Baybrooke Village Care And Rehab Center
BAYBROOKE VILLAGE CARE AND REHAB CENTER in MCKINNEY, TX — inspection on November 19, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
can treat any issues promptly and for general safety reasons. In interview with the DON on [DATE] 11:02 AM, she stated that her expectations were not met with LVN A and LVN B's conduct.
She was not notified of Resident #1's Lamotrigine issue until [DATE] and immediately called the pharmacy to address the issue.
Additionally, she expected LVN A and LVN B to notify the provider if any resident medications were missed for any reason.
She stated this was not done and it was not acceptable.
She stated she was not sure why LVN A and LVN B did not escalate this concern up the chain of command, but she terminated both nurses as a result of their actions.
She stated the issue with Resident #1's medication was related to an outstanding balance, and the pharmacy was withholding the medication until payment was received.
She stated she received corporate approval to resolve the bill quickly so the resident would receive his medications as soon as possible.
Additional intervention from the facility included extensive in-services and skills-checkoffs for staff that provide medications to the residents at the facility.
She stated it was important for resident safety and to avoid a negative outcome for all residents to receive their prescribed medication in a timely manner. In interview with the Administrator on [DATE] at 3:48 PM, he stated his expectations were not met with LVN A and LVN B's conduct. He stated it was important for nurses to inform the provider if any resident medications were missed for any reason so the provider was aware and could consider appropriate actions and/or alternative options. He stated this was not done and resulted in LVN A and LVN B's termination.
Record review of [Pharmacy] Request for Authorization to [NAME] House, dated [DATE], revealed the facility's DON authorized the payment of Resident #1's outstanding balance to [Pharmacy].
Record review of Training In-Service Form, dated [DATE] titled Resident Rights, Abuse + Neglect, and Medication Administration and Documentation, Notification to DON/Designee and MD When MD Not Available conducted by facility DON revealed multiple signatures including registered nurses, licensed vocational nurses, and certified medication aides.
Education provided included:-Forgetting to administer medication on time is an example of neglect-Medication errors must be documented-What do to when a resident refuses medication-Informed consent of psychotropic medications -Resident rights related to medication administration-Responsibility of nurses to ensure residents remain free from any medication errors-When administering medications, the right route must be considered-It is necessary for all medications to have a clinical indication-Residents must have medication review within 24 hours of admission to the facility, including re-admissions-Injuries/Accidents/Falls are considered an adverse consequence to medication-Facility nurses are responsible for the clarification of a medication order they do not understand
Record review of Competency Checklist, Skill/Procedure: Medication Administration, Feeding Tubes: Medication Administration Check-Off dated [DATE] conducted by facility DON revealed multiple facility staff that provided medications to residents received a multi-step procedural review of their skills of medication administration.
Record review of the facility's policy, Medication, rev. [DATE] revealed Staff will assist the. authorized prescriber with medication orders in accordance with standard practice guidelines. 2.
When medications are not available to staff to administer, medication aides will notify charge nurse. 3.
Charge nurse will attempt to obtain medication from emergency kit. If not available, charge nurse will reach out to pharmacy for a STAT delivery. 4.
Physician will be notified of missed doses due to medication availability. 7.
Updates are communicated to provider as needed for additional information.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Baybrooke Village Care and Rehab Center
8300 Eldorado Parkway West McKinney, TX 75070
SUMMARY STATEMENT OF DEFICIENCIES
facility-wide elopement drill.
Record review of facility Wander Drill, dated [DATE] at 3:40 PM revealed documentation of a facility-wide elopement drill.
Record review of facility Wander Drill, dated [DATE] at 11:45 PM revealed documentation of a facility-wide elopement drill.
Record review of facility's QAPI documentation, dated [DATE], revealed Resident #1's elopement discussed with PHYSICIAN, Administrator, AND DON,
Record review of Training In-Service Form, dated [DATE] between 1:41 PM and 1:56 PM, titled Elopement Drill and Policy/Procedure Education, revealed multiple signatures including staff from administrative, therapy, dietary, housekeeping, and nursing departments.
Education provided included:-Charge nurse role -Where to look for missing residents-Who to inform once a resident is missing-Once resident is located, nurse completes a head-to-toe assessment-To initiate incident report if not found after 30 minutes
Record review of Training In-Service Form, dated [DATE] titled Elopement Procedures, revealed multiple signatures including staff from administrative, therapy, dietary, housekeeping, and nursing departments.
Education provided included facility's policy on elopement management.
Record review of Training In-Service Form, dated [DATE] titled Protocol for Reporting Allegations of Abuse, revealed multiple signatures including staff from administrative, therapy, dietary, housekeeping, and nursing departments.
Education provided included facility's policy on abuse, neglect, exploitation, and misappropriation of resident property.
Record review of the facility's policy, Elopement Management, revised [DATE] revealed An immediate investigation and search will be conducted if a resident is considered missing.
The resident will be located and returned to a save environment within standard practice guidelines.
Record review of the facility's policy, Abuse, Neglect and Exploitation and Misappropriation of Resident Property, revised [DATE] revealed The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding protection of. residents from abuse, neglect, exploitation and misappropriation of resident property.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Baybrooke Village Care and Rehab Center
8300 Eldorado Parkway West McKinney, TX 75070
SUMMARY STATEMENT OF DEFICIENCIES
facility.
She stated it was important for resident safety and to avoid a negative outcome for all residents to receive their prescribed medication in a timely manner. In interview with Administrator on [DATE] at 3:48 PM, he stated his expectations were not met with LVN A and LVN B's conduct. He stated it was important for nurses to inform the provider if any resident medications were missed for any reason so the provider was aware and could consider appropriate actions and/or alternative options. He stated his was not done and resulted in LVN A and LVN B's termination.
Record review of [Pharmacy] Request for Authorization to [NAME] House, dated [DATE], revealed the facility's DON authorized the payment of Resident #1's outstanding balance to [Pharmacy].
Record review of Training In-Service Form, dated [DATE] titled Resident Rights, Abuse + Neglect, and Medication Administration and Documentation, Notification to DON/Designee and MD When MD Not Available conducted by facility DON revealed multiple signatures including registered nurses, licensed vocational nurses, and certified medication aides.
Education provided included:-Forgetting to administer medication on time is an example of neglect-Medication errors must be documented-What do to when a resident refuses medication-Informed consent of psychotropic medications -Resident rights related to medication administration-Responsibility of nurses to ensure residents remain free from any medication errors-When administering medications, the right route must be considered-It is necessary for all medications to have a clinical indication-Residents must have medication review within 24 hours of admission to the facility, including re-admissions-Injuries/Accidents/Falls are considered an adverse consequence to medication-Facility nurses are responsible for the clarification of a medication order they do not understand
Record review of Competency Checklist, Skill/Procedure: Medication Administration, Feeding Tubes: Medication Administration Check-Off dated [DATE] conducted by facility DON revealed facility nursing staff received a multi-step procedural review of their skills of providing medications.
Record review of facility policy, Medication, rev. [DATE] revealed Staff will assist the. authorized prescriber with medication orders in accordance with standard practice guidelines. 2.
When medications are not available to staff to administer, medication aides will notify charge nurse. 3.
Charge nurse will attempt to obtain medication from emergency kit. If not available, charge nurse will reach out to pharmacy for a STAT delivery. 4.
Physician will be notified of missed doses due to medication availability. 7.
Updates are communicated to provider as needed for additional information.
Facility ID: