Atrium Health Navicent Baldwin

In the surveyor’s words

From the most serious findings on record at Atrium Health Navicent Baldwin, in the surveyor’s own words.

• Actual harm, isolatedF655Dec 8, 2025

  Based on observations, staff interviews, and record review, the facility failed to implement the baseline care plan for one of one residents (R) (R14) who received wound care. On 12/8/2025, actual harm occurred when Licensed Practical Nurse (LPN) AA failed to administer pain medication to R14 prior to providing wound care treatment, resulting in pain during the treatment.Findings include:Review of the medical record for R14 revealed the resident was admitted with a diagnosis including, but not limited to, osteomyelitis on the left heel, pressure ulcers of skin of multiple topographic sites, decubitus ulcer of ankle, peripheral vascular disease, and type 2 diabetes.Review of the baseline care plan for R14, dated 12/3/2025, revealed a care plan problem/goal for Pain - Adult,… […]

• Actual harm, isolatedF697Dec 8, 2025

  Based on observation, staff interviews, record review, and review of facility policy titled Pain Management, and Wound Assessment, the facility failed to stop and address verbal and facial expressions during wound care for one of one residents (R) (R14) observed for wound care. On 12/8/2025, actual harm occurred when Licensed Practical Nurse (LPN) AA failed to administer pain medication to R14 prior to providing wound care treatment, resulting in pain during the treatment.Findings Include: Review of the facility policy titled Pain Management, dated 1/9/2024, revealed the Purpose section included, To ensure optimal patient comfort through a proactive pain management plan. […]

• No harm, potential for more than minimal, isolatedF638May 26, 2021

  Based on record review and staff interview, the facility failed to ensure that a Quarterly Minimum Data Set (MDS) Assessment was completed in a timely manner for one of nine sampled residents (R) (#155). Findings include: Review of the Center for Medicare/Medicaid Services (CMS) RAI Version 3.0 Manual, page 5-4 dated October 2016 revealed: Assessment Schedule: An Omnibus Budget Reconciliation Act (OBRA) assessment (comprehensive or quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments. R#155 was admitted on [DATE]. Review of the MDS revealed an entry tracking record dated 8/5/2020. Review of the clinical record revealed an admission assessment was completed on 8/5/2020. […]

• No harm, potential for more than minimal, isolatedF812May 26, 2021

  Based on interview and observations, the facility failed to discard expired items and failed to label and date items in the one of two refrigerators. Findings include: Observation on [DATE] at 11:30 a.m. during a brief kitchen tour with the Dietary Manager (DM) revealed the following: 1. In the pantry was a 14 ounce (oz.) package of seasoning which was opened and unlabeled. 2. In the pantry was a 50 oz. can of cream of potato soup which was dented. 3. In the walk-in Refrigerator #2 there was one case of rotting plums. 4. In the walk-in Refrigerator #2 there was one opened container of pasta salad that expired on [DATE]. 5. In the walk-in Refrigerator #2 there was one opened container of peeled potatoes that expired on [DATE]. 6. […]