Inspection Report
Follow-Up
Census: 37
Deficiencies: 1
Jun 30, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 06/30/2025 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies, indicating that the previously cited deficiencies related to policies and procedures were corrected.
Complaint Details
The complaint investigation was triggered by an allegation that a resident exited the facility from a secured courtyard in the memory care unit through a faulty fire door that did not lock or alarm. The investigation found the elopement occurred due to an unlocked and unalarmed emergency exit door, and the facility lacked a policy for routine checks of secured unit exits. Abuse/neglect was unsubstantiated.
Deficiencies (1)
| Description |
|---|
| Failure to develop and implement policies and procedures to provide necessary care and services for residents, including those with special needs, and to train staff on supervision and monitoring of residents including accounting for residents who leave the premises. |
Report Facts
Total residents: 37
Resident sample size: 3
Residents at risk for elopement: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Prentice | Complaint Investigator | Conducted the complaint investigation and on-site verification |
| Jamie Singer | Field Manager | Signed the follow-up inspection letter and plan of correction |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Sep 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation related to a COVID-19 outbreak involving 15 residents and 4 staff members at the assisted living facility.
Findings
The facility had no hospitalizations or deaths from COVID-19 infection, but failed to have medical evaluations available or on file for 17 of 37 staff members as required, placing residents at risk for respiratory infection.
Complaint Details
The complaint investigation was substantiated with a failed provider practice identified and citation(s) written. The facility had a COVID outbreak and failed to maintain required medical evaluations for staff respirator use.
Deficiencies (1)
| Description |
|---|
| Failure to have medical clearance records for respirator mask use for 17 of 37 healthcare workers, placing 44 residents at risk for respiratory infection. |
Report Facts
Residents in COVID outbreak: 15
Staff in COVID outbreak: 4
Total residents: 44
Resident sample size: 3
Staff without medical clearance records: 17
Total healthcare workers: 37
Residents at risk: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Prentice | Complaint Investigator | Conducted the complaint investigation and onsite verification |
Inspection Report
Follow-Up
Census: 42
Deficiencies: 0
Jul 3, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection on 07/03/2024 found no deficiencies and confirmed the facility meets Assisted Living Facility licensing requirements. Previous deficiencies cited on 04/29/2024 and 05/01/2024 were corrected.
Report Facts
Residents sampled: 8
Current residents census: 42
Former residents sampled: 0
Staff sampled for fingerprint background check: 5
Staff without fingerprint background check: 1
Residents at risk due to fingerprint background check deficiency: 42
Residents with inaccurate medication records: 6
Kitchen staff sampled: 12
Kitchen staff without valid food handler's permits: 2
Staff N shifts worked: 28
Staff O shifts worked: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erin Steinbrenner | Nursing Consultant Institutional | Department staff who did the on-site verification |
| Faith Le | NCI | Department staff who did the on-site verification and inspection |
| Jamie Singer | Field Manager | Signed multiple letters and reports related to the inspection and follow-up |
| Staff B | Certified Nursing Assistant | Failed to complete national fingerprint background check |
| Staff F | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and side rail risks |
| Staff G | Licensed Practical Nurse (LPN) | Observed administering medications and documentation issues |
| Staff J | Certified Nurse Assistant | Interviewed about bed rail use for Resident 1 |
| Staff M | Director of Culinary Services | Observed during food service and kitchen tour |
| Staff K | Dishwasher | Observed not following handwashing protocol and wearing gloves |
| Staff L | Diet Aide | Observed plating and serving food, took temperature readings |
| Staff N | Cook | Did not have valid food handler's permit on file |
| Staff O | Dishwasher | Did not have valid food handler's permit on file |
| Staff P | Director of Human Resources | Could not produce food handler's permit records for Staff N and Staff O |
| Staff Q | Administrator | Acknowledged missing staff initials on MARs as documentation errors |
| Staff H | Human Resource Specialist | Interviewed regarding fingerprint background check for Staff B |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 5
Oct 4, 2023
Visit Reason
The Department completed a complaint investigation of the Assisted Living Facility based on complaint number 98573, focusing on medication administration issues and compliance with Assisted Living Facility requirements.
Findings
The investigation found that the facility had isolated occasions of delayed medication administration due to staffing and communication issues, missed medication doses due to supply and retrieval problems, and failed to notify the physician when a resident refused medication, placing residents at risk. A failed provider practice was identified and citation(s) were written.
