Baldwin Care Center

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 30 residents residing in the facility. Dietary [NAME] G did not monitor that dishes were being washed with the minimum requirement of 120 degrees Fahrenheit for proper sanitization of dishes.

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program so the facility is free of rodents with the potential to affect all 30 residents. Surveyor observed mouse droppings in the dry storage room located in the kitchen area. This is evidenced by:Surveyor reviewed facility policy titled, Pest Control, dated revised on 09/30/2024, which stated in part: .-Purpose: To reduce the potential of specific pest problems within the facility. Policy: Maintenance staff will monitor all parts of the building for prevention and elimination of any insects and/or rodents in a safe, efficient manner. Procedure: A specific pest control service plan will always be in place at facility. Services provided will include prevention and elimination of any insects and/or rodents in a safe, efficient manner. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure residents/representatives received notice before transfer or discharge, notice of bed-hold policy, and did not send a copy of the discharge notice to the Office of the State Long Term Care Ombudsman Notification for 2 of 2 residents (R7 and R39). R7 and/or representative were not provided/received notice of transfer to hospital, notice of bed-hold policy and facility did not notify Ombudsman of transfer. Facility did not notify Ombudsman of R39's discharge. The facility policy titled Notice of Bedhold Policies undated, states in part: If a Resident of [name of facility] is temporarily transferred to a hospital or another health care facility for emergency care .[Facility] will hold the resident's bed until the resident or residents representative waives the right to have the bed held for the resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not follow best standards of practice when administering medication for 1 resident (R26) of 25 residents reviewed for medication administrationR26's Gabapentin medication was removed from its original packaging from pharmacy, placed into a medication cup, stored in a locked cupboard to be administered 2 hours later to a resident, which has potential for a medication related adverse event to occur.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure procedures were in place to ensure medication with expired dates were removed/destroyed from 1 of 2 medication storage rooms. Four bottles of Aspirin were expired in 1 of 2 medication storage rooms. On 12/09/2025 at 1:40 PM, Surveyor observed the medication storage room on one unit with assist of Registered Nurse (RN) D and observed 4 bottles of Aspirin 325 mg that were expired: 2 unopened bottles that expired June 2025; 1 bottle open with approximately 1/2 of remaining tablets that expired June 2025; and 1 unopened bottle expired August of 2025. RN D stated there was a resident who was in the facility during June 2025, who the bottles of Aspirin were used for. This resident was no longer in the facility and no other resident since then required Aspirin 325mg. RN D stated RN D will destroy immediately. [...]

Inspectors wroteBased on observation and interview, the facility did not maintain infection prevention to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infection for 2 residents (R32, R17) of 5 residents reviewed for infection prevention in a sample of 12. Facility did not:Perform hand hygiene between feeding multiple residents at same time which could result in possible infection transmission. Perform hand hygiene after touching contaminated surfaces and prior to feeding residents which could result in possible infection transmission by cross contamination. Offer hand hygiene to residents prior to meal being served. Perform hand hygiene during peri-area cares which could result in possible infection transmission.

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility did not adequately clean light fixtures that were placed above serving areas. The facility did not ensure staff used proper hand hygiene when distributing food. This has the ability to affect all 39 of 39 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, and a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 39 residents in the facility. -The facility did not have a tracking program in place for the early detection of infected and exposed residents (R) and staff for COVID-19 and Norovirus during an outbreak. -Certified Nursing Assistant (CNA) did not perform hand hygiene during water pass that affected all residents. -Observations were made of the facility not implementing Enhanced Barrier Precautions (EBP) for 2 sampled residents on EBP. [...]

