Baybrooke Village Care and Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident has a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure that Resident #1's personal information was kept private and confidential when a pre-filled affidavit of heirship containing the resident's information was sent to the family of Resident #2. This failure could place residents at risk of having their sensitive information accessible to unauthorized individuals.

Inspectors wroteBased on interview and record review, the facility failed to permit residents from returning to the facility after a hospitalization for 1 of 3 residents (Resident #3) reviewed for discharge rights. The facility failed to allow Resident #3 to return to the facility after the resident discharged from the hospital. The facility issued Resident #3 a discharge notice on 01/23/26 for non-payment of services rendered; however, the resident appealed the discharge and the discharge was reversed after a fair hearing on 03/26/26. This failure could place residents at risk of not receiving appropriate ongoing care, which could lead to worsening conditions or serious harm.

Inspectors wroteBased on interview and record review, the facility failed to have physician orders for the resident's immediate care, at the time the resident was admitted for 1 of 5 residents (Resident #1) reviewed for admission orders. The facility failed to have Physician orders to provide wound care for Resident #1 who admitted on [DATE] until 2 days later on [DATE]. This failure could place the residents at risk of not receiving necessary physician ordered care that could result in worsening conditions or decline in health.

Inspectors wroteBased on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to complete a baseline care plan that addressed hospice services for Resident #1. This failure could place residents at risk of not being provided with the necessary care and having personalized plans developed to address their specific needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to order and administer Levothyroxine (Levothyroxine Sodium) for Resident #1 while at the facility from 05/01-[DATE]. This failure could place residents at risk of not receiving the intended therapeutic benefits of prescribed medications.

Inspectors wroteBased on interview, observation and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and other practitioners participating in the provision of care for 1 of 4 residents (Resident #1) reviewed for hospice services. The facility failed to ensure Resident #1 had a physician order for hospice care. This failure could place residents at risk of receiving inadequate end-of-life care, coordination of care and communication of resident needs.

Inspectors wroteBased on observation, interviews and record review the facility failed to maintain medical records that were complete and accurately documented for 2 (Resident #50 and Resident #9) of 16 residents reviewed for resident records.1. The facility failed to accurately document Resident #50's use of a hand splint on 04/07/26 and 04/08/26 when the splint was not applied.2. The facility failed to ensure Resident #9's physician orders had the correct medication administration route for eight medications, which were orders to give medications by mouth, when the resident had a nothing by mouth status. These failures could affect any resident, placing them at risk of inaccurate information and resulting inappropriate care.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 2 residents (Resident #2) reviewed for PASARR.The facility failed to refer Resident #2 for a PASRR Level II assessment when the facility failed to correct his PASRR level I assessment. This failure could place residents at risk of not receiving specialized services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 1 of 18 residents (Resident #102) reviewed for baseline care plans. The facility failed to ensure Resident #102 had a baseline care plan, or conversely a comprehensive care plan, within 48 hours of admission. These failures could place the residents at risk of not having their needs and preferences met.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #56) reviewed for care plans. The facility failed to ensure Resident #56 had a care plan that addressed the residents' need for oxygen use. This failure could place residents at risk for incomplete assessments which could cause incorrect care and services in oxygen support and could result in a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #28) of 4 residents reviewed for ADLs. The facility failed to ensure Resident #28's fingernails were kept clean. This failure had the potential to affect residents by placing them at risk for poor personal hygiene, odors and a decline in their quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 6 residents (Resident #50) reviewed for range of motion. The facility failed to ensure Resident #50 had her hand splint applied to her left hand per physician orders for contracture management. The failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, based on a resident's comprehensive assessment, maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or the resident preferences indicated otherwise for of 1 of 6 residents (Resident #53) reviewed for nutrition. The facility failed to monitor Resident #53's weight when she gained 16 pounds in 20 days, while receiving all her nutrition via a feeding tube. This failure could place the residents at risk of weight loss/gain, and a decline in their physical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 3 residents (Resident #9) reviewed for enteral feeding. 1. The facility failed to ensure RN G mixed each crushed medication with water and administered one medication at a time through Resident #9's g-tube.2. The facility failed to ensure RN G administered Resident #9's g-tube medication by gravity. These failures could place residents at increased risk of aspiration, bloating discomfort, and not receiving the full benefit of the medications administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 (Resident #56) of 6 residents reviewed for respiratory care, in that: The facility failed to obtain a physician order for Resident #56's use of supplemental oxygen. This deficient practice could affect residents who received oxygen therapy continuously placed residents at-risk for respiratory infection, and ineffective treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for 1 of 1 resident (Resident #58) reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #58. This failure could place residents at risk of inadequate post-dialysis care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 4 medication carts (Hall 100 and 200 carts) reviewed for pharmacy services. The facility failed to ensure two boxes of fast acting 40% glucose gel, with an expiration date of April 2025, had been removed from the Hall 100 and 200 medication carts. This failure could place residents at risk of receiving medications that were ineffective.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 2 (Resident #1 and Resident#2) of 4 residents reviewed for quality of care.1. The facility failed to ensure Residents #1 was being provided with oxygen on 03/05/26 at 02:02PM as per physician's orders. 2. The facility failed to ensure Resident #2 had physician's order in her chart for oxygen that was observed being provided on 03/05/26. This failure could place residents at risk of illness and respiratory complications.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Residents #1) of 1 resident reviewed for quality of care. The facility failed to ensure Resident #1's Stage 4 pressure ulcer on his sacrum was covered with a dressing on 03/05/26. This failure could place residents at risk of severe pain, and lead to systemic infections causing harm for residents.

