Baldwin Gardens Nursing Center

In the surveyor’s words

From the most serious findings on record at Baldwin Gardens Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF689May 13, 2021

  Based on interview and record review, the facility failed to prevent a resident who was a high risk for falls, and needed one-on-one supervision (one staff supervising one resident) when up in a therapeutic recliner chair (an armchair with the capability to lower the back and raise the foot part) from falling and sustaining injuries by failing to: 1. Provide one-on-one supervision at all times while Resident 1 was lying in the therapeutic recliner chair as indicated in the resident's care plan for one of three sampled residents (Resident 1). Certified Nursing Assistant (CNA) 1 left Resident 1 unattended in the facility dining room while the resident was lying in the reclining chair. […]

• No harm, potential for more than minimal, widespreadF921Mar 7, 2023

  Based on observation, interview and record review, the facility failed to provide a safe and functional environment by not notifying the fire department and the authority having jurisdiction (AHJ) when the automatic sprinkler system was out of service in the appropriate timeframe. The facility ' s automatic sprinkler system was non-functional and the fire department and AHJ were not notified per the facility ' s fire watch policy. This deficient practice could have a negative effect on the health, safety, and welfare of the residents, staff, and the public. Findings: On 2/6/2023, at 12:30 pm, a complaint investigation was initiated regarding the facility's broken water sprinkler pipe. […]

• No harm, potential for more than minimal, patternF812Jan 30, 2026

  Based on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) for one of one facility kitchen, as evidenced by:1.Ground turkey meat bag dated 5/15/25 was placed on top of an ice bag inside the kitchen freezer. 2.Ten (10) fruit cups inside the kitchen refrigerator were expired, dated 1/26/26.3. Fourteen (14) red pudding cups inside the kitchen refrigerator were expired, dated 1/26/26.4. [NAME] rice and [NAME] rice inside plastic containers had a best by date of 1/6/26 in the dry storage room. 5. Test strips to measure the concentration of the sanitizer solution inside the Red bucket had an expiration date of 11/1/24. […]

• No harm, potential for more than minimal, patternF880Jan 30, 2026

  Based on observation, interview, and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for four of eight sampled residents (Residents 1, 27, 43, and 61) by failing to: a. Cover the [NAME] Valve's (a device that controlled fluid flow in medical tubing) port, which had dry brown crust inside on Resident 1's gastrostomy tube (G-tube [GT], a surgical opening fitted with a device to allow feedings/medications to be administered directly to the stomach) and ensure Resident 1's abdominal binder (a wrap that kept the belly secure to stop G-tube pulling) did not have brown stains. b. […]

• No harm, potential for more than minimal, patternF558Nov 22, 2024

  Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for four of four sampled residents (Residents 7, 9,12 and 23). These deficient practices had the potential for Residents 7, 9,12 and 23 not to receive necessary care or receive delayed services, placing the residents at risk for falls or injury. Findings: a. During a review of Resident 12's Admission Record (AR), the AR indicated Resident 12 was initially admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (type of ischemic [deficient supply of blood] stroke [sudden death of brain cells in a localized area… […]