Bay View Rehabilitation Hospital, LLC

In the surveyor’s words

From the most serious findings on record at Bay View Rehabilitation Hospital, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 15, 2026

  Based on observation, interview and record review the facility failed to protect two of ten sampled residents (Resident 2 and Resident 3), and one visitor (Visitor 1, family member of Resident 7), from abuse when:Resident 1 fondled the genitals of Resident 2 on 5/24/26.Resident 1 hit the arm of Resident 3 on 6/4/26.The facility relocated Resident 1 to the same unit as Resident 2 after an alleged sexual assault by Resident 1 to Resident 2 on 6/5/26.The facility placed Resident 1 in a room with two vulnerable residents (Resident 9 and Resident 10) on 6/10/26.Additionally, R1 displayed physical aggression towards an unrelated Visitor on 6/4/26. […]

• Immediate jeopardy, isolatedF610May 16, 2024

  Based on observation, interview and record review, the facility failed to protect residents in the facility from physical abuse when Certified Nursing Assistant 1 (CNA1) deliberately poked one resident (Resident 1) in the right cheek, smacked Resident 1 in the hand and then forced Resident 1 down in her wheelchair causing Resident 1 to cry out. The facility failed to protect 16 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16) assigned to CNA1, from possible physical abuse when the Administrator (ADM) returned CNA1 to direct care duty before completion of a thorough abuse investigation, including interviewing all witnesses. […]

• No harm, potential for more than minimal, widespreadF609Jun 15, 2026

  Based on interview and record review, the facility failed to identify, investigate, and report one sexual assault allegation within two hours of incident notification and one abuse allegation within 24 hours of incident notification to the California Department of Public Health (CDPH), and the Ombudsman for two of ten sampled residents (Resident 2 and Resident 3).This failure resulted in one allegation of physical abuse and one allegation of sexual abuse going uninvestigated and unreported resulting in emotional harm to Resident 2 and Resident 3, in addition to the potential for physical and/or emotional harm to other vulnerable residents.During a review of the AR for Resident 1 printed on 6/10/26, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that… […]

• No harm, potential for more than minimal, widespreadF801Jun 24, 2021

  The facility failed to ensure the competency of the Dietary Manager (DM) when: 1. the DM did not ensure the cleanliness and maintenence of equipment in the kitchen (Cross-reference F812 and F908); and 2. the DM did not adequately oversee the safe cooling of meat. This failure to maintain equipment and a clean kitchen environment had the potential to result in cross-contamination of food and lead to foodborne illness for 129 residents who received food from the kitchen out of a facility census of 141. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF802Jun 24, 2021

  Based on observation, interview, and facility document review, the facility failed to ensure the competency of Food and Nutrition Services staff when: 1. Dietary Cook 1 (DC1) did not correctly date thawing chicken stored in a refrigerator; and 2. DC1 and Dietary Cook 2 (DC2) did not follow standardized recipes when preparing food. The failure to ensure staff competency for food related tasks had the potential to cause contamination of food resulting in food borne illness; provide food for residents which did not meet the nutrients according to the planned menu resulting in nutritional related medical issues; and provide food to residents with an inappropriate texture for medical needs resulting in choking or death for 129 residents who received food from the kitchen out of a census of 141. […]