BAYSIDE OF POQUOSON HEALTH AND REHAB Inspection Report, Violations & Safety Grade (POQUOSON, Virginia)

1 VANTAGE DRIVE, POQUOSON, Virginia 23662

Phone: 7578689960

CMS Overall:2/5

Overview & Bed Count

Certified Beds

Avg Residents/Day

55.1

Ownership

For profit - Corporation

Provider Type

Medicare and Medicaid

County

Poquoson

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall2/5

Health2/5

Staffing2/5

Quality3/5

Nurse Staffing Check

Metric	This Facility	Virginia Avg	Difference
RN Hours per Resident per Day	0.48	0.71	-0.23
Total Nurse Hours per Resident per Day	3.43	3.88	-0.44
CMS Staffing Rating	2/5	2.5/5	-
Nursing Staff Turnover	44.6%	47.5%	-

Health Citation History

70 health citations on record

Date	Category	Description	Severity
2025-03-27	Resident Rights Deficiencies	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	E – Moderate Harm Potential
2025-03-27	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	E – Moderate Harm Potential
2025-03-27	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	E – Moderate Harm Potential
2025-03-27	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	E – Moderate Harm Potential
2025-03-27	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	E – Moderate Harm Potential
2025-03-27	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	E – Moderate Harm Potential
2025-03-27	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2025-03-27	Quality of Life and Care Deficiencies	Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	D – Moderate Harm Potential
2025-03-27	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	D – Moderate Harm Potential
2025-03-27	Administration Deficiencies	Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.	D – Moderate Harm Potential
2024-08-29	Nursing and Physician Services Deficiencies	Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.	F – Moderate Harm Potential
2024-08-29	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2024-08-29	Environmental Deficiencies	Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.	E – Moderate Harm Potential
2024-08-29	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	D – Moderate Harm Potential
2024-08-29	Resident Rights Deficiencies	Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.	D – Moderate Harm Potential
2024-08-29	Resident Rights Deficiencies	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	D – Moderate Harm Potential
2024-08-29	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential
2024-08-29	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	D – Moderate Harm Potential
2024-08-29	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2024-08-29	Pharmacy Service Deficiencies	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	D – Moderate Harm Potential
2024-08-29	Pharmacy Service Deficiencies	Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	D – Moderate Harm Potential
2024-08-29	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	D – Moderate Harm Potential
2021-05-11	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	G – Actual Harm
2021-05-11	Resident Rights Deficiencies	Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.	E – Moderate Harm Potential
2021-05-11	Resident Rights Deficiencies	Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	E – Moderate Harm Potential
2021-05-11	Resident Rights Deficiencies	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	E – Moderate Harm Potential
2021-05-11	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from the wrongful use of the resident's belongings or money.	E – Moderate Harm Potential
2021-05-11	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	E – Moderate Harm Potential
2021-05-11	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	E – Moderate Harm Potential
2021-05-11	Nursing and Physician Services Deficiencies	Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.	E – Moderate Harm Potential
2021-05-11	Quality of Life and Care Deficiencies	Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.	E – Moderate Harm Potential
2021-05-11	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	E – Moderate Harm Potential
2021-05-11	Pharmacy Service Deficiencies	Ensure that residents are free from significant medication errors.	E – Moderate Harm Potential
2021-05-11	Nutrition and Dietary Deficiencies	Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.	E – Moderate Harm Potential
2021-05-11	Administration Deficiencies	Have a plan that describes the process for conducting QAPI and QAA activities.	E – Moderate Harm Potential
2021-05-11	Administration Deficiencies	Have the Quality Assessment and Assurance group have the required members and meet at least quarterly	E – Moderate Harm Potential
2021-05-11	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2021-05-11	Resident Rights Deficiencies	Allow resident to participate in the development and implementation of his or her person-centered plan of care.	D – Moderate Harm Potential
2021-05-11	Resident Rights Deficiencies	Honor the resident's right to choose his or her attending physician.	D – Moderate Harm Potential
2021-05-11	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	D – Moderate Harm Potential
2021-05-11	Resident Rights Deficiencies	Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.	D – Moderate Harm Potential
2021-05-11	Resident Rights Deficiencies	Keep residents' personal and medical records private and confidential.	D – Moderate Harm Potential
2021-05-11	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	D – Moderate Harm Potential
2021-05-11	Resident Rights Deficiencies	Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.	D – Moderate Harm Potential
2021-05-11	Resident Rights Deficiencies	Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.	D – Moderate Harm Potential
2021-05-11	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential
2021-05-11	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2021-05-11	Quality of Life and Care Deficiencies	Provide appropriate foot care.	D – Moderate Harm Potential
2021-05-11	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	D – Moderate Harm Potential
2021-05-11	Quality of Life and Care Deficiencies	Provide safe, appropriate dialysis care/services for a resident who requires such services.	D – Moderate Harm Potential

Showing 50 of 70 citations.

Fire Safety Citation History

15 fire safety citations on record

Date	Category	Description	Severity
2024-08-29	Emergency Preparedness Deficiencies	Establish an Emergency Preparedness Program (EP).	E – Moderate Harm Potential
2024-08-29	Egress Deficiencies	Install emergency lighting that can last at least 1 1/2 hours.	D – Moderate Harm Potential
2024-08-29	Smoke Deficiencies	Install a fire alarm system that can be heard throughout the facility.	D – Moderate Harm Potential
2024-08-29	Smoke Deficiencies	Properly provide smoke detection systems in areas open to corridors.	D – Moderate Harm Potential
2024-08-29	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	D – Moderate Harm Potential
2024-08-29	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	D – Moderate Harm Potential
2021-05-11	Emergency Preparedness Deficiencies	Establish emergency prep training and testing.	C – Minimal Harm Potential
2021-05-11	Emergency Preparedness Deficiencies	Establish staff and initial training requirements.	C – Minimal Harm Potential
2019-08-16	Construction Deficiencies	Use approved construction type or materials.	E – Moderate Harm Potential
2019-08-16	Egress Deficiencies	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	E – Moderate Harm Potential
2019-08-16	Miscellaneous Deficiencies	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	E – Moderate Harm Potential
2019-08-16	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	E – Moderate Harm Potential
2019-08-16	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	D – Moderate Harm Potential
2019-08-16	Egress Deficiencies	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	D – Moderate Harm Potential
2019-08-16	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	D – Moderate Harm Potential

Total Penalties & Fines

Total Fine Amount (CMS)

Number of Fines

Total Penalties

No penalty records found.

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Need Help Finding Safe Care?

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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.