Bay Terrace Rehabilitation And Health Center
BAY TERRACE REHABILITATION AND HEALTH CENTER in DOVER, DE — inspection on February 24, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
identified. 2/20/26 - 2/24/26 - Through interviews and record reviews, the Surveyor confirmed the
jeopardy to resident health or likely to be affected by an inappropriate discharge from the facility.
Audits of discharge safety documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs for the last 7 days were reviewed by the NHA in
were reviewed by the Administrator, DON, Director of Social Services, and the Director of Rehabilitation to ensure home health services, appropriate care/giver/family support, and necessary services to meet the resident's care needs are in place before discharge.
Actions to Prevent Occurrence/Reoccurrence: The facility took the following actions to prevent an adverse outcome from recurring.
Root cause analysis was determined to be failure to have a robust discharge care plan meeting with the Interdisciplinary team, with the resident and resident representative.The procedure for safe and effective discharge planning was reviewed with the IDT.Discharge planning IDT will be re-educated on the policy and procedure to ensure sufficient preparation and orientation to ensure a safe discharge.
Residents who are scheduled to be discharged within 14 days will be reviewed to ensure appropriate discharge planning is in place.Residents who are scheduled to be discharged in the next 14 days will be reviewed to ensure support for ADLs is in place, durable medical equipment is available prior to or on the discharge date , medications are available upon discharge, and identified needs/support are available.Two times a week, residents who are scheduled for discharge will be reviewed to ensure safe discharge is in place.
Any issues identified will be addressed accordingly.Weekly, during utilization review, NHA/Designee will oversee discharge planning to ensure preparation and services are in place prior to discharge.2/20/26 - The facility's response initiated for R2's inappropriate discharge to home included audits, educational in-services to the IDT team and staff interviews with E1 (NHA), E2 (DON), E3, (SW), E4 (DOR), E8 (ADON) and E9 (RNAC) confirmed education received for a residents discharge from the facility to the community and or other facility transfers, the facility's date of abatement for the immediate jeopardy was determined on 2/20/26. 2/24/26 2:15 PM -Findings were reviewed with E1 (NHA), E2(DON), and E8 (ADON) at the exit conference.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.