Baldwin Gardens Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an individualized care plan (a document that outlines a person's health needs and the care they require) for one out of three sampled residents (Resident 1) when: 1. Facility did not ensure a care plan was developed for Resident 1's diagnosis of rhabdomyolysis ([rhabdo] a life-threatening medical condition involving the rapid breakdown of damaged skeletal muscle). This deficient practice negatively affected Resident 1's care and created an immediate risk to Resident 1's health, safety, and quality of life. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared and served to meet individualized needs for one of three sampled residents (Resident 3) when: 1. Dietary cook (DC) failed to honor Residents 3's food dislikes and served Resident 3 turkey for lunch. 2. Licensed nurses did not verify Resident 3's food was correct prior to serving food to Resident 3. These deficient practices did not meet Residents 3's individual needs. It had the potential to impact Resident 3's nutritional intake. It made Resident 3 feel unsatisfied with the meal and caused Resident 3 not to want to eat the meal. During an observation on 6/23/2026 at 12:38 p.m., in Resident 3's room, Resident 3 was sitting at bedside staring at food tray. Food was untouched. [...]

Inspectors wroteBased on observation and interview, the facility did not provide a working call light to one of four sampled residents (Resident 3). This deficient practice had the potential to cause a delay or the inability in obtaining necessary care and services for Resident 3. During an observation on 6/23/2026 at 12:42 p.m., in Resident 3's room, Resident 3 pushed call light and call light outside of room did not light up and there was no audible sound. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks) and left artificial knee joint (replaces a missing or damaged natural joint). [...]

Inspectors wroteBased 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. These deficient practices had the potential for food borne illnesses.

Inspectors wroteBased 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. Ensure the incentive spirometer (IS, a tool that helps lungs breathe better) mouthpiece was not placed on the flat top surface of the nightstand for Resident 27. c. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a signed Informed Consent (IC-ethical and legal process where a resident voluntarily confirms willingness for a procedure after being informed of relevant risks, benefits, and alternatives) from the resident's responsible party (RP) prior to the administration of Mirtazapine (medication used to treat depression [mood disorder causing persistent sadness]) 7.5 milligram (mg- unit of measurement), for one of one sampled resident (Resident 59). This deficient practice violated Resident 59 and the RP's right and had the potential for Resident 59 to receive medication against Resident 59 or Resident 59's RP's will.

Inspectors wroteBased on interview and record review, the facility failed to provide the notice of discharge to the Ombudsman (an advocate for residents of nursing homes) in a timely manner for one of one sampled resident (Resident 57). This deficient practice increased the risks of unsafe discharge and violation of Resident 57's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a Significant Change - Minimum Data Set (MDS - a comprehensive assessment and care screening tool) assessment for one of one sampled resident (Resident 51). The resident was readmitted from the hospital with an indwelling catheter (a flexible tube that's put into your bladder to drain urine into an external bag). This failure had the potential to affect the accuracy of the resident's assessment, care planning, and monitoring of the resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive assessment and care screening too) reflected the presence of an indwelling urinary catheter for one of one sampled resident (Resident 51). This failure had the potential to negatively affect the resident's care planning and clinical decision-making.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order regarding the use of incentive spirometer (IS, a tool that helped lungs breathe better) for one of one sampled resident (Resident 27). This violation had the potential to compromise Resident 27's health and safety.

Inspectors wroteBased on observation, interview, and record review for one of three sampled residents (Resident 3), the facility failed to:a. Ensure the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) was set accurately for Resident 3.b. Obtain a physician order for the use of LALM for Resident 3. These failures had the potential to impede healing and worsen Resident 3's wounds and cause further skin injuries.

