Baybrooke Village Care and Rehab Center

In the surveyor’s words

From the most serious findings on record at Baybrooke Village Care and Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF697Oct 7, 2022

  Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 24 residents (Residents #63 and #188) reviewed for pain management. 1. The facility failed to assess, provide effective pain treatment, and address pain promptly for Resident #63 when she showed signs and symptoms of significant pain which was unrelieved by ordered Tylenol during wound care for her Stage 4 pressure wounds on 10/05/22. 2. […]

• Immediate jeopardy, isolatedF600Feb 7, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF580Oct 7, 2022

  Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representatives when there was a significant change in the resident's physical, mental, or psychosocial status and a need for 1 (Resident #63) of 5 residents reviewed for physician notification. The facility failed to immediately notify Resident #63's attending physician when she had significant pain which was unrelieved by ordered Tylenol. An immediate Jeopardy (IJ) situation was identified on 10/05/22 at 5:40 PM. The DON and the ADM were notified, the IJ template was provided, and a POR was requested. […]

• Actual harm, isolatedF689May 8, 2021

  Based on observation, interview and record review, and review of facility policies, the facility failed to provide supervision and/or assistive devices to prevent accidents for four residents (Resident # 6, R20, R23, and R24) of 14 residents reviewed for accidents out of 31 sampled residents. 1. R#23 and R#6 both sustained nasal fractures after multiple falls, 2. R#20 sustained a fall in which he incurred lacerations to the forehead which required hospital treatment. 3. In addition, R#24 left the facility without staff supervision. These failures could affect residents by placing them at risk of elopement and sustaining falls, with severe injuries. Findings include: 1. Review of R#23's closed record revealed he was admitted to the facility from the hospital on 02/01/21. […]

• No harm, potential for more than minimal, widespreadF812Dec 7, 2023

  Based 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. Findings include: 1. Observation on 12/05/23 at 9:48 AM revealed 3 of 4 kitchen trash cans, which had food debris, did not have full covered lids. […]