Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bay View Rehabilitation Hospital, Llc during CMS and state inspections, most recent first.
A resident with a Stage 3 sacrococcyx pressure injury, diabetes, malnutrition, CVA, and hemiplegia/hemiparesis did not receive the ordered hydrogel dressing on multiple days after admission. The hospital discharge instructions required the sacral wound to be covered, assessed every shift, and changed as needed, but the treatment record lacked documentation of the dressing being provided. The TLN stated that if the wound treatment record was not signed, it was not done, and the DON confirmed the ordered treatment was missed.
A resident with severe cognitive impairment and multiple diagnoses, including respiratory failure, pneumonia, cerebral infarction, and metabolic encephalopathy, attended a medical appointment without ordered pelvis and left hip x-rays being completed. The record showed the x-ray was ordered but no results were available, the office had requested the images multiple times, and the LVN confirmed the x-ray was not performed. The DON stated missing ordered tests can compromise care and lead to negative outcomes.
A resident with severe cognitive impairment was moved to a different room without receiving the required written notification, violating their rights. The facility staff only provided verbal notifications, contrary to the policy that mandates advance written notice, including the reason for the change.
The facility failed to maintain a safe and comfortable room temperature for three residents, with temperatures dropping below 71 degrees for over six hours. The Maintenance Director confirmed that resident rooms lacked hot air circulation outlets, and the Administrator acknowledged the issue, stating it would take hours to adjust temperatures. The Director of Staff Development and the Director of Nursing expressed concerns about health risks like hypothermia. A review of the temperature log showed multiple rooms with low temperatures, and no follow-up actions were taken despite awareness of the issue.
The facility failed to complete required Level I PASARR screenings for two residents who stayed beyond 30 days and did not ensure the accuracy of a screening for another resident with schizophrenia. The Administrator was unaware of the requirement, and the Director of Nursing was responsible for these oversights.
A facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who was admitted to hospice care due to a terminal illness. Despite the requirement to perform the SCSA within 14 days of hospice enrollment, the facility did not complete this assessment, resulting in a deficiency.
The facility failed to ensure accurate MDS assessments for six residents, leading to discrepancies in medical records. Errors included incorrect medication records, untriggered PASARR for mental illness, omitted PTSD diagnosis, incorrect discharge location, and inaccurate assessment of paraplegia. The facility's policy requires accuracy in MDS assessments, but these inaccuracies indicate a failure to adhere to this policy.
A facility failed to create a comprehensive care plan for a resident with PTSD, despite the resident's intact cognition and medical history indicating the need for such a plan. The responsibility for developing the care plan was with the social services department, which acknowledged the oversight. The Administrator confirmed that a care plan should have been in place, as per the facility's policy.
A resident with quadriplegia developed a pressure injury on the upper back due to lying on a nephrostomy tube, which was not properly managed by the staff. The injury was noted as redness and attributed to trauma from the tube. Staff interviews indicated that preventive measures were not included in the care plan, and the injury could have been avoided by ensuring the resident was not lying on the tube.
A resident alleged that a CNA slapped them, but the LVN failed to report the incident within the required 2-hour timeframe. The resident, diagnosed with Major Depressive Disorder, showed redness on their face. The SOC 341 was completed and faxed several hours late, contrary to the facility's policy requiring immediate reporting to the Administrator, CDPH, ombudsman, and law enforcement.
A CNA in an LTC facility was reported for physically abusing a resident, including poking and forcefully seating them, causing distress. Despite the report, the facility returned the CNA to duty before completing a thorough investigation, which lacked a required post-incident assessment. This premature action placed residents at risk, leading to an Immediate Jeopardy situation.
A resident with dementia was physically abused by a CNA, who poked her cheek, smacked her hand, and forcefully sat her down in a wheelchair, causing distress. An LVN witnessed the incident and reported it, but was instructed by the ADM to alter her statement. The police investigation confirmed the abuse, highlighting a failure to uphold resident rights and abuse prevention policies.
The facility failed to ensure a safe environment by not having working locks on sliding and screen doors in multiple residents' rooms. Residents expressed concerns about safety, and the Maintenance Director confirmed the lack of locking mechanisms. Clinical records indicated various medical conditions among the residents involved.