Inspectors wroteBased on observations, interview and record review the facility did not consult with the physician for changes in condition for R3. This occurred for 1 of 2 sampled residents (R) R3. R3 was admitted to the facility on [DATE] and has diagnoses that include heart failure, dementia, type 2 diabetes, major depressive disorder, hypertension and congestive heart failure. On 08/07/24 at 10:01 AM, Surveyor observed Licensed Practical Nurse (LPN) G complete a dressing change on R3's right leg. R3's leg was red and shiny in color; the wounds were weeping and open. R3 was complaining about the back of their calf hurting. After the bandages were applied, R3 and family member decided to go to urgent care to rule out a blood clot. R3 had doctor's orders that read, Weigh 2 times per week, Monday and Friday AM monitor weight call MD if goes up. On 7/01/24, R3 weighed 158.4 pounds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 1 of 3 residents (R) reviewed for pressure injuries (PI) (R4) received care consistent with professional standards of practice to prevent and promote healing of existing PIs. R4 did not have comprehensive weekly assessments of R4's pressure injuries. Physician was not notified when PI had increased size or changes in drainage. R4's pressure relief for ankle was not observed. R4 was not repositioned as instructed on the PI care plan. This is evidenced by: Guidelines from the National Pressure Injury Advisory Panel (NPIAP) 2016, Pressure Injury Prevention Points, accessed 07, March 2024, Prevention Points | National Pressure Ulcer Advisory Panel (npiap.com), states in part: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a medication error rate of 5% or less. During the medication administration task, Surveyor observed 2 errors out of 28 medication opportunities, resulting in an error rate of 7.14%. Staff administered 2 insulin injections without knowing if the insulin was expired. This affected 1 of 11 residents (R31) observed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility did not prepare, distribute and serve food in a manner that prevents foodborne illness to 33 out of 33 residents reviewed. Kitchen staff did not check the temperature of a reheated piece of left-over chicken after cooking in the microwave and served to R10. Dietary Aide touched bun with dirty gloves when serving meals in the Whispering Pines kitchenette. This affected all 17 residents (R) served meals from that area. (R10, R21, R6, R8, R4, R13, R33, R28, R34, R18, R23, R14, R2, R29, R16, R12, R5) The facility did not ensure the foods were served at safe temperatures in accordance with professional standards for food safety. Staff did not check the temperatures of the food prior to serving meals in the Woodland Heights kitchenette. This affected all 16 residents (R) served meals from that area. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that every resident was treated with dignity and respect when providing activities of daily living (ADL) for 1 of 12 residents (R15) reviewed. During two observations of cares provided to R15, the nurse providing cares did not speak to R15 or explain what cares they were going to provide. This is evidenced by: R15 was admitted on [DATE]. R15's Minimum Data Set (MDS), dated [DATE], stated in part, diagnoses of quadriplegia unspecified, anoxic brain damage, cerebral palsy, and gastrostomy. Surveyor reviewed R15's nursing care plan which, stated in part, .for functional level [R15] is total assist/cares and unable to communicate needs. Interventions included in part, . [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a resident received treatment based on current standards of practice for jejunostomy (J) tube for 1 of 1 residents (R) with a J-tube. (R15) Staff did not check for proper placement of R15's J-tube when providing treatment and administering medications and nutrition via J-tube. This is evidenced by: Facility policy entitled Gastric Tube Feeding, last revised 05/11/23, stated in part, .Check for residual and placement by attaching sixty ml piston syringe to gastric tube and gently pull back, if meet resistance as aspirate content, stop procedure, if no resistant, not amount of residual, then return gastric contents back into stomach. Appearance of gastric content implies that the tube is patent and in the stomach. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide pharmaceutical services, including dispensing and administering of all drugs, to meet the needs for 2 of 12 residents (R20 and R26). Registered Nurse (RN) F dispensed R20's nebulizer medication solutions into the nebulizer cup without R20 in the room and then documented in the Medical Administration Record (MAR) that the medication was administered at that time. R20 did not self-administer the nebulizer medication until three hours later. Lung sound assessments were not completed daily as per facility policy. Certified Nursing Assistant (CNA) G applied prescribed Nystatin cream to R26. This was evidenced by: The facility policy, entitled Administering Nebulizer Medications, dated 6/1/23, states: .After medication administration is completed .Document administration of medication. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure prescribing provider evaluated the resident and documented a clinical rationale for extending PRN (as needed) anti-psychotic medication beyond 14 days for 1 of 5 residents (R) reviewed for unnecessary medications. (R13) R13 had an order for PRN olanzapine (anti-psychotic medication) for greater than 6 months with no end date and no documentation of evaluation by prescribing provider with a rationale for continuing the anti-psychotic medication beyond 14 days.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less. During medication administration task, surveyors observed 3 errors out of 36 medication opportunities, resulting in an error rate of 8.33%. This affected residents (R20 and R4) 2 of 5 residents in the medication administration sample. Observations revealed Registered Nurse (RN) F placed Pulmicort inhalation solution and Ipratropium-Albuterol inhalation solution (2 separate medications) into the nebulizer cup for R20 and documented the administration time at 8:08 AM. R20 did not start administration of the two nebulizer solutions until 11:10 AM. The AM medication pass time range was between 7:00 AM until 10:30 AM, resulting in the two medications being administered late. RN K administered insulin medication without checking the expiration date for R4.

Inspectors wroteBased on observation and interview, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and did not ensure medication was labeled to determine the expiration date for 1 of 1 resident (R) (R4). R4 had one insulin Lantus pen not labeled with an open date or expiration date of medication.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 36 residents in the building. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Describe the building's water system using a flow diagram of the system to include an assessment of the facility's water system to identify all locations where Legionella could grow and spread. - Identify where control measures should be applied. - Include a process to confirm the WMP was being implemented and was effective. - Document and communicate all the activities. [...]