Bay Terrace Rehabilitation and Health Center

In the surveyor’s words

From the most serious findings on record at Bay Terrace Rehabilitation and Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF627Feb 24, 2026

  Based on interviews, record review, and review of other documentation as indicated, it was determined that for one (R2) out of three residents sampled for discharge, the facility failed to ensure durable medical equipment and home health services were in place prior to R2's discharge. R2 was discharged from the facility on 2/9/26 at 6:00 PM and transported home via medical transport services and assisted up the stairs to a three-story residence by transport, where no caregiver support was in the home. On 2/11/26, R2 was found in the home by the home health agency nurse in unsafe conditions. […]

• Actual harm, isolatedF684Dec 2, 2024

  Based on record review and interview, it was determined for one (R1) out of three residents reviewed for hospitalization, the facility failed to provide services to maintain R1's bowel function. The facility's failure to initiate the bowel protocol resulted in harm to R1 as it resulted in R1 undergoing a fecal disimpaction procedure during his 11/23/24 hospitalization. Additionally, the facility failed to obtain ordered blood work, to provide neb treatment due to machine not available and failed to obtain peripheral access for intravenous fluid infusion and supplemental oxygen order. […]

• No harm, potential for more than minimal, patternF697Feb 19, 2025

  Based on observation, interview, and record review it was determined that for three (R63, R53, and R59) out of three residents reviewed for pain, the facility failed to ensure that that adequate pain management was provided and pain assessments were not conducted with a consistent scale for pre and post pain assessments. Findings include: April 2002 - The pain management standards by the American Geriatrics Society included: appropriate assessment and management of pain; assessment in a way that facilitates regular reassessment and follow-up; same quantitative pain assessment scales should be used for initial and follow up assessment; set standards for monitoring and intervention; and collect data to monitor the effectiveness and appropriateness of pain management. […]

• No harm, potential for more than minimal, patternF812Feb 19, 2025

  Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. Findings include: 1. 2/11/25 8:39 AM - During the initial tour of the kitchen the surveyor observed the following: - The hair on the front of E5's (FSS) head was unsecured by a hair net. - The hand washing sink located in the dish area was obstructed by a fan and the paper towel dispenser was empty. - The small refrigerator for milk storage contained an opened gallon of milk with an expiration date of 2/5/25. 38302 2. 2/17/25 10:06 AM - During a tour of the kitchen, food particles were splattered on the top and sides of the cooktop and oven. […]

• No harm, potential for more than minimal, patternF657Feb 23, 2024

  Based on record review and interview, it was determined that for eight (R3, R7, R9, R10, R14, R27, R32 and R53) out of of sixteen (16) sampled residents, the facility failed to have input from all required interdisciplinary team (IDT) members at the residents' care plan meetings. In addition, R53's nutrition risk care plan was not revised. Findings included: 1. Review of R3's clinical record revealed: 5/25/05 - R3 was admitted to the facility. 2/21/24 - A review of quarterly care plan meetings for the following dates 1/12/23, 4/6/23, 6/29/23, 9/21/23 and 12/14/23 lacked evidence of input from the Physician and the CNA. 2. […]