Baldwin Healthcare & Rehab Center, LLC

In the surveyor’s words

From the most serious findings on record at Baldwin Healthcare & Rehab Center, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 14, 2023

  The facility identified a census of 51 residents. The sample included three residents reviewed for elopement (when a cognitive impaired resident with little or poor safety awareness exits the facility without staff knowledge). Based on observation, record review, and interview, the facility failed to identify the increased level of risk and respond with appropriate interventions and adequate supervision, to prevent an elopement for Resident (R) 1, who was cognitively impaired, at risk for elopement, and had a recent history of aggressive exit seeking behaviors on 02/07/23 and 02/09/23. […]

• Actual harm, isolatedF600Oct 24, 2022

  The facility identified a census of 51 residents. The sample included three residents reviewed for neglect. Based on record review and interviews, the facility failed to prevent an instance of neglect on 09/26/22 at approximately 07:30 PM when Certified Nurse Aid (CNA) O attempted to transfer Resident (R)1 from a wheelchair to R1's bed using the full-body mechanical lift. CNA O knew R1's care plan directed R1 required two staff assistance with the lift. As a result of the deficient practice, R1 fell , hit her head on the floor, and sustained a laceration (cut) which required emergent treatment and a staple. R1 also had impaired psychosocial wellbeing evidenced by tearfulness and expressions of guilt related to the incident. […]

• Actual harm, isolatedF602Oct 24, 2022

  The facility identified a census of 51 residents. The sample included three residents identified at risk for abuse, neglect, exploitation, and/or misappropriation of property. Based on record review, observations, and interviews, the facility failed ensure an environment free from misappropriation of resident property when facility staff took Resident (R)2's new laptop computer without R2's permission or knowledge. As a result of this action, R2 experienced mental anguish and an impaired sense of security. Findings included: - R2's Electronic Medical Record (EMR) revealed R2 admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Oct 5, 2022

  The facility had a census of 51 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety for the 51 residents who resided in the facility and received their food from the facility kitchen, when the facility failed to ensure clean and sanitary food prep and storage areas. This placed the 51 residents at risk for foodborne illness. Findings included: On 10/03/22 at 10:47 AM, observation in the kitchen revealed the following: Loose plaster located in the crack between sheet rock on the ceiling on both sides of the kitchen approximately six feet (ft) long and 2 inches (in) wide. […]

• No harm, potential for more than minimal, patternF761Apr 15, 2026

  Based on observation, record review, and interviews, the facility failed to appropriately store medications and biologicals when staff set up 11 residents' medication early and placed them in medication cups in the medication cart, labeled with resident's initials but lacking the required information regarding each medication (prescription and dosing information).Findings included:- On 04/13/26 at 07:42 AM, the medication carts were placed outside the dining room. Inspection of the medication carts revealed 11 medication cups marked with initials that contained medications. The medication cups were stored in the top left-hand drawer of the medication cart. […]