Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Civita Care Bayview during CMS and state inspections, most recent first.
A resident with cognitive impairment, mobility limitations, and a history of pulmonary embolism was inadvertently given Suboxone prescribed for another resident after an LPN, interrupted multiple times during medication preparation, entered the wrong room and failed to verify the resident’s identity by name or bracelet. The resident, who had never been prescribed opioids, subsequently developed opioid-induced respiratory depression with low O2 saturation, pinpoint pupils, and altered mental status, requiring Narcan administration, ED transfer, ICU admission, IV medications, continuous monitoring, and an extended hospitalization. The facility’s policy defined this as a significant medication error because it required hospitalization, treatment with prescription medication, and was life-threatening.
A resident with vascular dementia, muscle weakness, and significant ADL dependence, who was ordered to be transferred with a mechanical lift and two staff, was manually transferred by a single NA who relied on an outdated assignment sheet instead of the resident care card. The NA attempted a pivot transfer using a gait belt without obtaining a second staff member or a mechanical lift, and did not adequately verify that the wheelchair brakes were fully engaged. The resident was only partially seated when the wheelchair rolled backward, causing the resident to fall forward and sustain a facial laceration and bloody nose that required hospital evaluation and sutures.
Two residents with multiple diagnoses and identified fall risks did not have their required quarterly fall risk evaluations completed, despite the assessments being opened in the system and a facility policy requiring fall risk evaluations at admission, quarterly, annually, and after a fall. One resident with vascular dementia, muscle weakness, and significant dependence for mobility had a blank quarterly fall risk assessment and later sustained a witnessed fall during a transfer when wheelchair locks failed, resulting in facial injuries and hospital transfer. Another resident with polyneuropathy, epilepsy, weakness, and recent admission status also had a blank quarterly fall risk assessment and later slid to the floor while attempting to reach the bathroom after feeling weak. The MDS assistant and MDS RN reported that nursing staff were responsible for completing these assessments and could not explain why they were not done, and the DON confirmed they should have been completed as scheduled.
Surveyors found that medications were left unattended at the bedsides of four residents, including while some were asleep, without proper physician orders for self-administration. An LPN left medication cups at the bedside for multiple residents, some of whom did not have authorization to self-administer, and in one case, a medication not approved for bedside use was present. Nursing staff and the DON confirmed that facility policy was not followed, resulting in unsecured medications and noncompliance with medication administration protocols.
A resident with cognitive impairment and chronic health conditions required reminders and set up for daily hygiene, with a care plan directing staff to notify the conservator of any refusals of care. Documentation showed that staff did not consistently record or notify the conservator when the resident refused care, particularly outside of scheduled shower days. Interviews confirmed that the resident often declined daily hygiene tasks, and the DON was unaware that notifications were not being made as required by the care plan.
Kitchen dry goods were found with missing or expired labeling, including muffin mix, stuffing mix, and opened croutons with no expiration date. The kitchen hood also had visible dust and debris, including on the fire suppression system, and there was no cleaning log or date of last cleaning available. Staff and management gave inconsistent accounts of routine hood cleaning and scheduling, and the vendor reported an unpaid balance prevented return service.
Missing Water Management Documentation and Meeting Records: The facility failed to maintain required water management records for legionella sampling, monthly ice machine cleaning, and annual water management committee meetings. Staff reported the contracted water management company had not been paid, and the facility did not have copies of sampling results or an updated plan. Records also showed no documented ice machine cleaning for several months and no meeting minutes beyond a prior committee meeting.
Advance Directive Code Status Not Honored: The facility failed to honor elected DNR/DNI status for multiple residents. For one resident with dementia and diabetes, one resident with anxiety, chronic embolism, and depression, and one resident with dementia and substance-related disorders, the paper chart contained DNR/DNI or DNR elections, but the EHR, bed board, physician orders, and care plans reflected full code/CPR. Staff interviews confirmed the mismatch between the signed advance directive forms and the active code status entries.
Surveyors found that residents were placed on secured or locked units without documented criteria, consent, or ongoing review, and staff said the unit placement was based mainly on dementia or safety concerns without a written policy. One resident with intact cognition and no wandering risk was described as feeling stuck in the room, another resident on the secured unit became aggressive toward another resident, and a third resident was moved after wandering, but the chart did not show prior interventions or clear placement rationale. The second-floor unit also required a code for exit, and residents and visitors were not given the code.
