Baldwin Healthcare & Rehab Center, LLC

Inspectors wroteBased 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).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) were in place for Resident (R) 7 who had a Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) to the sacral (tailbone) area and failed to ensure staff used the appropriate personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) while providing wound care to R7.

Inspectors wroteBased on interviews, observation, and record review the facility failed to ensure Resident (R) 2's needs were met when staff failed to provide R2 with a call light in order to communicate her needs and wants to staff.

Inspectors wroteBased on record review and interview, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ).

Inspectors wroteThe facility identified a census of 51 residents. The sample included four residents reviewed for dignity and resident rights. Based on record review, observation, and interview the facility failed to maintain an environment that treated Resident (R) 1 with respect and dignity and maintained or enhanced R1's quality of life. This placed R1 at risk for impaired dignity.

Inspectors wroteThe facility had a census of 53 residents. The sample included 16 residents with two reviewed for accidents. Based on observation, record review, and interview the facility failed to secure hazardous cleaning chemicals in a safe, locked area, and out of reach of the seven cognitively impaired, independently mobile residents. This placed the affected residents at risk for preventable accidents. Findings Included: - On 06/10/24 at 07:10 AM an inspection of the facility's south hall revealed an unattended shower room with the entry door propped open. An inspection of an unlocked closet inside the shower room revealed a full-gallon bottle of bleach, purple disinfectant wipes, and several cleaning spray cans left on the shelf inside the closet. [...]

Inspectors wroteThe facility identified a census of 53 residents. The facility identified 11 residents on enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to follow sanitary infection control standards related to enhanced barrier precautions, wound care, disinfection of mechanical lifts, and maintaining oxygen therapy equipment. These deficient practices placed the residents at risk for infectious diseases. Findings Included: - On 06/10/24 at 07:08 AM an inspection of Resident (R) 1's room revealed her supplemental oxygen tubing rested on the back of her wheelchair next to her canister. No clean bag or storage device was in the room to store the oxygen equipment when not in use. [...]

Inspectors wroteThe facility identified a census of 53 residents. The sample included 16 residents with one resident reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide a dignified care environment for Resident (R)40, R41, and R256. This deficient practice placed the residents at risk for impaired dignity and quality of life. Findings Included: - On 06/10/24 at 07:52 AM an inspection of the hallway behind the activity room revealed a clear file box attached to the wall. A grievance form completed by Resident (R)256's resident representative was placed in the clear box with the details of the grievance visibly displayed. On 06/10/24 at 12:19 AM R41 sat in his Broda chair (specialized wheelchair with the ability to tilt and recline) in the dining room. [...]

Inspectors wroteThe facility identified a census of 53 residents. The sample included 16 residents. One resident was sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure that resident (R)1 had foot pedals on her wheelchair while being pushed. This deficient practice left R1 vulnerable to preventable accidents and injuries due to unmet care needs.

Inspectors wroteThe facility identified a census of 53 residents. The sample included 16 residents with one resident reviewed for a baseline care plan. Based on observation, record review, and interviews, the facility failed to develop a person-centered baseline care plan for Resident (R) 304 to include his hemodialysis (a procedure where impurities or wastes were removed from the blood) provider, days of the week, and time for dialysis. This deficient practice placed R304 at risk of impaired care related to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 53 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 51's comprehensive care plan was updated to include staff direction on the collaboration between the dialysis (a procedure where impurities or wastes were removed from the blood) clinic and the facility. The facility failed to ensure the care plan was updated with interventions to direct staff on the days, times, location, and contact numbers of R51's dialysis treatment clinic. This placed R51 at risk for complications related to dialysis due to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 53 residents. The sample included 16 residents with two residents reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to obtain communication from the dialysis center and assess the pre-dialysis and post-dialysis status for Resident (R) 304. This deficient practice placed R304 at risk of potential adverse outcomes and physical complications related to dialysis.

Inspectors wroteThe facility reported a census of 53 residents. The sample included 16 residents with five reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to follow orders related to medication monitoring when the facility administered Resident (R)50's anti-hypertensive beta-blocker (class of medication used to treat high blood pressure) medication on multiple occasions outside the physician ordered parameters without physician notification. This deficient practice placed R50 at increased risk for unnecessary medication and side effects.

Inspectors wroteThe facility had a census of 53 residents. The sample included 16 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure a gradual dose reduction (GDR) was attempted or addressed by the physician for Resident (R) 43's antipsychotic (class of medications used to treat a mental disorder characterized by a gross impairment testing) medication, who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications.

Inspectors wroteThe facility identified a census of 53 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure nurse staffing data was posted daily.

Inspectors wroteThe 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.

Inspectors wroteThe facility had a census of 51 residents. The sample included 13 residents with five reviewed for Activities of Daily Living (ADLs). Based on observation, record review, and interview, the facility therapy failed to provide reasonable accommodations to Resident (R) 29's to address limitations which inhibited her ability to perform oral cares. This placed the resident at risk for diminished abilities with her ADLs.

Inspectors wroteThe facility had a census of 51 residents. The sample included 13 residents, with one reviewed for dental. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for dental for one sampled resident, Resident (R) 8, who's teeth were in poor condition which caused difficulty chewing. This placed the resident at risk for weight loss and pain.

Inspectors wroteThe facility had a census of 51 residents. The sample included 13 residents, with one reviewed for dental. Based on observation, record review, and interview, the facility failed to honor Resident (R) 8's stated food preferences, who requested raisin bran (cereal containing raisins and bran flakes) due to the inability to chew toasted oats cereal (whole grain oats in the shape of a circle) but was served the toasted oat cereal anyway. This placed the resident at risk for weight loss and imparied autonomy.

Inspectors wroteThe facility had a census of 51 residents. The sample included 13 residents with two reviewed for urinary catheter or Urinary Tract Infection (UTI -Infection of any part of the urinary system). Based on observation, record review, and interview the facility failed to follow standards of infection control when staff failed to use appropriate hand hygiene while providing care to Resident (R) 36, who had history of urinary tract infections. This placed the resident at increased risk for UTI and other infectious disease.