenettes.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records on each resident that are complete and accurately documented, relative to hearing aids for 1 of 1 resident reviewed for hearing impairment, Resident ID #46.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provided services that meet professional standards of quality for 1 of 3 residents reviewed for behaviors, Resident ID #66.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 1 of 2 residents reviewed with an indwelling foley catheter (a flexible tube that collects urine from the bladder and empties the urine into a drainage bag), Resident ID #83.

Inspectors wroteBased on surveyor observation, record review, and staff interview it has been determined that the facility failed to ensure each resident's medication regimen is free from a medication error rate of 5% or greater. Based on 29 opportunities for errors observed during the medication administration task, there were 3 errors resulting in an error rate of 10.34% relative to enteral medication administration via gastrostomy tube (g-tube; a tube that provides direct access to the stomach for supplemental feeding, hydration, or medication).

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that 1 of 3 medication carts were kept locked or kept under direct observation of authorized staff in an area where residents could access it. Additionally, the facility failed to store all drugs and biological's in accordance with currently acceptable professional principles for 3 of 4 medication carts observed, Country Two Meadow Road cart, Side Two Country cart, and Ocean Unit cart.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to protect a resident's right to be free from sexual abuse for 1 of 5 residents reviewed, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 4 of 7 residents reviewed for medication administration, Resident ID #s 29, 54, 81 and 507.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for 1 of 3 residents reviewed relative to requiring supervision while eating, Resident ID #50.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that services provided by the facility failed to meet professional standards of quality relative to a dressing observed on a resident without a physician's order for 1 of 1 resident reviewed, Resident ID #96.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident received adequate supervision while eating for 1 of 3 residents reviewed who require supervision during meals, Resident ID #50.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 1 of 7 residents reviewed for medication administration, Resident ID #29.

Inspectors wroteBased on surveyor observations, record review, and staff interview, it has been determined that the facility failed to store and label drugs and biological's in accordance with currently accepted professional principles for 1 of 2 medication storage rooms, the Country Unit.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to accommodate residents' food preferences for 3 of 21 sample residents reviewed, Resident ID #s 29, 81, and 513.