Unsecured Medication Cart and Medication Room Keys: A DNS handed a set of keys to an RN, who used them to open the med cart and med room on a dementia unit. After the observation and narcotic count, the RN placed the keys in a plastic bin on top of the nurse's station desk. The DNS stated the keys should have remained on the nurse's person for the entire shift and then been handed to the oncoming nurse after report.
Call Bell System Not Functioning: The resident call bell system was not working properly, with no audible alarm when activated and no bells available in resident bathrooms. Residents reported the system had been down for a while and that hand bells were used instead, but they were not always within reach and were not in the restroom. Resident council minutes and staff interviews confirmed the system had been off and on for months, with attempts to reset it and a replacement quote already obtained, but no repair documentation could be found.
Failure to follow bowel regimen and monitor BMs for two residents. Two residents with cognitive impairment and extensive assistance needs had standing orders for Senna plus a stepwise constipation protocol, but staff did not administer the ordered bowel regimen despite prolonged periods without documented BMs. One resident later developed nausea/vomiting with hypoactive bowel sounds and a KUB showed moderate stool burden compatible with constipation; the other later complained of constipation after many shifts without a BM. Interviews confirmed staff expected the bowel protocol to start after 9 shifts without a BM, but it was not carried out as ordered.
A resident with sleep apnea went without a properly fitting BiPAP mask for about 2 weeks because the equipment was not ordered in a timely manner, and staff reported confusion about who was responsible for ordering it. Another resident with a history of sleep apnea had oxygen tubing left in place far beyond the ordered weekly change schedule, and an LPN was unsure who was responsible for the task.
Failure to Offer Pneumococcal Vaccine on Admission: A resident with anxiety, dementia, and HTN was admitted with documented prior pneumococcal immunizations, but the clinical and consent records did not show that the pneumococcal vaccine was offered on admission. The IP RN stated she was responsible for ensuring residents are offered the vaccine, but she did not offer it because she believed the resident had already completed the series and did not discuss vaccine appropriateness with the provider.
Facility assessment failed to identify secured nursing units and did not include criteria or policies related to those units. Survey observations found locked units on the first and second floors with code-required egress, but the assessment only described the facility’s licensed beds and nursing units without noting either secured unit. The former Administrator stated she completed the assessment and that it should be updated when facility changes occur.
Failure to Provide Bed-Hold Notice During Hospital Transfers: The facility did not document that written bed-hold notices were provided to residents and/or their representatives when residents were transferred to the hospital. One resident was cognitively intact and had CHF, AFib, and COPD; two residents had severely impaired cognition, with one transferred after a fall with head bleeding and another after becoming unresponsive with facial droop/drooling and later returning from the hospital still lethargic. Staff interviews and facility policy indicated the bed-hold notice should accompany transfer paperwork and be mailed to the responsible party, but the notices were not completed.
MDS assessments failed to accurately code PASRR status for multiple residents with documented mental health diagnoses and positive level II PASRR determinations. The MDSs listed the residents as cognitively intact, without behaviors, and without a positive level 2 PASRR, despite the medical record and PASRR screenings showing otherwise; the SW stated the assessments should have reflected positive level 2 PASRR status.