Failure to Follow Ordered Wound Treatment for Sacrococcyx Pressure Injury
Penalty
Summary
The facility failed to follow the physician’s ordered wound treatment for a resident admitted with a Stage 3 pressure injury to the sacrococcyx. The resident had moderate cognitive impairment, malnutrition, diabetes, cerebrovascular disease, and hemiplegia/hemiparesis. The hospital discharge instructions directed staff to cover the sacrum with an optiview hydrogel dressing, assess it every shift, change it as needed, and not leave it on for more than 7 days. The admission note also documented sacrococcyx redness, and the resident’s MDS identified the pressure ulcer as present on admission and noted the need for nonsurgical dressings. The January treatment record showed the resident did not receive the ordered hydrogel dressing to the sacrum on multiple days, and the treatment nurse stated that if the wound treatment record was not signed, it was not done. The wound care physician stated the expectation was for the treatment nurse to follow the wound regimen, and the DON stated the resident did not receive the hydrogel dressing on multiple days despite the physician order. The resident’s care plan included treatment as ordered and evaluation of effectiveness, and the surgical consult later documented continued sacrococcyx wound care needs along with risk factors including limited mobility and diabetes.
Failure to Complete Ordered X-Rays for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure resident-directed care for one resident when the resident attended a medical appointment without physician-ordered x-rays being completed. The resident was admitted with diagnoses including acute respiratory failure with hypoxia, pneumonia, cerebral infarction, metabolic encephalopathy, alcohol abuse, stimulant abuse, anxiety, and delusional disorder. The resident’s MDS assessment dated 12/15/25 showed a BIMS score of 7 out of 15, indicating severe cognitive impairment. The record showed an x-ray was ordered to be completed on 4/20/26, but during the resident’s medical office visit on 4/29/26, pelvis and left hip x-rays were not available despite multiple requests by the office to the facility. Review of the medical record on 5/13/26 showed no x-ray results for April 2026, and the LVN stated the x-ray was not performed. The DON stated that missing ordered tests can compromise care and lead to negative outcomes. The facility policy stated licensed nursing staff will verify orders with the physician and communicate with other disciplines necessary treatment and/or services to meet resident needs.
Failure to Provide Written Notification of Room Change
Penalty
Summary
The facility failed to provide written notification to a resident and their responsible party (RP) regarding a room change, violating their rights. The resident, who was admitted with a diagnosis of dementia and had a severe cognitive impairment as indicated by a BIMS score of 6 out of 15, was moved to a different room without receiving the required written notice. The RP confirmed during a phone interview that they were not informed of the reason for the room change. The Social Services Assistant (SSA) and Registered Nurse Supervisor (RNS) both acknowledged that only verbal notifications were given, either in person or via phone call, contrary to the facility's policy which mandates advance written notice. The SSA was unaware of the requirement for written notification and could not locate the Notification of Room Change form for the resident in question. The facility's policy clearly states that all parties involved should receive advance notice, including the reason for the change, which was not adhered to in this case.
Failure to Maintain Safe Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable and safe room temperature for three residents, resulting in temperatures below 71 degrees for over six hours. This deficiency was identified through observations, interviews, and record reviews. The Maintenance Director (MD) confirmed that the resident rooms lacked hot air circulation outlets, which were only present in the hallways. The Administrator acknowledged the issue and stated that it would take several hours to adjust the room temperatures to the required range of 71 to 81 degrees. The Director of Staff Development and the Director of Nursing both expressed concerns about the potential health risks associated with the cold temperatures, such as hypothermia and blood circulation issues. The deficiency was further supported by a review of the facility's temperature log, which showed that eight out of 30 resident rooms had recorded temperatures below 71 degrees. Despite being aware of the low temperatures, the MD had not taken any follow-up actions. The facility's policy and procedure on maintaining internal temperature stated that the environment should be kept at a level that residents find comfortable, specifically between 71 and 81 degrees. However, this policy was not adhered to, leading to an unhomelike environment and potential health risks for the residents involved.
Failure to Complete and Ensure Accuracy of PASARR Screenings
Penalty
Summary
The facility failed to complete a Level I preadmission screening and resident review (PASARR) for two residents who remained in the facility beyond 30 days. Resident 116, admitted with a history of anxiety disorder, schizoaffective disorder, and PTSD, did not have a new Level I Screening submitted on the 31st day of admission, as required by the California Department of Health Care Services. Similarly, Resident 152, with a diagnosis of schizoaffective disorder, also lacked a new Level I Screening on the 31st day. The facility's Administrator was unaware of the requirement and the letter indicating the necessity for the PASARR, and the Director of Nursing was identified as responsible for ensuring the completion of these screenings. Additionally, the facility failed to ensure the accuracy of a Level I Screening for Resident 96, who had a diagnosis of schizophrenia. The resident's PASARR, dated 12/05/2023, inaccurately indicated the absence of a serious mental disorder, despite the resident's known condition. The Admission Director stated that nursing staff were responsible for reviewing PASARRs for accuracy, and the Administrator confirmed the inaccuracy, attributing responsibility to the Director of Nursing. The facility's policy required all admissions to be screened for mental disorders, intellectual disabilities, or related disorders, but this was not adhered to in these cases.
