Nmmc Baldwyn Nursing Facility

Inspectors wroteBased on observation, resident and staff interviews, and facility policy review, the facility failed to provide sufficient nursing staff to ensure residents received necessary care as evidenced by failure to complete activities of daily living (ADL) care, including bathing, grooming, and nail care; failure to ensure call lights were answered in a timely manner; and failure to address repeated concerns voiced by residents during resident council meetings regarding delays in care and unmet needs for three (3) of four (4) survey days.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure informed consent was obtained prior to the initiation of a psychotropic medication for one (1) of two (2) residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, staff and resident interviews, record reviews, and facility policy reviews, the facility failed to implement a Catheter and Activities of Daily Living (ADL) care plan for five (5) of 25 resident care plans reviewed. (Resident #4, Resident #7, Resident #10, Resident #46, and Resident #54)

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure Activities of Daily Living (ADL) was provided to residents requiring assistance with personal hygiene for four (4) of the twenty-five sampled residents. (Residents #7, # 10, #46, and #54)

Inspectors wroteBased on record review, facility policy review, and resident and staff interviews, the facility failed to ensure necessary treatment and care were provided to promote healing and prevent worsening of pressure ulcers for one (1) of four (4) residents reviewed for pressure ulcers (Resident #7).

Inspectors wroteBased on observation, record review, staff interview, and facility policy review, the facility failed to ensure adequate supervision and implementation of interventions to prevent accidents for one (1) of four (4) falls reviewed. Resident #65. Findings Include:Review of the facility policy titled Fall Prevention and Post Fall Assessment & (and) Follow-up revealed under, Rational: To provide guidelines for the identification of residents at risk for falls. To provide assessments, interventions, and documentation after a resident fall. Also revealed under, Policy: It is the policy of 'Proper name of the facility' to identify residents at risk for falls in the attempt to help prevent falls and resident falls should be handled appropriately. An observation outside Resident #65's room on 3/23/26 at 12:20 PM revealed that the door was closed. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide a catheter securement device for a resident with an indwelling catheter for one (1) or four (4) catheters observed.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure adequate nutritional support and implementation of physician-ordered interventions to prevent significant weight loss for one (1) of six (6) residents reviewed for nutrition. Resident #1 Findings Include: Review of the facility policy titled Weight Loss: Monitoring of unrevised, revealed under, Policy: It is the policy of 'Proper name of the facility 'that the weight and the nutritional status of residents be monitored. Also revealed under, Procedure: If a resident has a weight loss greater than 5 (five) percent of body weight in one month or 10 percent of body weight in a six month period, the dietician should be consulted and recommendations of dietician should be followed. Record review of Resident #1's Flowsheet History revealed the following weights: [...]

Inspectors wroteBased on observation, record review, staff interview, and facility policy review, the facility failed to ensure the safe use, assessment, and ongoing evaluation of bed rails and failed to identify and remove a known entrapment hazard for one (1) of 25 sampled residents. Resident #65 Findings Include: Record review of the facility policy titled Bed Rails revised 9/18, revealed under, Policy: It is the policy of 'Proper name of the facility' that bed rails should be used appropriately. This failed practice was not in accordance with facility policy requiring appropriate use and assessment of bed rails. An observation of Resident #65 on 3/23/26 at 12:20 PM revealed he was lying in bed, awake and non-verbal. The left side of the bed was against the wall and one-half (1/2) upper side rails were observed to the left and right side of the bed with a fall mat on the floor. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure medications and treatment solutions were secured and not accessible to the resident for three (3) of four (4) survey days. Findings Include: Review of the facility policy titled Medication Administration revised 3/11/24 revealed, 3. No medications should be left in the resident's room [ROOM NUMBER]. Storage of medications and several other associated products should be secure, i.e., in a locked drawer/cabinet, or under constant surveillance. An observation inside room C3 on 3/23/26 at 11:12 AM and again on 3/24/26 at 8:14 AM revealed four (4) bottles of Dakin's solution quarter-strength (1/4), 16 fluid ounce bottles; two (2) bottles sitting on a table beside the bed and the other two (2) in a pink pail by the sink. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain effective infection control practices as evidenced by uncovered clean utility cart, staff not wearing gowns for enhanced barrier precautions, and handling soiled linens without a barrier bag, increasing the risk of cross-contamination and infection transmission for one (1) of four (4) survey days. Findings Include: Review of the facility's policy titled, EVS-Residential Laundry with an issued date of 4/1/18, revealed under Policy: All potentially contaminated linen should be handled with appropriate measures to prevent cross-transmission . Linen should be carried away from the body and clothing. Clean linens and residential laundry should be stored on clean, covered carts. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure skin care treatments were completed as ordered for one (1) of three (3) residents reviewed for wound and skin care. This deficient practice resulted in deterioration of a resident's wound, including a significant increase in wound size for Resident #1.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure wound care treatments were completed as ordered for two (2) of three (3) residents reviewed for pressure ulcer wound care (Residents #2 and #3).