Significant Medication Error from Misidentification and Wrong-Resident Opioid Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a Schedule III opioid medication (Suboxone 8-2 mg) prescribed for another resident was inadvertently administered to Resident #1. Resident #1 had diagnoses including pulmonary embolism, depression, and difficulty walking, and was care planned for self-care deficits with interventions to administer medications as ordered and monitor for side effects. The five-day MDS showed short- and long-term memory deficits (BIMS score of 7), dependence on staff for toileting, dressing, bed mobility, and transfers, and non-ambulatory status with wheelchair use. On the evening of 2/5/26, LPN #1, who was administering medications for the first time to Resident #1, was preparing medications for Resident #2 when a family member interrupted and requested that she meet Resident #1 because she was Spanish speaking. After meeting Resident #1, LPN #1 returned to preparing medications for Resident #2 and reported an additional interruption by a nursing assistant. She then entered Resident #1’s room, mistakenly believing this resident was Resident #2 because both residents were Spanish speaking, and began administering medications without verifying the resident’s identity by name or checking the name bracelet. Resident #2 refused all medications except Suboxone, and LPN #1 later realized during shift change that she had administered the Suboxone dose to Resident #1 instead of Resident #2 and had not administered medications to Resident #2. Following the error, Resident #1 was found with oxygen saturation levels between 83% and 86% on room air, a respiratory rate of 13 (previously 18), heart rate of 92, and pinpoint pupils, while previously normal vital signs had been documented. The APRN, RN supervisor, and DON were notified, and the APRN confirmed that Suboxone was not prescribed for Resident #1, who had never been on opioids, and identified that the dose given was supratherapeutic for an opioid-naïve individual and constituted a significant medication error. Resident #1 required oxygen, Narcan administration, transfer to the ED, and subsequent ICU admission with additional Narcan doses, IV potassium for hypokalemia, IV Diltiazem for hypertension, and continuous telemetry and pulse oximetry monitoring, with a total hospitalization of 11 days. The facility’s Medication Error Policy defined a significant medication error as one resulting in hospitalization, requiring prescription medication to treat the error, or being life-threatening or potentially leading to death, criteria that were met in this incident.
Removal Plan
- Train staff on the five rights of medication administration and perform medication competencies for all licensed nursing staff.
- Provide one-to-one education to the LPN from the consulting pharmacy.
- Conduct random audits of narcotic reconciliation, medication pass observations with licensed staff, change-of-condition documentation, and RN assessments.
- Review audit results at the QAPI meeting.
- Assign the Director of Nursing to implement and monitor the corrective actions with the Administrator maintaining regulatory oversight.
Failure to Follow Transfer Requirements and Verify Wheelchair Brakes Resulting in Fall Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer for a resident who required two-person assistance and a mechanical lift, resulting in a fall with injury. The resident had vascular dementia without behavioral disturbances, muscle weakness, anxiety disorder, and a BIMS score of 6/15, indicating poor short- and long-term memory. A physician’s order dated 10/28/25 and the resident’s care plan dated 11/13/25 specified that the resident required a mechanical lift and assistance of two staff for all transfers due to generalized weakness, vascular dementia, and forgetfulness. The quarterly MDS documented that the resident was dependent on staff for bed mobility and transfers. On 12/12/25, a nurse aide (NA #1) who did not consistently care for this resident relied on an assignment sheet that incorrectly indicated the resident was an assist of one for transfers. NA #1 did not review the resident care card, was not sure what a resident care card was or where it was located, and was unaware that transfer status on the care card, not the assignment sheet, should be followed. NA #1 positioned the wheelchair at the right side of the bed, sat the resident at the edge of the bed, applied a gait belt, and attempted a manual pivot transfer without obtaining a second staff member or using a mechanical lift, contrary to the physician’s order and care plan. During the transfer, NA #1 noted the resident was much weaker and heavier than expected but did not sit the resident back on the bed or request assistance. Instead, he bear hugged the resident and pivoted with difficulty, resulting in the resident being only partially seated at the edge of the wheelchair. Although NA #1 reported that he applied the wheelchair brakes, he did not move or jiggle the wheelchair to ensure the locks were fully engaged. The wheelchair began to roll backward, and the resident fell forward to the floor, striking the face and sustaining a bloody nose, a skin tear to the bridge of the nose, and a nasal laceration that required sutures in the emergency department. The facility’s wheelchair policy required positioning the wheelchair appropriately, applying brakes to lock the wheels, and using proper transfer techniques with a gait belt, which were not fully followed during this transfer.
