Inspection Reports for
Bayberry Nursing Home
40 Keogh Lane, New Rochelle, NY, 10805
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Inspection Report — Jul 18, 2025
Annual Inspection CMS
Date: Jul 18, 2025
Visit Reason
The inspection was a recertification survey conducted from 07/15/2025 to 07/18/2025 to assess compliance with regulatory standards for Bayberry Nursing Home.
Findings
The facility was found deficient in providing appropriate respiratory care, food safety practices, and antibiotic stewardship. Specifically, oxygen was administered at incorrect flow rates, food items were stored without proper expiration dates, and the antibiotic monitoring program was not properly implemented.
Citations (3)
F 0695: The facility did not ensure each resident received necessary respiratory care as prescribed. Resident #35 was observed receiving oxygen at 4.5 liters per minute instead of the ordered 1 liter per minute.
F 0812: The facility did not ensure food was stored according to professional standards. Opened food without expiration dates and expired marshmallows were found in storage areas.
F 0881: The facility failed to implement an effective antibiotic stewardship program. Resident #27 was not included on the antibiotic tracking list despite ongoing antibiotic use.
Report Facts
Oxygen flow rate observed: 4.5
Physician oxygen order flow rate: 1
Expiration date of marshmallows: 2025
Antibiotic dosage: 800
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Stated they did not touch the oxygen concentrator flow meter. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Responsible for oxygen administration but did not check flow meter dial. |
| Licensed Practical Nurse/ Unit Manager #3 | Licensed Practical Nurse/ Unit Manager | Responsible for ensuring correct oxygen administration but did not check oxygen concentrator for Resident #35. |
| Director of Nursing/Infection Preventionist | Director of Nursing/Infection Preventionist | Acknowledged failure to maintain accurate antibiotic tracking list. |
| Food Service Manager | Food Service Manager | Responsible for receiving and checking expiration dates of food; admitted oversight of expired and undated food items. |
| Administrator | Administrator | Acknowledged the antibiotic stewardship problem and stated it needed to be addressed. |
Inspection Report — Jul 17, 2025
Complaint Investigation State
Date: Jul 17, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2022 to 2025 with deficiency and complaint history.
Complaint Details
The state logged 14 complaints about this facility; 2 led to on-site inspections with no citations resulting from those complaints.
Findings
Across 6 inspections, 23 citations were issued including 11 standard health and 12 Life Safety Code citations. Two complaint-related on-site inspections were conducted with no enforcement actions recorded.
Citations (20)
Antibiotic Stewardship Program: Standard Health Citation for quality of care with minor potential harm.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation for quality of care with minor potential harm.
Respiratory/tracheostomy Care And Suctioning: Standard Health Citation for quality of care with minor potential harm.
Develop Ep Plan, Review And Update Annually: Life Safety Code Citation for NFPA requirements with potential for minimal harm.
Discharge From Exits: Life Safety Code Citation for NFPA requirements with minor potential harm.
Electrical Equipment - Power Cords And Extens: Life Safety Code Citation for NFPA requirements with minor potential harm.
Electrical Systems - Other: Life Safety Code Citation for NFPA requirements with minor potential harm.
Exit Signage: Life Safety Code Citation for NFPA requirements with minor potential harm.
Fire Alarm System - Testing And Maintenance: Life Safety Code Citation for NFPA requirements with minor potential harm.
Illumination Of Means Of Egress: Life Safety Code Citation for NFPA requirements with minor potential harm.
Maintenance, Inspection & Testing - Doors: Life Safety Code Citation for NFPA requirements with minor potential harm.
Portable Fire Extinguishers: Life Safety Code Citation for NFPA requirements with minor potential harm.
Sprinkler System - Installation: Life Safety Code Citation for NFPA requirements with minor potential harm.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation for NFPA requirements with minor potential harm.
Stairways And Smokeproof Enclosures: Life Safety Code Citation for NFPA requirements with minor potential harm.
Increase/prevent Decrease In Rom/mobility: Standard Health Citation for quality of care with minor potential harm.
Resident Rights/exercise Of Rights: Standard Health Citation for quality of care with minor potential harm.
Reporting - National Health Safety Network: Standard Health Citation for quality of care with minor potential harm, not yet corrected.
Reporting - National Health Safety Network: Standard Health Citation for quality of care with minor potential harm, not yet corrected.
Reporting - National Health Safety Network: Standard Health Citation for quality of care with minor potential harm, not yet corrected.
Report Facts
Inspections on page: 6
Total violations/deficiencies cited: 23
Inspections with violations: 5
Inspections without violations: 1
Total complaints: 14
On-site complaint inspections: 2
Citations issued from complaints: 0
Total enforcement actions: 0
Inspection Report — May 30, 2023
Annual Inspection CMS
Date: May 30, 2023
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with resident rights and care standards at Bayberry Nursing Home.
Findings
The facility failed to ensure residents' rights to dignity and privacy by displaying a sign with personal medical information visible to others. Additionally, the facility did not provide appropriate care to maintain or improve range of motion for a resident by failing to ensure physician-ordered hand splints were applied as required.
Citations (2)
F 0550: The facility did not ensure residents had a right to a dignified existence and privacy. A sign with personal wound care instructions was visible from the roommate's side of Resident #20's room, violating privacy.
F 0688: The facility failed to provide appropriate care to maintain or improve range of motion for Resident #9. The resident was observed without physician-ordered hand splints, and documentation for their application and removal was missing.
Report Facts
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager (RNUM) #1 | Interviewed regarding the sign above Resident #20's bed and privacy concerns | |
| MDS Coordinator #1 | Interviewed regarding awareness of the sign above Resident #20's bed | |
| Certified Nurse Assistant (CNA) #1 | Interviewed about Resident #9's splints and care documentation | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about Resident #9's hand splints and medical orders | |
| Director of Nursing (DON) | Interviewed about missing physician orders and documentation for Resident #9's splints |
Inspection Report — Sep 11, 2020
Annual Inspection CMS
Date: Sep 11, 2020
Visit Reason
The inspection was conducted as a Life Safety Recertification and recertification survey to ensure compliance with applicable federal, state, and local laws, including infection prevention and control requirements.
Findings
The facility failed to install carbon monoxide detectors in the kitchen and first floor as required by fire safety codes. Additionally, the facility did not properly establish or maintain an infection prevention and control program related to legionella, lacking a water management plan, annual risk assessments, and legionella culture sampling.
Citations (2)
F 0836: The facility did not install a carbon monoxide detector in the kitchen or throughout the first floor as required by the 2015 International Fire Code and New York State regulations.
F 0880: The facility failed to provide and implement an infection prevention and control program by not having a site-specific water management plan, annual legionella risk assessment, or legionella culture sampling and analysis.
Report Facts
Date of survey completion: Sep 11, 2020
Date of water sampling: Jul 10, 2018
Number of pneumonia cases in 2019: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding carbon monoxide detection and legionella testing oversight | |
| Medical Director | Documented QAPI study on legionella pneumonia and pneumonia cases | |
| Director of Nursing | Interviewed about legionnaires disease surveillance and resident symptoms |
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