Inspectors wroteBased on interviews, and record review, the facility failed to inform the resident's physician, responsible party, and notify, consistent with his or her authority, when there was a change in condition for 1 of 4 residents (Resident #1) reviewed for notification of changes. The facility failed to promptly notify Resident #1's physician when a change in blood pressure was discovered for Resident #1. The physician was not made aware of the continuous low blood pressure vital checks until Resident #1 was being evaluated to be transferred to the hospital for an unrelated treatment. This deficient practice could place residents at risk of not having their physicians informed when there was a change in condition resulting in a delay in medical intervention and decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents are free from significant medication errors for one (Resident #1) of 5 residents reviewed for significant medication errors. The facility failed to ensure Resident #1 received his prescribed seizure medication between [DATE] and [DATE]. This failure placed Resident #1 at risk for adverse effects, injury, and decrease in quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure facility staff consulted with resident physician in a timely manner when there was a change in resident's physical, mental, or psychosocial status one (Resident #1) of four residents reviewed for physician notifications. The facility failed to notify Resident #1's physician that he was not provided his medication for epilepsy at any point between [DATE] - [DATE]. This failure placed Resident #1 at risk for adverse effects, injury, and decrease in quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received adequate supervision and assistance devices to prevent elopement for one (Resident #1) of six residents reviewed for elopements. The facility failed to ensure Resident #1 remained at the facility where he eloped [DATE] between 11:30 PM and 12:00 AM. Resident #1 was located approximately 0.1 miles away from the facility and returned to the facility by LVN F approximately 12:30 AM on [DATE]. This failure could place residents at risk of injury and a decreased quality of life. Based on record review and interview, the facility failed to ensure residents received adequate supervision and assistance devices to prevent elopement for one (Resident #1) of six residents reviewed for elopements. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of two residents reviewed for Respiratory Care. The facility failed to ensure Resident #1's breathing mask for his nebulizer (a medical device that turns liquid medicine into mist that could be inhaled through a face mask) was properly stored when not in use on 04/23/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of 2 residents reviewed for Infection Control. The facility failed to ensure CNA B performed hand hygiene and changed her gloves while providing incontinent care to Resident #2 on 04/23/2025. This failure could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received food that accommodated their preferences for 3 (Resident #40, Confidential #1 and #2) of 8 residents reviewed for dietary services . 1. The facility failed to honor Resident #40's preferences and recommendations as indicated on his menu . 2. The facility failed to honor the preferences of Confidential Resident #1 as indicated on their menu selections. 3. The facility failed to honor Confidential Resident #2's wishes and continued to send the wrong food items on their tray. This failure could place residents at risk for not having their choices and food preferences accommodated, possible weight loss and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to ensure food in the facility's dry storage, refrigerator, and freezer areas were labeled and dated according to guidelines. 2. The facility failed to seal open items in plastic bags in the dry storage pantry, refrigerator, and freezer areas. 3. The facility failed to ensure that expired items in the dry storage pantry, refrigerator and freezer areas were removed. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other air-borne illnesses. Findings Included: [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Resident #39, Resident #40, Resident #34, and Resident #52) of nine residents observed for infection control. 1. ADON A failed to perform hand hygiene between cleaning Resident #39's wounds and applying the clean dressings. 2. ADON A failed to perform hand hygiene and change her gloves when moving between wound sites during wound care for Resident #40. 3. CNA B failed to implement enhanced barrier precautions and don a gown while providing incontinent care to Resident #34. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one of two residents (Resident #38) reviewed for quality of care The facility failed to ensure LVN F and CNA J used a gait belt when transferring Resident #38 from her wheelchair to bed on 01/28/25. These failures could place residents at risk for discomfort, pain, falls, injuries, and skin tears.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of two residents (Resident #39) reviewed for feeding tubes. 1. The facility failed to ensure LVN F flushed Resident #39's feeding tube by gravity and not by pushing water by the plunger during medication administration. 2. The facility failed to ensure LVN F checked Resident #39's feeding tube placement and residual when starting a feeding. These failures could affect residents by placing them at risk of abdominal discomfort and obstruction of the G-tube.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 39 medication administration opportunities with 6 errors resulting in a 15% medication error rate, for 3 of 6 residents (Residents #66, #42, & #00) reviewed for medication administration. 