Failure to Complete Quarterly Fall Risk Evaluations for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete required quarterly fall risk evaluations for two residents in accordance with professional standards and the facility’s Falls Management policy. For one resident with vascular dementia, muscle weakness, anxiety disorder, and a care plan identifying a high risk for falls, the quarterly Fall Risk Evaluation opened on 12/2/25 was left blank with no fall risk score determined. This resident’s care plan included use of a mechanical lift with two staff for transfers, environmental safety measures, and reminders to use the call light, and the quarterly MDS showed significant cognitive impairment and dependence on staff for bed mobility and transfers. On 12/12/25, this resident experienced a witnessed fall when a nurse aide transferred the resident into a wheelchair, the wheelchair locks failed, and the resident fell to the floor, sustaining a bloody nose and a skin tear to the bridge of the nose and requiring transfer to the hospital. A second resident, with diagnoses including polyneuropathy, epilepsy, weakness, and anxiety, also had a quarterly Fall Risk Evaluation opened on 12/10/25 that was left blank with no fall risk score determined. The quarterly MDS documented that this resident was alert and oriented and independent with bed mobility, transfers, and ambulation, and the care plan identified fall risk related to new admission, generalized weakness, syncopal episodes, and seizures, with interventions such as keeping the call light within reach and orienting the resident to surroundings. On 1/1/26, this resident reported feeling weak while attempting to get to the bathroom and slid to the floor onto their knees. Interviews with the MDS assistant and MDS nurse indicated that the assistant opened required assessments so they would appear on the dashboard, and that nursing staff were responsible for completing fall risk evaluations on admission, quarterly, annually, and after a fall; they were unable to explain why the two quarterly fall risk evaluations were not completed. The DON confirmed that the quarterly fall risk evaluations for both residents should have been completed when due, and the facility’s Falls Management policy directed that a fall risk evaluation be conducted on each resident upon admission, with the quarterly MDS cycle, and when a significant change in status occurs, including a fall.
Failure to Secure Medications and Adhere to Self-Administration Protocols
Penalty
Summary
Surveyors identified that medications and biologicals were not properly secured in accordance with professional standards, as required by facility policy and federal regulations. Specifically, medications were left unattended at the bedsides of four residents without appropriate physician orders for self-administration, and in some cases, while the residents were asleep. For example, one resident with mild cognitive impairment, COPD, and congestive heart failure was found sleeping with a cup of medications left on the bedside table, and there was no physician order permitting self-administration. The LPN responsible stated she left the medications because the resident was asleep and intended to return, but acknowledged this was not standard practice without a self-administration order. Another resident with diabetes, asthma, and anxiety had a physician order to self-administer certain medications, but a pill not matching the approved list was found at the bedside while the resident was asleep. The LPN explained she left the medication because of the self-administration order, but the medication present was not authorized for bedside self-administration. Two additional residents, one with end stage renal disease and macular degeneration and another with osteomyelitis, diabetes, anxiety, and opioid dependence, were also found with medication cups at their bedsides containing unidentified tablets. Neither had current physician orders or care plan documentation permitting self-administration, yet the LPN stated she believed they had such orders. Interviews with nursing staff and the DON confirmed that medications should not be left at the bedside without a physician order for self-administration, and never if the resident is asleep. The facility's own policy requires a physician's order for all self-administered medications, and the DON acknowledged that the policy was not followed in these instances. The deficiency was based on direct observations, record reviews, and staff interviews, all indicating a failure to properly secure medications and adhere to established protocols.
Failure to Implement Care Plan and Notify Conservator of Care Refusals
Penalty
Summary
The facility failed to fully implement a care plan for a resident with mild cognitive impairment, COPD, and congestive heart failure, who required set up and reminders for daily hygiene care. The care plan specified that the resident's conservator should be notified whenever the resident refused any portion of daily care. However, documentation from July through October showed that while the resident was mostly compliant, there were occasions when care was not provided and no documentation was completed. Medication Administration Records indicated that notification to the conservator for refusals of care was only documented on shower days, and nurse's notes did not reflect any notifications for refusals of care during a specified period. Interviews with the resident and staff revealed that the resident often chose not to perform daily hygiene tasks, such as washing, tooth brushing, or changing clothes, except on shower days. The primary nurse aide confirmed that the resident refused assistance with certain tasks and claimed to complete them independently. The DON acknowledged that the facility had agreed to notify the conservator of all refusals but was unaware that this was not consistently documented as required by the care plan. The facility's care plan policy required that care plans be developed and implemented with the resident and/or caregiver, but this was not fully adhered to in this case.