Inspectors wroteBased on observation, staff and resident interview, record review, and facility policy review the facility failed to implement care plans for a dependent resident with a negative pressure wound therapy system (wound vac) in place and who required assistance with Activities of Daily Living for one (1) of four (4) residents sampled. Resident #1. Findings Include: Review of the facility policy, Care Plan Policy with reviewed date of 10/20 revealed, It is the policy of (Proper Name Facility) that care plans should be properly developed and implemented. Record review of Resident #1's Care Plan updated 04/11/25 revealed that she required assistance with ADL's (activities of daily living) related to End Stage Renal Disease on dialysis, Decreased Mobility, and Generalized Weakness. [...]

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to provide a dependent resident with assistance to change clothes prior to going to bed for one (1) of four (4) residents reviewed. Resident #1. Findings Include: Review of the facility policy AM/PM Care dated March 2020 revealed, .Resident's clothing should be changed daily and when soiled. On 04/29/25 at 9:47 AM, an interview with the complainant at the facility revealed that Resident #1, had been at the facility for a little over a year. She revealed that she had declined since admission into the facility and was now more dependent on the staff for her care. Activities Director revealed that she came into the facility one Saturday morning and found that Resident #1 had the same clothes on she had worn to dialysis the day before. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide treatment consistent with professional standards of practice to an existing surgical wound for one (1) of three (3) residents reviewed for wound care. Resident #1. Findings Include: Review of the facility policy Negative Pressure Wound Therapy System, Single Use dated 03/03/2025 revealed The pump may be disconnected from the dressing if there is a requirement to disconnect - such as the need to have a shower An interview on 04/29/25 at 10:00 AM with the complainant revealed that Resident #1, recently had an infected fistula removed from her left arm and she had a wound vac in place. The complainant revealed that she had a concern with the nurses not keeping the wound vac hooked up to suction all the time like they were supposed to. [...]

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to properly store medications needing refrigeration in one (1) of two (2) medication storage rooms. Station one (1) Medication Storage Room. Findings Include: Review of the facility policy, Medication Storage with last modified date of 03/14/2024, revealed, It is the policy of (proper name) that all medications should be appropriately delivered and stored. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to submit accurate information into the Payroll Based Journal (PBJ) system for one (1) of four (4) quarters reviewed.

Inspectors wroteBased on resident and staff interviews, and facility policy review, the facility failed to honor a resident right to vote in the 2024 election for one (1) of 23 sampled residents. Resident #72 Findings Include: Review of the facility policy titled Resident Rights: Participation in Groups and Activities of Choice with a review date of 2/12/24 revealed under, Procedure: . Residents should be encouraged to exercise their rights to vote in local, state, and national elections. An interview with Resident #72 on 1/8/24 at 8:11 AM revealed she had lived at the facility for over a year and did not get to vote this past election. She explained that she was registered to vote in a different county and had waited for the staff to bring her the necessary forms to complete, but no-one ever did. She revealed she always voted in the past, and it was important for her to continue to do so. [...]

