Deficiency Records for Baybrooke Village Care and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Baybrooke Village Care and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-07 | 2024-01-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-07 | 2024-01-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-07 | 2024-01-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-07 | 2024-01-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-07 | 2024-01-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-07 | 2024-01-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-07 | 2024-01-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-05 | 2024-01-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-12-05 | 2024-01-02 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-12-05 | 2024-01-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-19 | 2023-10-10 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-09-19 | 2023-10-03 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-05-03 | 2023-05-27 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-26 | 2023-02-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-07 | 2022-10-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-07 | 2022-10-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-07 | 2022-10-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-07 | 2022-10-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-07 | 2022-10-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-07 | 2022-10-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-06 | 2022-10-28 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-10-06 | 2022-10-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-01 | 2022-03-20 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-08-19 | 2021-09-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-19 | 2021-09-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-08-19 | 2021-09-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-19 | 2021-09-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-19 | 2021-09-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-19 | 2021-09-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-19 | 2021-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-19 | 2021-09-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-19 | 2021-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-19 | 2021-09-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-08-19 | 2021-09-12 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-08-19 | 2021-09-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-08 | 2021-07-12 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-05-08 | 2021-06-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-08 | 2021-06-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-08 | 2021-06-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-08 | 2021-06-09 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-08 | 2021-06-09 | Y |
| Report COVID19 data to residents and families. | Health | 2021-05-08 | 2021-06-09 | Y |