1. RN G failed to administerAcetaminophen 500 mg per physician order, medication was administered at 09:30 and the medication was scheduled at to be administered at 12 pm. 2. RN G failed to administer Resident #42 Olmesartan during medication administration that was scheduled at 8 am. 3. RN G failed to administer Resident #00 medication per physician orders, medications scheduled at 8 am was administered at 11:15 am This deficient practice placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six (Resident #2, Resident #3, Resident #4, Resident #5, Resident # 6, and Resident #7) of eighteen residents observed for Infection Control. 1. The facility failed to ensure RN B performed hand hygiene during Resident #2 and Resident #3's wound care. 2. The facility failed to ensure MA E sanitized the blood pressure cuff between use for Resident #4, Resident #5, and Resident #6. 3. The facility failed to ensure CNA F changed her gloves and performed hand hygiene while providing incontinent care to Resident #7. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored securely for one (Resident #1) of five residents reviewed for storage of medications. The facility failed to ensure a bottle of Nystatin topical powder was not left inside Resident #1's room. This failure could place the residents at risk of not receiving medications as ordered by the physician, accidental overdose, or misuse of medications.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of three residents reviewed for respiratory care. The facility failed to ensure Resident #1's nasal cannula was properly stored when not in use. The facility failed to ensure Resident #1's humidifier bottle had water in it. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 1 (Resident #1) of five residents reviewed for abuse. The facility failed to supervise and protect Resident #1, who did not have the ability to consent, from sexual abuse. CNA A was observed, on a camera video footage, engaging in an inappropriate, sexual oriented activity with Resident #1 on 02/02/24. The noncompliance was identified as PNC. The IJ began on 02/02/24 and ended on 02/04/24. The facility had corrected the noncompliance before the survey began on 02/05/24. This failure placed residents at risk for serious injuries, abuse, and serious psychosocial harm.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1. The facility failed to ensure trash cans were covered and wiped down. 2. The facility failed to ensure 2 of 2 ovens were cleaned. 3. The facility failed to ensure the fryer was clean on the front and sides. 4. The facility failed to ensure the thickener container was sealed and the sugar plastic container wiped down, in the dry storage area. These failures place residents at risk for food-borne illness and food contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Residents #52 and Resident #14) reviewed for ADL care. The facility failed to ensure staff provided consistent showers/baths and grooming for Resident #52 and Resident #14. This failure could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, a loss of dignity and self-worth.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for three of six residents (Residents #63, # 35 and #33) reviewed for pharmacy services. 1. LVN C failed to follow the manufacturer's instructions to [NAME] the Novolin R Insulin (Hormone) Pen prior to dialing in the required amount of Insulin to be administered to Resident #63. 2. LVN C failed to follow the manufacturer's instructions to [NAME] the Admelog Insulin (Hormone) Pen prior to dialing in the required amount of Insulin to be administered to Resident #35. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of eight residents (Residents #63, #35 and #33) reviewed for infection control. 1. LVN C failed to perform hand hygiene after performing FSBS on Resident # 63. 2. LVN C failed to perform hand hygiene after performing insulin injection on Resident #63. 3. LVN C failed to perform hand hygiene after cleaning the soiled glucometer and prior to administering Resident #35's pain medication. 4. LVN D failed to perform hand hygiene after cleaning the soiled glucometer and prior to drawing up Resident #33's insulin. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plans were prepared by an IDT that included the attending physician and a nurse aide with responsibility for the resident, and a member of food and nutrition services staff for one of 8 residents (Resident #54) reviewed for care plans. The facility failed to ensure the attending physician, a CNA, and dietary staff participated in the care plan conference for Resident #54. This failure could place residents at risk for not receiving adequate or individualized care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for one of eight residents (Resident #35) reviewed for quality of care. The facility failed to ensure facility staff reported a wound on Resident #35's right upper arm which was first observed on 12/05/23 which in a delay of treatment until 12/06/23. This failure could place residents at risk of not receiving the care and treatment needed to their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two of eight residents (Resident #10, Resident #12) reviewed for accident hazards and supervision. The facility failed to properly maintain wheelchairs for Residents #10 and #12. This failure could place residents at risk for discomfort, pain, and injuries.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment for areas in the facility (handrails) observed for a clean environment. The facility failed to ensure the handrails throughout the facility were cleaned daily, and in accordance with the facility's policy on Environmental Services. This deficient practice could negatively impact the facility's ability in preventing the spread of disease-causing organisms in residents' living areas and does not present a Clean Homelike Environment.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerator, and freezer were stored according to guidelines. The facility failed to ensure the Ice Scooper Holder, located in the facility's only kitchen, was clean and sanitary. The facility failed to ensure the Iced Tea dispenser, prepared for residents, was covered, and sealed from air-borne diseases once prepared. The facility failed to ensure kitchen equipment was clean and sanitary. These failures could place residents at risk for cross contamination and other food-borne illnesses. [...]