Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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to be transferred with a mechanical lift and two staff, was manually transferred by a single NA who relied on an outdated assignment sheet instead of the resident care card.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.
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.
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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.
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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 | — | 14 | 2 |
| 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 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.