Failure to Complete SCSA for Hospice Enrollment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who was admitted to hospice care. The resident, who was admitted to the facility with a medical history of cerebral infarction and Parkinson's disease, was enrolled in hospice care on 10/15/2024 due to a terminal illness related to a cerebrovascular accident. According to the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, an SCSA is required within 14 days of a resident's enrollment in hospice care. However, the facility did not complete this assessment within the specified timeframe, leading to a deficiency finding during the survey.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for six residents, leading to discrepancies in their medical records. Resident 116 was admitted with a cardiac pacemaker and was inaccurately recorded as taking anticoagulant medication, which was not prescribed. The MDS Resource confirmed the inaccuracy after reviewing the physician orders. Similarly, Resident 13 and Resident 17, both diagnosed with bipolar disorder, were not flagged by the state level II preadmission screening and resident review process (PASARR) for serious mental illness, despite having active diagnoses that should have triggered the PASARR. Resident 148, admitted with anxiety disorder, had an MDS indicating an active diagnosis of PTSD, which was later omitted in a subsequent assessment despite the condition being active. Resident 157 was recorded as discharged to a short-term general hospital, although the Nurses Notes indicated the resident was discharged home. The MDS Resource acknowledged the coding error. Lastly, Resident 60, diagnosed with paraplegia, was inaccurately assessed as having no functional limitations in range of motion, contradicting the diagnosis. The facility's policy on certifying the accuracy of resident assessments requires that any person completing a portion of the MDS must sign and certify its accuracy. The policy also specifies that the information captured should reflect the resident's status during the observation period. However, the inaccuracies in the MDS assessments for these residents indicate a failure to adhere to this policy, as confirmed by interviews with the MDS Resource and the Administrator.
Failure to Develop Comprehensive Care Plan for PTSD
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with PTSD, as required by their policy. The resident, admitted on June 6, 2024, had a medical history that included anxiety disorder and PTSD, with an intact cognition as indicated by a BIMS score of 15. Despite these diagnoses, the resident's care plan lacked specific goals or interventions to address the PTSD, which is a critical component of their care needs. Interviews with facility staff revealed that the responsibility for creating the care plan for PTSD lay with the social services department. The Social Services staff acknowledged that a care plan should have been developed to ensure the resident's needs were met, particularly to help the staff understand how to make the resident feel safe. The Administrator confirmed that a care plan should have been in place, aligning with the facility's policy that mandates comprehensive, person-centered care plans with measurable objectives and timetables for each resident.
Failure to Prevent Pressure Injury from Nephrostomy Tube
Penalty
Summary
The facility failed to prevent a medical device-related pressure injury for a resident with quadriplegia and hydronephrosis, who was dependent on staff assistance for movement. The resident developed a pressure injury on the left upper back due to lying on a nephrostomy tube, which was not adequately managed or repositioned by the staff. The injury was first noted as redness on the resident's back, measuring 3.3 by 1.3 by 0 centimeters, and was attributed to trauma from the nephrostomy tube. Interviews with staff revealed that the injury could have been prevented by ensuring the resident was not lying on the nephrostomy tube. However, the care plan did not include preventive measures to address this issue. The staff, including a Licensed Vocational Nurse and Certified Nursing Assistants, were aware of the nephrostomy tube but failed to implement effective strategies to prevent the pressure injury, such as repositioning the resident or adequately securing the tube.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to adhere to its policy and procedure for the immediate reporting of alleged abuse. Specifically, the facility did not report an allegation made by a resident who claimed that a Certified Nursing Assistant (CNA) slapped them in the face. The incident was reported to a Licensed Vocational Nurse (LVN) at around 10:00 a.m., who observed redness on the resident's face. However, the LVN did not report the alleged abuse or complete and submit the required Report of Suspected Dependent Adult/Elder Abuse (SOC 341) to the Administrator, California Department of Public Health (CDPH), the ombudsman, or law enforcement within the mandated 2-hour timeframe. Instead, the SOC 341 was completed and faxed at 6:10 p.m., several hours after the initial report. The resident involved in the incident was admitted to the facility in 2020 and had a diagnosis of Major Depressive Disorder, Single Episode. The Director of Nursing (DON) confirmed that the SOC 341 was submitted late and reiterated the facility's policy to report alleged abuse immediately or within 2 hours to ensure timely investigation and resident safety. The facility's policy, updated in 2019, mandates that all employees report suspected abuse immediately to the Administrator/Abuse Coordinator and other relevant authorities. The delay in reporting had the potential to hinder the investigation and affect the resident's physical and psychological well-being.