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to provide a clean, safe, and homelike environment as evidenced by bugs in ceiling lights, walls and ceiling in disrepair, blind slats broken and bent, broken wood molding, unclean air/heating unit and floors for six (6) of 67 rooms in facility.

Inspectors wroteBased on staff interview and record review, the facility failed to accurately complete section A of the Minimum Data Set (MDS) for a resident with a serious mental illness for two (2) of 26 MDS reviewed. Resident #2 and #76 Findings Include: The facility provided a statement on letterhead dated 1/8/25 and signed by the Administrator that read, We follow the CMS (Centers for Medicare and Medicaid) RAI (Resident Assessment Instrument) version 3.0 for policy information regarding MDS (Minimum Data Set) accuracy. Resident #2 Record review of Resident #2's PASRR (Preadmission Screening and Resident Review) Summary Findings dated 6/25/24 revealed under, Mental Health: . The individual meets criteria for having a diagnosis of mental illness as defined by PASRR. Also revealed under, Axis I primary: Schizophrenia was listed. [...]

Inspectors wroteBased on observations, staff interviews, and facility policy review the facility failed to ensure food items in the refrigerator/freezer were labeled and dated or discarded by expiration date and failed to ensure a dietary cook was wearing a beard restraint while prepping foods, for one (1) of two (2) kitchen tours. Findings Include Record review of the facility policy titled, Food and Supply Storage with a revision date of 1/23 revealed Policies: All food, non-food items, and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . Procedures: . Cover, label and date unused portions and open packages .Discard food past the use-by or expiration date . Record review of facility policy titled, Uniform Dress Code with a revision date of 1/23, Policy #E006 revealed .Procedures: [...]

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to provide dignity to a resident with a urinary catheter bag for one (1) of six (6) residents with a urinary catheter. Resident #52 Findings Include: Review of the facility policy titled Resident Rights: Dignity and Respect with a revision date of July 2012 revealed under, Policy: It is the policy of (proper name of facility) that residents should be treated with dignity and respect. The facility provided documentation titled Facility Specific Handout that revealed under, Providing Excellent Resident Care: . 5. Catheters: Use privacy bag or pillowcase . An observation on 9/06/23 at 10:25 AM, revealed the resident lying in bed with a urinary catheter drainage bag containing light yellow urine that was uncovered and visible from the hallway. [...]

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to promptly address and provide a follow up to grievances for four (4) of 32 residents reviewed. Resident #45, Resident #47, Resident #62, and Resident #64. Findings Include Record review of facility policy titled, Resident Rights: Complaint/Grievance Policy and Procedure dated 10/17, revealed, Policy: To provide a timely mechanism for receiving, responding, resolving, and documenting the outcome of patient complaints and grievances that is in compliance with current Resident Rights guidelines. The policy also revealed, 5. Response to a grievance is expected to take place within five business days of receipt of grievance and acknowledged in writing appropriately to the resident council, resident, or his/her representative. [...]

Inspectors wroteBased on observation, staff and resident interviews, record review and facility policy review the facility failed to develop and implement a comprehensive care plan for a resident requiring nail care Resident #71 and for a resident with limited range of motion (ROM) Resident #26 and Resident #45 for three (3) of 23 resident care plans reviewed.

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to provide personal hygiene to a resident requiring assistance as evidenced by long dirty jagged nails for one (1) of 23 residents reviewed.

Inspectors wroteBased on observations, staff and resident interviews, record review and facility policy review, the facility failed to provide range of motion (ROM) exercise for a resident at risk for contractures Resident #45, and a splint for a resident with contractures Resident #26 for two (2) of 44 residents reviewed with limited ROM.

Inspectors wroteBased on observation, staff interview and facility policy review the facility failed to safely secure medications as evidenced by an unlocked and unattended medication cart on one (1) of three (3) survey days.