Inspectors wroteBased on interview and record review, the facility Administrator (ADM) and Director of Nursing (DON) failed to report an injury of unknown origin (IUO- injury in which the cause cannot be determined due to lack of witnesses and resident injured unable to express how the injury occurred) to officials including the State Survey Agency (SSA) and adult protective services (APS), immediately, but no later than 24 hours, and according to the facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating for one of two sampled residents (Resident 1). This failure had the potential for IUO to occur to other residents without appropriate reporting and investigation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled bathrooms (Bathroom Room [BR] 1) had a functioning call light. This failure had the potential to result in residents being unable to notify staff for assistance.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to provide information regarding Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents when individuals are not able to make their own healthcare decisions) for two of two sampled residents (Residents 11 and 25) in accordance with the facility's Policy and Procedure (P&P) titled Advance Directives. This failure had the potential for the facility staff to provide services and treatment against the residents' choices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents' (Residents 16 and 55) Minimum Data Set (MDS - a federally mandated resident assessment tool) reflected an accurate assessment, by failing to: a. Ensure Resident 16's discharge destination was coded correctly. Resident 16 was discharged to a Skilled Nursing Facility (SNF - care provided by trained registered nurses in a medical setting under a doctor's supervision) and was coded in the MDS assessment as being discharged to home or community. b. Ensure Resident 55's diagnosis was coded accurately. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents had an environment free from accident hazards(risks) for two of five sampled residents (Residents 7 and 53) by failing to: a. Ensure Resident 7's bilateral 1/4 siderails were padded as ordered by the physician. b. Ensure Resident 53's floor mat (used to reduce fall related trauma if a patient gets up from bed, loses balance, and falls to the floor) was close to the bed and the resident's bed lowered at the lowest position. These failures had the potential to result in accidents and hazards for Residents 7 and 53.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) site as ordered by the physician and as indicated in the plan of care for three of four sampled residents (Residents 1, 26 and 36). These failures had the potential for complications related to tube feedings for Residents 1, 26 and 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt the use of appropriate alternatives to siderails before its installation for two of two sampled residents (Residents 9 and 39 ). These failures placed Residents 9 and 39 at risk for entrapment and injury from the use of siderails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Low Air Loss (LAL) mattress (Alternating Pressure Mattress which provides alternating pressure and is designed to be used in the prevention, treatment and management of pressure injury [PI- a localized damage to the skin and underlying soft tissue usually over a bony prominence]) was set up accurately based on the resident's weight for one of two sampled residents (Resident 10). This failure had the potential risk for Resident 10 to develop PI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for a resident with Foley catheter (a medical device that helps drain urine from the bladder) in accordance with the facility's Policy and Procedure (P&P) on catheter care for one of one sampled resident (Resident 9). This failure had the potential to result in catheter-related complications for Resident 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and date the intravenous (IV, administered into a vein) site consistent with professional standards of practice for one of one sampled resident (Resident 157). This deficient practice had the potential to result in infection to Resident 157.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to label the nasal cannula (NC- tube which on one end splits into two prongs which are placed in the nostrils to deliver oxygen) tubing for one of two sampled residents (Resident 41). This failure had the potential to result in infection to Resident 41.

Inspectors wroteBased on interview and record review, the facility failed to follow up on the pharmacist's medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication.) recommendations of the physician evaluating the use of Cyclobenzaprine (muscle relaxant medicine) in the elderly for one of five sampled residents (Resident 10). This deficient practice had the potential to result in the resident receiving unnecessary medications and not maintaining the resident's highest practicable level of physical, mental, and psychosocial well-being and not preventing or minimizing adverse consequences related to medication therapy to the extent possible.

Inspectors wroteBased on interview and record review, the facility failed to offer pneumococcal vaccine that protects against serious and potentially fatal pneumococcal disease that is caused by bacteria called Streptococcus pneumoniae (pneumococcus)] based on the Centers of Disease Control and Prevention (CDC)'s recommended schedule guidelines for one of five sampled residents (Resident 10). This failure had the potential to result in leaving residents at risk of acquiring, transmitting, or experiencing complications from pneumococcal disease.

Inspectors wroteBased on interview and record review, the facility failed to include the census information on the daily shift staffing posting for three of three recertifications days inspected (11/19/2024, 11/20/2024, and 11/21/2024). This deficient practice of posting incomplete daily shift staffing information could mislead the residents and visitors and potentially affect the quality of nursing care provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide needed care and services by failing to: a. Assess one of one sampled resident (Resident 17) who developed edema (swelling caused by too much fluid trapped in the body's tissues) of the left lower leg. This deficient practice had the potential to result in delayed care and services to address Resident 17's edema. b. Complete a Situation, Background, Assessment, Recommendation (SBAR-a written communication tool that helps provide essential, concise information during crucial situations) report for one of one sampled resident (Resident 7), when Resident 7 was transferred to General Acute Care Hospital 1 (GACH 1) for a medical emergency. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure opened food items had use by date for one of one dry storage area in the kitchen. This deficient practice had the potential for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Policy and Procedure titled Confidentiality of Information and Personal Privacy by ensuring the resident's identifiable, personal, and medical information were not exposed on the computer screen unattended and in view of unauthorized persons for two of two sampled residents (Residents 1 and 47). This deficient practice resulted in Residents 1 and 47's violation of resident's right for privacy to keep their personal and medical records confidential and not readily observable and accessible by others.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for one of one sampled resident (Resident 46) who was at risk for fall, by failing to ensure the resident's call light was within reach as indicated in the facility's Policy and Procedure, titled Answering the Call Light and the resident's plan of care. This deficient practice had the potential for Resident 46 not to receive or received delayed care to meet the necessary services that could potentially result in falls and/or accidents.

Inspectors wroteBased on interview and record review the facility failed to develop and implement an individualized person-centered plan of care (details why a person received care, assessed health or care needs, medical history, personal details, expected and aimed outcomes, and what care and support will be delivered, how, when and by whom) with measurable objectives, timeframe, and interventions to meet the residents' needs for one of one sampled resident (Resident 36) who had type 2 diabetes mellitus (DM - a chronic condition that affects the way the body processes blood sugar) and was on Humulin R (type of insulin [a hormone that works by lowering levels of sugar in the blood]) as indicated in the facility's Policy and Procedure titled Care Plans, Comprehensive Person-Centered. This deficient practice had the potential for Resident 36 to not receive the necessary care, treatment and/or services.

Inspectors wroteBased on interview and record review, the facility failed to provide activities in accordance with the resident's comprehensive assessment for one of two sampled residents (Resident 50). This deficient practice had the potential to not support the physical, mental, and psychosocial well-being of Resident 50.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and monitor the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts or bacteria that could indicate infection) in the urine for one of four sampled residents (Resident 36) with suprapubic catheter (a hollow flexible tube that is inserted into the bladder through a cut in the abdomen used to drain urine from the bladder) as indicated in the facility's Policy and Procedure, titled Suprapubic Catheter Care and the resident's plan of care. This deficient practice had the potential for Resident 36 not to receive care or delayed care and treatment for urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system), hospitalization or sepsis (severe infection).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the head of bed was kept elevated to 30 to 45 degrees for one of two sampled residents (Resident 16) with ongoing G-tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding. This deficient practice had the potential to result in complications from aspiration (food, liquid, or other material enters a person's airway and lungs by accident).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe administration of medication for one of three sampled residents (Resident 7) during medication pass administration. Licensed Vocational Nurse 4 (LVN 4) crushed Alfuzosin (medication used to treat symptoms of an enlarged prostate in men, including difficulty urinating) Hydrochloride (HCL) Extended Release (ER-medications that slowly released over a period of time, that do not immediately release the active ingredients of the medication into the body, through the use of enteric coating which should not be crushed) and administered the medication to Resident 7 through the G-tube (external opening into the stomach for medication/nutritional support). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nectar-thickened fluid (liquid having the same thickness as vegetable juices and milkshakes) was provided to one of one sampled resident (Resident 21) in accordance with the physician's order. This deficient practice had the potential for aspiration (accidentally swallowing food or liquid into the lungs) for Resident 21.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dietary supplement was served as ordered for one of one sampled resident (Resident 22). This deficient practice had the potential to affect the resident's dietary intake which could result in inadequate nutrition or further weight loss of Resident 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nasal cannula tubing (a device used to deliver oxygen to a resident) did not touch the floor for one of six sampled residents (Resident 58) in accordance with the facility's Policy and Procedure, titled Departmental (Respiratory Therapy) - Prevention of Infection. This deficient practice had the potential to increase the risk of infection to Resident 58.