Baybrooke Village Care And Rehab Center

Penalties

• Feb 7, 2024 — Fine ($15,642)

Inspection findings

1. Jun 17, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Jun 18, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0627 Resident Rights Deficiencies

     Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

     Corrected Jun 18, 2026 · CMS health inspection

2. Jun 2, 2026 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0635 Resident Assessment and Care Planning Deficiencies

     Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

     Corrected Jun 17, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Jun 17, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Jun 17, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0849 Administration Deficiencies

     Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

     Corrected Jun 17, 2026 · CMS health inspection

3. Apr 9, 2026 Health · 14 findings
   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected May 7, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected May 3, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected May 3, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected May 3, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected May 3, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected May 3, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

     Corrected May 3, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected May 3, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected May 3, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected May 3, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected May 3, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Apr 30, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Apr 30, 2026 · CMS fire safety

4. Mar 5, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Mar 10, 2026 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Mar 10, 2026 · CMS health inspection

5. Dec 3, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Dec 5, 2025 · CMS health inspection

6. Nov 19, 2025 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Nov 21, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Nov 21, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Nov 21, 2025 · CMS health inspection

7. Apr 23, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Apr 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 27, 2025 · CMS health inspection

8. Jan 30, 2025 Health · 9 findings
   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Mar 3, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

     Corrected Mar 3, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Mar 3, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0806 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

     Corrected Mar 3, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Mar 3, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 3, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Mar 5, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Mar 5, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

     Corrected Mar 5, 2025 · CMS fire safety

9. Sep 11, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Sep 16, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 16, 2024 · CMS health inspection

10. Jul 2, 2024 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0695 Quality of Life and Care Deficiencies

      Provide safe and appropriate respiratory care for a resident when needed.

      Corrected Jul 30, 2024 · CMS health inspection

11. Feb 7, 2024 Health · 1 finding
    • Serious Scope/severity J Complaint

      F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

      Corrected Feb 4, 2024 · CMS health inspection

12. Dec 7, 2023 Health · 10 findings
    • Not serious Scope/severity D

      F0657 Resident Assessment and Care Planning Deficiencies

      Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

      Corrected Jan 2, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0677 Quality of Life and Care Deficiencies

      Provide care and assistance to perform activities of daily living for any resident who is unable.

      Corrected Jan 2, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Jan 2, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Jan 2, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0755 Pharmacy Service Deficiencies

      Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

      Corrected Jan 2, 2024 · CMS health inspection

    • Not serious Scope/severity F

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Jan 2, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Jan 2, 2024 · CMS health inspection

    • Not serious Scope/severity E

      K0345 Smoke Deficiencies

      Have approved installation, maintenance and testing program for fire alarm systems.

      Corrected Jan 2, 2024 · CMS fire safety

    • Not serious Scope/severity E

      K0374 Smoke Deficiencies

      Install smoke barrier doors that can resist smoke for at least 20 minutes.

      Corrected Jan 2, 2024 · CMS fire safety

    • Not serious Scope/severity C

      K0916 Gas, Vacuum, and Electrical Systems Deficiencies

      Have a battery powered remote alarm panel in a location accessible by operating personnel.

      Corrected Jan 2, 2024 · CMS fire safety

13. Sep 19, 2023 Health · 2 findings
    • Not serious Scope/severity E Complaint

      F0584 Resident Rights Deficiencies

      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.

      Corrected Oct 3, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Oct 10, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• CAMPBELL, SCOTT — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 12/01/2025
• CHANCE, JAMES — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 12/01/2025
• DOSHI, DIPAUNI — adp of the snf, NOT APPLICABLE, since 01/01/2024
• FISHER, JAMES — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 12/04/2025
• LANGDON, THOMAS — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 12/01/2025
• MAJOR, SAMUEL — adp of the snf, NOT APPLICABLE, since 01/27/2025
• MAJOR, SAMUEL — operational/managerial control, NOT APPLICABLE, since 01/27/2025
• MCGEHEE, WILLIAM — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 12/01/2025
• PRICE, LARRY — corporate officer, NOT APPLICABLE, since 06/01/1982
• TAYLOR, JOHN — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 12/01/2025
• WILLIAMS, TABITHA — adp of the snf, NOT APPLICABLE, since 09/13/2021
• YAZDANI, REHAN — adp of the snf, NOT APPLICABLE, since 05/18/2025
• LIFETIME WELLNESS, LTD. — adp of the snf, NOT APPLICABLE, since 09/23/2021
• MARTUS FINANCIAL SERVICES, INC. — adp of the snf, NOT APPLICABLE, since 12/31/2023
• PF BAYBROOKE SNF OPS, LLC — operational/managerial control, NOT APPLICABLE, since 09/23/2021
• PF BAYBROOKE SNF OPS, LLC — adp of the snf, NOT APPLICABLE, since 11/26/2025
• PHARMERICA DRUG SYSTEMS LLC — adp of the snf, NOT APPLICABLE, since 08/27/2017
• PRESERVATION FREEHOLD COMPANY — adp of the snf, NOT APPLICABLE, since 09/23/2021
• REHAB PRO LP — adp of the snf, NOT APPLICABLE, since 09/23/2021
• SANCTUARY LTC, LLC — adp of the snf, NOT APPLICABLE, since 09/23/2021
• SOUTH LIMESTONE HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 02/27/2015
• STONEGATE SENIOR LIVING, LP — operational/managerial control, NOT APPLICABLE, since 06/22/2022
• STONEGATE SENIOR LIVING, LP — adp of the snf, NOT APPLICABLE, since 11/26/2025
• UMB BANK NATIONAL ASSOCIATION — 5% or greater mortgage interest, NOT APPLICABLE, since 09/23/2021