Improper Dry Storage Labeling and Unclean Kitchen Hood
Penalty
Summary
Kitchen dry goods were found stored with incomplete or missing labeling and expired product during an initial kitchen tour with the Dietary Director. In the dry storage area, a muffin mix bag had a receipt date of 8/1 with no year and no expiration date. Four bags of traditional stuffing mix were present, including one opened bag and three unopened bags, and all had a best-by date of 8/7/25. One opened bag of croutons also had no expiration date. The Dietary Manager stated that anyone in dry storage is responsible for checking whether food is labeled or expired, and that food should have a receipt date, open date, and expiration date if not already printed on the package, but said this had been missed. The kitchen hood was observed with visible dust and debris matted under the hood, including the fire suppression system, and no date of last cleaning or cleaning log was available to review. The Dietary Manager stated the hood is usually cleaned weekly by dietary staff and every six months by a professional company, but no log was kept and staff had not been cleaning it recently due to short staffing. Later interviews identified that the hood had last been cleaned by a professional company on 11/19/24, that maintenance was responsible for scheduling the cleanings, and that the company had not returned because a previous balance had not been paid.
Missing Water Management Documentation and Meeting Records
Penalty
Summary
The facility failed to provide documentation for its infection prevention and control water management program, including water sampling results for legionella and other waterborne pathogens, monthly ice machine cleaning records, and records of the annual water management plan meeting. Review of facility documentation showed the ice machines were not documented as cleaned from August 2024 through December 2024, and no water sampling test results were available for testing reportedly done on 1/29/24 and 1/27/25. Facility staff stated the water management company would notify the facility or the State agency if a positive result occurred, but also acknowledged the facility did not have copies of the results because of lack of payment to the contracted company. The facility’s Water Management Plan required monthly flushing of infrequently used water supply areas, twice-yearly legionella sampling, hot water temperature checks, and monthly ice machine cleaning, and it also required the facility to maintain environmental assessment, sampling, and management records on site for at least three years. Review of records found the last water management meeting was held in July 2024, and no meeting minutes were provided for January 2024 through September 2025 except for the July 2024 meeting. The Administrator identified the water management committee was supposed to include the infection control nurse, DNS, Director of Maintenance, and Administrator, but staff reported no water management meetings had occurred and no updated or revised plan was available because the contracted company had not been paid.
Advance Directive Code Status Not Honored
Penalty
Summary
The facility failed to ensure residents’ elected code status and advance directive choices were honored for 3 of 3 sampled residents reviewed for advance directives. Resident #1 had dementia with agitation, type II diabetes mellitus with hyperglycemia, and difficulty walking, and the admission MDS identified severely impaired cognitive skills for daily decision making. The clinical record contained a Facility Advance Directives Declaration Code Status form identifying the resident as DNR/DNI, but the physician order, care plan, and APRN progress note all reflected full code/CPR. Staff interviews confirmed the EHR and bed board showed full code, while the paper chart contained the DNR/DNI election, and the nursing supervisor and DNS acknowledged the discrepancy. Resident #58 had diagnoses including adjustment disorder with anxiety, chronic embolism, and depression, and the quarterly MDS identified intact cognition. The record contained a signed advance directive form showing DNR/DNI elected by the POA, but the APRN progress note, physician order, interdisciplinary care plan meeting form, and care plan reflected full code/CPR. Staff interviews again confirmed the EHR and bed board listed full code while the paper chart contained the DNR/DNI election. The DNS reviewed the chart and stated the resident should be DNR, indicating the code status had been entered in the computer as CPR. Resident #110 had unspecified dementia, alcohol dependence with alcohol-induced persisting dementia, unspecified mood disorder, and UTI. The record contained a Facility Advance Directives Declaration Code Status form showing the resident did not want resuscitation efforts and elected DNR, signed by the resident and witnessed by a nursing supervisor. After a hospital stay and readmission, the physician orders, care plan, and bed board/EHR reflected full code/CPR, despite the prior DNR election in the chart. The DNS acknowledged the resident should be DNR based on the previously signed advance directive, but the code status had been ordered in the computer as CPR and had not been followed up after readmission.
