Inspection Reports for Baybrooke Village Care & Rehab Center

The complaint investigation found that the facility did not notify the physician or nurse practitioner of Resident #1's low blood pressure readings beginning on 11/24/2025 and continuing through 11/30/2025. The physician stated that notification was necessary to prevent potential serious outcomes. The facility staff acknowledged the failure and planned staff training to improve notification compliance.

The facility failed to notify Resident #1's physician of continuous low blood pressure readings from 11/24/2025 through 11/30/2025, resulting in delayed medical intervention. Interviews with medical staff confirmed the lack of notification despite policy requirements, posing a risk of harm to residents.

The complaint investigation focused on Resident #1, who missed approximately 10 doses of epilepsy medication due to pharmacy withholding medication over an outstanding balance. The facility failed to notify the physician timely. Resident #1 also eloped from the facility and was found nearby. Staff involved in medication errors and failure to notify were terminated. The resident expired on hospice prior to the investigation completion.

The facility failed to notify Resident #1's physician about missed epilepsy medication doses, resulting in approximately 10 missed doses. The resident eloped from the facility and was found 0.1 miles away. The facility also failed to ensure residents were free from significant medication errors, specifically the failure to administer prescribed seizure medication timely. Staff responsible for these failures were terminated, and corrective actions including staff training and policy reinforcement were implemented.

The facility failed to provide proper respiratory care for Resident #1 by not properly storing the nebulizer breathing mask, and failed to maintain an effective infection prevention program as CNA B did not perform hand hygiene or change gloves appropriately during incontinent care for Resident #2. Both deficiencies posed risks of respiratory infection and cross-contamination.

The facility was found deficient in multiple areas including failure to use gait belts during resident transfers, improper feeding tube care, medication administration errors exceeding 5%, failure to honor resident dietary preferences, improper food storage and labeling in the kitchen, and lapses in infection prevention and control practices.

The complaint investigation revealed medication was left unsecured in a resident's room despite being discontinued, and multiple failures in infection control practices including hand hygiene lapses by RN B, MA E, and CNA F, and failure to sanitize equipment, increasing risk of cross-contamination and infection.

The facility failed to ensure secure storage of medications, specifically a bottle of discontinued nystatin powder left inside a resident's room, and failed to maintain proper infection prevention and control practices including hand hygiene, glove changes, and sanitization of equipment, placing residents at risk of medication misuse and infections.

The facility failed to ensure that Resident #1's nasal cannula was properly stored when not in use and that the humidifier bottle had water in it, which could place residents at risk for respiratory infection and inadequate respiratory care. Interviews and observations confirmed these deficiencies and staff acknowledged lapses in following proper procedures.

The complaint investigation was substantiated. The allegation of sexual abuse was confirmed by video evidence, police investigation, and CNA A's admission. CNA A was arrested on 02/05/24 and later on 02/25/24. The facility took immediate corrective actions including suspension and termination of CNA A, in-service training for staff, and quality assurance meetings.

The facility failed to protect Resident #1 from sexual abuse by CNA A, who was observed on video engaging in inappropriate sexual activity with the resident. The abuse was confirmed by the facility's investigation and law enforcement, resulting in the immediate suspension and termination of CNA A. The facility implemented corrective actions including in-service training on abuse and neglect for staff.

The visit was complaint-related, focusing on infection control practices. The complaint was substantiated based on observations, interviews, and record reviews showing failures in hand hygiene by licensed vocational nurses during medication administration and blood glucose monitoring.

The facility failed to ensure proper hand hygiene by nursing staff during fingerstick blood sugar (FSBS) testing, insulin administration, and medication delivery for three residents, which could place residents at risk for cross contamination and transmission of communicable diseases. Observations and interviews confirmed multiple instances where hand hygiene was not performed as required.

The facility failed to ensure interdisciplinary care plan participation, consistent ADL care, timely wound treatment, proper wheelchair maintenance, correct insulin administration, food safety standards, and infection control practices. These deficiencies posed risks of inadequate individualized care, hygiene neglect, delayed treatment, resident discomfort, medication errors, food contamination, and infection transmission.

The facility failed to maintain a clean and homelike environment, specifically with unclean handrails and inadequate cleaning practices. Additionally, the kitchen sanitation was deficient, with improper food storage, unclean equipment, and uncovered food items, posing risks of infection and foodborne illnesses.

The complaint investigation focused on Resident #1 who was not readmitted after hospitalization due to aggressive behaviors. The facility cited safety concerns for other residents and staff. The resident was cleared by psychiatric services but refused therapy and medication compliance. The resident was discharged to another facility approximately two weeks prior to the survey. The complaint was substantiated by observations, interviews with the administrator, DON, patient advocate, and physician, and review of nursing notes and discharge documentation.

The facility failed to readmit Resident #1 after hospitalization despite the resident's request and clearance from psychiatric services. Resident #1 exhibited aggressive behaviors, including verbal aggression and physical actions toward staff and others, leading to discharge and refusal of readmission by the facility. Documentation and interviews confirmed these behaviors and the facility's concerns about safety for Resident #1 and others.

The facility was found to have immediate jeopardy related to failure to provide effective pain management for residents with significant pain, failure to provide adequate assistance with activities of daily living including nail care, failure to maintain a safe environment to prevent falls, and medication errors including incomplete medication orders and incorrect medication administration.