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse when a Certified Nursing Assistant (CNA1) deliberately poked a resident in the cheek, smacked the resident's hand, and forcefully sat the resident down in a wheelchair, causing the resident to cry out in pain. This incident was witnessed by a Licensed Vocational Nurse (LVN1), who reported the abuse to the Administrator (ADM). Despite the report, the facility returned CNA1 to direct care duties before completing a thorough investigation, which included interviewing all witnesses. The facility's investigation into the abuse allegation was deemed incomplete, as it failed to include a post-incident 72-hour assessment by the Interdisciplinary Team (IDT), as required by the facility's policy. The investigation was concluded prematurely, and CNA1 was allowed to resume duties, providing care to multiple residents, including the one involved in the incident. This decision was made despite the ongoing investigation and the lack of a comprehensive assessment of the situation. The failure to conduct a thorough investigation and the premature return of CNA1 to duty placed residents at risk of further abuse. The facility's actions resulted in an Immediate Jeopardy situation, as the safety and well-being of the residents were compromised. The facility's policy on abuse allegations required the suspension of the alleged perpetrator pending a complete investigation, which was not adhered to in this case.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with Alzheimer's Disease and Non-Alzheimer's Dementia, who primarily communicated in Tagalog. The abuse occurred when the CNA deliberately poked the resident in the cheek, smacked her hand, and forcefully sat her down in a wheelchair, causing the resident to cry out in pain, hyperventilate, and visibly shake. This incident was witnessed by a Licensed Vocational Nurse (LVN), who reported the abuse to the Director of Nursing (DON) and the Administrator (ADM). The LVN provided a detailed account of the incident, stating that the CNA handled the resident roughly and yelled at her in Tagalog. The LVN also reported that the CNA applied A&D ointment to the resident's face without a doctor's order. The LVN's initial written statement was altered at the request of the ADM, who instructed her to remove details that made the CNA look bad. The LVN complied out of fear of retaliation but later confirmed the original details to a police officer investigating the incident. The police officer's investigation corroborated the LVN's verbal account, noting discrepancies between the LVN's initial and rewritten statements. Another LVN, who was nearby during the incident, heard the resident's screams and confirmed the abusive actions described by the first LVN. The facility's policies on resident rights and abuse prevention were not upheld, as evidenced by the CNA's actions and the ADM's attempt to alter the LVN's statement.
Failure to Ensure Safe and Functional Environment
Penalty
Summary
The facility failed to ensure a safe and functional environment for residents and staff by not having working locks on sliding doors and screen doors in multiple residents' rooms. During observations and interviews, it was found that six out of 20 resident rooms in the Fernside Station had sliding doors that either did not have locks or had malfunctioning locks. These rooms had sliding doors that led to a public parking lot and a commercial shopping center, posing a potential safety risk. Residents expressed concerns about the lack of locks, especially at night, and the Maintenance Director confirmed that screen doors in all residents' rooms did not have locking mechanisms. The clinical records of the residents involved indicated various medical conditions, including difficulty walking, seizures, depression, morbid obesity, muscle weakness, anxiety disorder, dementia, and a history of falling. The Maintenance Director admitted that there was no record of regular inspections of resident rooms and doors for maintenance, and the facility's policy and procedure for general maintenance, which required monthly checks of resident rooms, was not being followed. The Licensed Vocational Nurse also noted that the sliding doors were sometimes hard to close and open because they would get stuck on the runners, further compromising the safety of the residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,053 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Alameda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alameda Hospital D/p Snf | 0.3 mi | ★★★★★ | 2 | 0 |
| Alameda Healthcare & Wellness Center | 0.6 mi | ★★★★★ | 1 | 0 |
| Marina Garden Nursing Center | 1.1 mi | ★★★★★ | 0 | 0 |
| West Shore Post Acute | 1.2 mi | ★★★★★ | 0 | 0 |
| Fruitvale Healthcare Center | 1.7 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bay View Rehabilitation Hospital, Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.