Locked-unit placement lacked criteria, documentation, and resident access
Penalty
Summary
The facility failed to ensure residents placed on secured or locked units had established criteria for that placement, documentation of the clinical basis for the placement, resident or representative involvement in the decision, and ongoing assessment of whether the placement remained appropriate. Surveyors observed the first-floor secured dementia unit required a numeric code for entry and exit, and the facility assessment did not identify that the unit was locked. The facility also failed to ensure residents and visitors had access to the code for independent egress from the second-floor unit, where doors to the elevators and stairwells were coded and no code was posted or available to residents or guests. For one resident on the first-floor secured unit, the clinical record showed diagnoses including adjustment disorder with anxiety, chronic embolism, and depression, but admission assessment, MDS, care plan, and social work documentation did not identify that the resident lived on a secure unit or the criteria for that placement. The resident was described as well adjusted, cheerful, cooperative, alert and oriented, ambulatory, not at risk for wandering or elopement, and not expressing a desire to leave. The resident and conservator reported feeling stuck in the room and stated the family had not signed consent for the locked placement. Staff interviews indicated the unit placement was based on a dementia diagnosis, but they also stated there was no policy or criteria for the secured unit and that placement discussions were not documented in the clinical record. For another resident on the secured unit, the record showed diagnoses including vascular dementia, depression, insomnia, and anxiety disorder, but the admission MDS identified intact cognition and no wandering or rejection of care. The care plan did not identify placement on a secured unit or any behaviors, and the social work note only documented that the family was agreeable to moving the resident to the secured unit after a competency evaluation showed lack of capacity to weigh risks and benefits. During observation, the resident exited the room, approached another resident, grabbed and threw a rolling walker, and threatened to kill the other resident, requiring removal from the area and one-to-one observation. Staff later stated the resident was not an appropriate fit for the secured unit, but the medical director said he did not document anything regarding secured-unit placement and would continue placing residents there because he did not want a resident wandering off and being harmed. For a third resident, the record showed diagnoses including alcohol dependence with alcohol-induced persisting dementia and mood disorder, with orders to monitor wandering and exit seeking. The resident was later moved to the locked unit after repeated wandering and attempts to go upstairs, but the care plan did not identify wandering prior to placement or other interventions attempted before the move. The resident stated there was no choice of where to live and that the facility told him or her the placement would continue until a significant other could take the resident home. On the second floor, several sampled residents had intact cognition or no wandering risk, yet their records did not include orders, consent, or care plan documentation supporting locked-unit placement, and staff stated the code was not given to residents because it could create a safety issue.
Unsecured Medication Cart and Medication Room Keys
Penalty
Summary
The facility failed to secure the keys that opened the medication cart and medication room on the dementia unit. During observation, the DNS handed a set of keys to RN #3, who used them to open the medication cart and then the medication room door for the medication cart review and narcotic count. After the observation was completed, RN #3 placed the same keys into a plastic three-drawer bin on top of the nurse's station desk. RN #3 stated that the keys had always been placed in that bin while working at the facility. The DNS stated that the keys for the medication cart and medication room should be kept on the nurse's person for the entire 8-hour shift and then given to the oncoming nurse after report, with no exceptions, and identified that RN #3 should not have left the keys in the bin. Review of the facility's Medication Storage Room/Medication Cart policy stated that medications are stored primarily in a locked mobile medication cart accessible only to licensed nursing personnel, and other medications are stored in a locked medication room.
Call Bell System Not Functioning
Penalty
Summary
The facility failed to ensure the resident call bell system was functioning properly, including in resident bathrooms and bathing areas. Observation on 9/15/25 at 9:45 AM found the second-floor resident call bell system was not functioning: there was no audible ring when the call bell was activated, although the light outside resident rooms did function. At that time, no staff were in the hall to see the light, and bells were located at residents’ bedside but were not present in the residents’ bathrooms. Resident interviews on 9/15/25 at 10:00 AM indicated the call system had not been functioning for a while. Residents reported they had been given hand bells as an alternative, but they did not always have them within reach and did not have bells in the restroom. Review of resident council minutes from July 2025 documented that the call bell system did not have sound, the lights went on, and hand bells had been handed out with in-service provided to staff. Maintenance and administrative interviews further identified the system had been down for several months, attempts had been made to reset it, a new system was needed, and a quote for replacement had been received on 8/22/24, but no work orders or completed repair paperwork could be located.
