Bay Breeze Rehabilitation by Harborview

In the surveyor’s words

From the most serious findings on record at Bay Breeze Rehabilitation by Harborview, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Aug 27, 2026

  Based on observation, interview, and record review, the facility failed to ensure that food preparation equipment was maintained in a clean and sanitary condition. All residents are able to eat, meaning the unsafe conditions had the potential to affect all residents in the facility.On 08/24/2026 at 11:34 AM, it was observed that two standard ovens and one double stacked oven contained visible buildup and residue accumulated on the interior surfaces. The interior bottom and side panels displayed dark discoloration and raised, textured debris. The facility's deep fryer contained dark brown, murky oil with visible brown sediment, and heavy buildup was noted along the fryer's interior sides.During this observation, an interview with Staff A, Head Cook. […]

• No harm, potential for more than minimal, patternF812Apr 2, 2026

  Based on observations and staff interviews, the facility failed to maintain appropriate food handling and storage practices, as numerous food items across dry storage, refrigeration, and freezer areas were found unlabeled, undated, uncovered, or unsanitary. The findings include: During a kitchen tour conducted with the Registered Dietitian Nutritionist (RDN) on 04/01/2026 at approximately 10:04 AM, multiple deficiencies in food labeling, storage, and sanitation practices were observed: In the dry storage area, two opened bags of pasta, a gallon of red wine vinegar, a gallon of apple cider vinegar, an opened bag of rice, two cartons of dried mashed potatoes, and more than thirty opened spice containers lacked labels indicating when the items were opened.In the refrigerated section, three… […]

• No harm, potential for more than minimal, isolatedF761Aug 27, 2026

  Based on observations, staff interviews, review of the electronic medical record (EMR) and review of the facilities policies and procedures the facility failed to provide safe and secure storage of medications for 2 of 16 residents reviewed for medication storage. (Resident #72 and #84)The findings included:On 8/24/2026 at 11:00 AM, an observation was conducted of multiple over-the-counter medications stored at the bedside of Resident #72, including a bottle labeled Magnesium Glycinate, a bottle labeled Antacid Chews, a tube labeled Icy Hot cream, and a box labeled Lidocaine patches. (Photographic evidence obtained)On 8/24/2026 at 11:30 AM, an observation was conducted of medication at the bedside of Resident #84. The medication cup contained a thick, orange-colored liquid medication. […]

• No harm, potential for more than minimal, isolatedF580Apr 2, 2026

  Based on interviews, record review, and policy review, the facility failed to ensure that 2 of 4 residents' family members was notified of a significant change in condition and subsequent transfer to the hospital, as required by facility policy and regulatory expectations. (Resident #2 and #4) During a 04/01/2026 interview at about 2:00 PM, Employee G (a Registered Nurse) stated that she completes the Situation Background, Assessment, Recommendation (SBAR) form and uses the communication book during any hospital transfer. […]

• No harm, potential for more than minimal, isolatedF656May 22, 2025

  Based on observations, record reviews and interviews, the facility failed to follow the plan of care for 1 of 2 residents sampled for pressure injuries. (Resident #36) The findings include: On 5/19/25, Resident #36 was observed lying in bed. There was no low air loss mattress in use. Further observations on 5/20/25 at 1:24 PM and 3:32 PM as well as on 5/21/25 at 8:45 AM and again at 11:40 AM revealed Resident #36 lying in bed with no low air loss mattress in use. On 5/20/25, a record review was conducted for Resident #36. The care plan, revised last on 7/1/24, contained skin impairment interventions which included the use of a low air loss mattress. (photographic evidence obtained). A review of the orders showed no physician orders for a low air loss mattress. […]