Complaint Details
Complaint investigation based on complaint number 98573. The complaint was substantiated with findings of medication administration deficiencies and failure to meet Assisted Living Facility requirements.
Deficiencies (5)
| Description |
|---|
| Failed to notify the prescribing physician and evaluate when a resident refused their medication, placing residents at risk of decline in health status. |
| Medications were given late due to lack of communication and nursing staff availability. |
| Missed medication dose due to lack of medication supply and failure to retrieve delivered medication. |
| Archaic and unsafe medication system relying on paper documentation. |
| Insufficient nursing staff to cover multiple floors of residents needing medication. |
Report Facts
Total residents: 39
Resident sample size: 3
Closed records sample size: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Prentice | Complaint Investigator | Investigator who conducted the complaint investigation and provided consultation |
| Jamie Singer | Field Manager | Field Manager who signed the letter regarding the complaint investigation |
Inspection Report
Life Safety
Deficiencies: 4
Jun 21, 2023
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at Bayview Manor Homes to assess compliance with fire protection codes and regulations.
Findings
The inspection identified multiple violations related to fire door operations, sprinkler head maintenance, commercial cooking system signage, and the improper mounting height of manual fire alarm boxes. Previous violations noted in a later inspection on 07/19/2023 were corrected.
Deficiencies (4)
| Description |
|---|
| Fire doors on multiple floors failed to close and latch properly due to malfunctioning door coordinators or missing closers. |
| Sprinkler heads in the kitchen dry storage, trash room, and kitchen coolers need to be lowered, replaced, or checked for age due to significant loading and high hazard environment. |
| The kitchen's automatic fire-extinguishing system lacks required signage listing the kitchen lineup as per code. |
| Manual fire alarm pull stations were mounted too high and need to be lowered to between 42 and 48 inches from the floor. |
Report Facts
Next inspection scheduled: Jul 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Arthur Jesse Ward | Deputy State Fire Marshal | Conducted the inspection and signed the report |
| Phillip Smith | Facility Director | Named as facility representative on the report |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Jan 4, 2023
Visit Reason
The investigation was initiated due to a complaint alleging that a named resident experienced long call light wait times of 45 to 50 minutes and may have had soiled undergarments.
Findings
The facility failed to provide timely assistance to the named resident, resulting in delayed call light response times that exceeded a reasonable threshold. A failed practice for delayed call light response was cited.
Complaint Details
The complaint was substantiated. The investigation found that the named resident experienced long call light wait times of 45 to 50 minutes, and the facility failed to provide timely assistance as required by the negotiated service agreement.
Deficiencies (1)
| Description |
|---|
| Failure to respond to call lights in a timely manner as established in the Negotiated Service Agreement for 1 of 3 residents, placing Resident 1 at risk of harm. |
Report Facts
Total residents: 35
Resident sample size: 5
Call light response times: 129
Call light response times over 10 minutes: 12
Call light response times over 20 minutes: 6
Call light response times over 30 minutes: 5
Call light response times over 40 minutes: 4
Call light response times over 50 minutes: 6
Call light response times over 60 minutes: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Prentice | Complaint Investigator | Department staff who conducted the on-site verification and investigation |
Inspection Report
Follow-Up
Census: 43
Deficiencies: 1
Dec 13, 2022
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to infection control.
Findings
The follow-up inspection found no deficiencies, confirming that the previously cited infection control deficiencies, specifically related to respiratory protection program and staff fit-testing for masks, were corrected.
Complaint Details
Complaint investigation conducted on 2022-10-20 found deficient practice related to COVID-19 respiratory protection program; failed provider practice identified and citation(s) written.
Deficiencies (1)
| Description |
|---|
| Failure to follow a Respiratory Protection Program by ensuring staff wore fit-tested masks while providing care, placing residents at risk for COVID-19 exposure. |
Report Facts
Total residents: 43
Resident sample size: 43
Deficiency correction timeframe: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hayley Pinkham | ALF Licensor | Investigator who conducted complaint investigation |
| Jamie Singer | Field Manager | Named in enforcement and follow-up correspondence |
| Erin Steinbrenner | Nursing Consultant Institutional | Conducted on-site verification during follow-up inspection |
Report
File
R_Bayview_Manor_Homes_Inspection_10-27-2022_-_AH.pdf
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