Failure to Follow Bowel Regimen and Monitor BMs
Penalty
Summary
The facility failed to monitor bowel movements and follow its bowel regimen for two residents with constipation orders. Resident #13 had diagnoses including chronic kidney disease stage 3, hypertension, and venous thrombosis, and was assessed as having moderate cognitive impairment and requiring extensive assistance with bed mobility, toilet hygiene, and transfers. The physician ordered Senna at bedtime and a stepwise bowel protocol of Milk of Magnesia, bisacodyl suppository, and fleet enema if no bowel movement occurred for 3 days, but the bowel flow sheet showed a large bowel movement on 9/3/25 and then no bowel movement from 9/4/25 through 9/11/25, followed by a small bowel movement on 9/12/25 and then no bowel movement again from 9/13/25 through 9/15/25. For Resident #13, the MAR showed no part of the facility bowel regimen was administered from 9/4/25 through 9/15/25. On 9/15/25, the resident developed nausea and vomiting, had hypoactive bowel sounds, and the physician was notified; lactulose was ordered and a KUB was obtained, which showed no bowel obstruction and a moderate amount of stool in the colon compatible with constipation. The record also showed the resident was continent of bowel and had a Foley catheter for urinary drainage. Resident #126 had diagnoses including low back pain, Parkinson’s disease, osteoarthritis, and lack of coordination, and was assessed as having severe cognitive impairment, requiring extensive assistance with bed mobility, toilet hygiene, and transfers, and being frequently incontinent of bowel with a Foley catheter. The physician ordered Senna and the same stepwise bowel protocol, but the bowel flow sheet showed no bowel movement for 22 shifts, with the last documented bowel movement on 8/13/25. The MAR showed no part of the bowel regimen was given during that period, and when the resident complained of constipation and had not moved bowels for 7 days, lactulose was ordered and administered. Interviews with nursing staff and the DNS confirmed that residents without a bowel movement for 9 shifts should have received the bowel protocol, but documentation of refusals was not available and the protocol was not followed for these two residents.
Respiratory Equipment and Oxygen Tubing Not Managed as Ordered
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident with sleep apnea, heart failure, and anxiety when BiPAP equipment was not ordered in a timely manner. The resident had a physician’s order for BiPAP at bedtime with oxygen at 2 to 3 liters per minute and the care plan identified use of BiPAP with oxygen to maintain an effective breathing pattern during sleep and restful sleep. The resident reported not having a BiPAP mask for about 2 weeks, and staff interviews showed the resident had been without a mask while several nurses were told masks were needed. The unit secretary or DNS usually ordered BiPAP masks, but the DNS stated the DME company was responsible for ordering BiPAP equipment and fit testing. The resident had refused the current mask because it did not fit and leaked, and the masks were not received until after the delay was identified. Safe and appropriate respiratory care was also not provided for another resident when the facility did not follow a physician’s order to change oxygen tubing weekly. The resident had diagnoses including breast cancer, liver disease, and depression, and a medical director note identified a history of sleep apnea. The care plan identified altered respiratory status or difficulty breathing and use of C-PAP and oxygen. A physician’s order directed oxygen tubing to be changed every Sunday on the 11-7 shift, but observation showed the tubing dated 6/22, over 2.5 months old. An LPN on the 11-7 shift stated the tubing was to be changed weekly but was not sure who was responsible for doing it.
Failure to Offer Pneumococcal Vaccine on Admission
Penalty
Summary
The facility failed to ensure that the pneumococcal vaccine was offered to Resident #11 upon admission. Resident #11 was admitted in May 2024 with diagnoses of anxiety, dementia, and hypertension, and the quarterly MDS identified moderately impaired cognition. Review of the resident’s immunization records showed prior receipt of Prevnar 13 on 06/06/2017 and PPSV23 on 6/2/2016 before admission, but the clinical record and consent records did not identify that the resident was offered the pneumococcal vaccine to complete the series on admission. During review with the Infection Preventionist, RN #4, the records still did not show that the vaccine had been offered. RN #4 stated she was responsible for ensuring residents are offered the pneumococcal vaccine on admission, but she had not offered it because she believed the resident had already completed the pneumococcal series. After reviewing the facility policy and the resident’s immunization history, she identified that Resident #11 was eligible to receive PCV20 or PCV21 and stated she should have offered the vaccine and reviewed the consent with the physician to select the appropriate vaccine. She also stated she had not discussed the appropriateness of pneumococcal vaccination with the provider because she did not think an additional pneumococcal vaccine was needed.
Facility Assessment Did Not Identify Secured Nursing Units
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that identified the resources necessary to care for residents competently during day-to-day operations and emergencies. Observation on all survey days identified that the facility had a secured, locked unit on the first floor and another secured unit on the second floor, both requiring a code for egress off the unit. However, the facility assessment dated [DATE], reviewed on 9/16/25, identified the facility as having 127 licensed beds with three nursing units consisting of a 37-bed dementia unit, a 30-bed subacute short-term care unit, and a 60-bed long-term care unit, but it did not identify that there was a secured/locked unit on the first floor and failed to note that the second floor was also secured. The assessment was signed by the Administrator, Medical Director, DON, Plant Manager, a direct care staff representative, and the resident council president. During interview, the former Administrator stated she completed the facility assessment, did not provide a reason why it did not address the secured units, and stated that the assessment should be updated with changes in the facility and that keeping it updated is the responsibility of the Administrator.
Failure to Provide Bed-Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to ensure that residents and/or their resident representatives were provided written notice of the bed-hold policy when the residents were transferred to the hospital. Review of the clinical record, facility documentation, facility policy, and staff interviews identified that written notice specifying the duration of the bed-hold policy was not documented as being provided for three sampled residents who had multiple hospitalizations. Resident #5 had diagnoses including congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease, and the quarterly MDS identified the resident as cognitively intact. The record did not show that written bed-hold notice was provided when the resident was transferred to the hospital on 7/6/25, 8/31/25, and 9/2/25. The DNS stated that a copy of the bed-hold policy should be provided at the time of transfer, attached to the paperwork sent with the resident, and mailed to the resident or representative, but identified that the notices for this resident were not completed. Resident #9 was admitted in February 2024 and had diagnoses including transient cerebral ischemic attack, dementia, and heart failure. The significant change MDS identified severely impaired cognition. The resident was sent to the hospital after a fall with a head laceration and bleeding, and again after becoming unresponsive with facial droop and drooling. The record did not reflect written bed-hold notice for either transfer. Resident #128 was admitted in January 2022 and had diagnoses including type 2 diabetes mellitus, anemia, and hypothyroidism, with severely impaired cognition on the quarterly MDS. The resident was transferred to the hospital after being found unresponsive and later returned from the hospital still lethargic and arousable only to sternal rub before being sent back to the emergency room. The record did not reflect written bed-hold notice for either hospital transfer. Facility interviews identified that the Director of Social Services was responsible for providing the bed-hold policy, while the DNS stated the notices should accompany the transfer paperwork and be mailed to the responsible party, but the notices for these transfers were not completed.
MDS Did Not Accurately Reflect PASRR Status
Penalty
Summary
The facility failed to ensure the MDS accurately reflected residents’ PASRR status for 3 of 5 sampled residents reviewed for PASRR. Resident #5 had diagnoses including schizoaffective disorder, vascular dementia, and bipolar disorder, and a PASRR assessment identified the resident as having diagnoses that qualified for a positive level II PASRR. However, the annual MDS identified the resident as cognitively intact, with no behaviors, and indicated the resident did not have a positive level 2 PASRR. Similar discrepancies were identified for Resident #6, whose diagnoses included bipolar disorder, anxiety disorder, and depression, and Resident #99, whose diagnoses included schizoaffective disorder depressive type, generalized anxiety disorder, and major depressive disorder; both residents had level II PASRR screenings that determined they qualified for a positive level II PASRR, but their annual MDS assessments documented intact cognition, no behaviors, and no positive level 2 PASRR. During interview, the Social Worker stated he was responsible for completing the MDS section addressing PASRR level 2 status and that he checks the medical record and looks for the level 2 PASRR assessment when making the determination. He further stated he had not completed the MDS assessments for the residents in question because they were completed by the former social worker, and that the MDS assessments should have reflected that Residents #5, #6, and #99 had positive level 2 PASRR assessments. The RAI manual was cited as guidance, and it notes that a positive PASRR screen indicates the resident has a mental illness, intellectual disability, or related condition and should be coded in section A1500 as yes.
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 131 citations issued within 25 miles in the last 12 months — including the 6 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 Waterford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New London Sub-acute And Nursing | 2.4 mi | ★★★★★ | 22 | 3 |
| Harbor Village North Health And Rehabilitation Cen | 3.4 mi | ★★★★★ | 5 | 0 |
| Beechwood Health & Rehabilitation Center | 3.9 mi | ★★★★★ | 3 | 0 |
| Bride Brook Rehabilitation & Nursing Center | 4.1 mi | ★★★★★ | 0 | 0 |
| Greentree Manor Nursing And Rehabilitation Center | 4.7 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Civita Care Bayview.
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 June 2026) and official state health department websites.