Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Baldwin Gardens Nursing Center during CMS and state inspections, most recent first.
Kitchen staff failed to follow food storage and sanitation practices when raw turkey was placed on top of an ice bag in the freezer, expired fruit cups and pudding cups were kept in the refrigerator, rice with an expired best-by date remained in dry storage, and expired sanitizer test strips were used to check the red bucket solution. The DON, DS, and IPN stated the items should not have been kept or used as found, and that expired strips could give inaccurate results for the sanitizing solution used on food prep surfaces.
A resident with a GT had an uncovered medication port with dry crust and a soiled abdominal binder, another resident with dementia had an IS mouthpiece left on the nightstand, a third resident on continuous oxygen had an undated NC storage bag, and a fourth resident with a Foley catheter had the drainage bag touching the floor. The IPN and DON stated these items should have been kept clean, covered, dated, or off the floor to prevent infection.
Incomplete Informed Consent for Mirtazapine: A resident with COPD, depression, severely impaired cognition, and no capacity for medical decisions was ordered Mirtazapine 7.5 mg for depression with poor PO intake, but the informed consent form was not signed by the resident or the RP. RN and DON confirmed the consent was incomplete, and the facility policy stated the physician or licensed practitioner must obtain informed consent from the resident or representative.
A resident with severely impaired cognition and dependence for multiple ADLs was transferred to an acute care hospital for congestion and distress, but the NPTD was not sent to the Ombudsman until more than a week later. Staff interviews confirmed the notice should have been faxed within 24 hours or the next business day, and the DON stated the delay was not acceptable.
Failure to complete a Significant Change MDS for a resident who returned from the hospital with an indwelling catheter. The resident had multiple diagnoses, was dependent for several ADLs, and later records showed the catheter was ordered and monitored, but the chart did not show a Significant Change assessment was completed. The MDS Coordinator stated the catheter was thought not to affect ADLs, but after reviewing the RAI Manual, acknowledged the resident returned with a significant decline from baseline.
MDS documentation failed to accurately reflect that a resident had an indwelling urinary catheter. The resident’s assessment and physician orders documented the catheter, but one MDS omitted it while later MDSs included it. The MDS Coordinator stated the MDS was not properly documented and no modification was submitted.
A resident with metabolic encephalopathy and dementia had an incentive spirometer at the bedside and reported using it daily for breathing exercises, but the active order record contained no physician's order for the device. The IPN confirmed the spirometer was for breathing exercises and stated an order should have been in place before it was provided, while the DON stated the LPN should have obtained the order first as part of standard nursing practice.
Improper LALM Setting and Missing Physician Order: A resident with DM, dementia, severe cognitive impairment, and eight pressure ulcers was observed lying on a LALM set at 200 lbs despite a recorded weight of 134 lbs. The WCN and DON stated the setting was not appropriate and that there was no documentation of RP preference for the higher setting. The record also showed the LALM was in use before a physician order was obtained.
A resident with intellectual disabilities and muscle weakness was found with a skin discoloration under the eye, and the cause was undetermined due to the resident's inability to communicate. Despite facility policy requiring immediate reporting of such injuries, the incident was not reported to the appropriate authorities within the required timeframe. The DON and ADM acknowledged the oversight, recognizing the incident as an IUO that should have been reported to ensure resident safety.
A facility failed to maintain a functioning call light system in one of its bathrooms, as observed during a survey. A CNA and the Maintenance Worker confirmed that the call light button did not stay activated, preventing staff from being alerted if a resident needed assistance. The DON acknowledged the issue, and the facility's policy requires defective call lights to be reported promptly, which was not adhered to.
The facility failed to ensure call lights were within reach for four residents, including those with hemiplegia and paraplegia, leading to potential delays in care. Observations showed call lights were either hanging out of reach or on the floor, contrary to care plans and facility policy. Staff confirmed the need for call lights to be accessible for timely assistance.
The facility failed to provide Advance Directive information for two residents with severely impaired cognition, as required by their policy. Both residents lacked the necessary Advance Directive Acknowledgement Forms in their charts, which should have been initiated upon admission to ensure their treatment preferences were documented.
The facility failed to ensure accurate MDS assessments for two residents, leading to incorrect reporting to CMS. A resident was discharged to an SNF but was coded as discharged to home/community, and another resident's MDS inaccurately indicated a PTSD diagnosis. These errors were confirmed by facility staff and attributed to previous mistakes.
The facility failed to implement safety measures for two residents, leading to potential accident hazards. One resident's siderails were not padded as ordered for seizure precautions, and another resident's bed was not lowered, with floor mats improperly positioned, despite a high fall risk. These oversights were contrary to physician orders and facility policies.
The facility failed to provide proper care for the gastrostomy tube sites of three residents, as per physician orders and care plans. One resident's GT stoma was found uncovered and red, another's GT tubing was left uncapped, and a third resident did not receive the ordered water infusion, risking dehydration. These deficiencies were acknowledged by the staff, including the DON.
The facility failed to attempt appropriate alternatives to siderails before their installation for two residents, placing them at risk for entrapment and injury. One resident, with intact cognition and requiring assistance with daily activities, had no documented evidence of alternatives being tried. Another resident, with severely impaired cognition and dependent on assistance, also had no alternatives attempted before siderail installation. The facility's policy requires attempts of least restrictive alternatives prior to siderail use.
A resident with a history of pressure injuries had their Low Air Loss (LAL) mattress incorrectly set at 280 lbs instead of their actual weight of 162 lbs. This discrepancy was observed and confirmed by staff, who acknowledged the importance of setting the mattress according to the resident's weight to prevent pressure injuries. The facility's policy and the mattress manual both emphasize the need for weight-based adjustments.
A facility failed to maintain a resident's Foley catheter tubing free from kinks, as observed during an interview with a Treatment Nurse. The resident, who had a history of UTIs and chronic kidney disease, was found with kinked catheter tubing, which could lead to urine backflow and increased infection risk. The facility's policy required frequent checks to ensure tubing was clear, but this was not followed.
A resident with osteomyelitis and a left foot amputation had an IV site that was not labeled or dated, and the IV tubing port was not capped or covered, contrary to facility policy. This oversight was confirmed by interviews with nursing staff, who acknowledged the importance of these measures to prevent infection.
A resident dependent on supplemental oxygen had their nasal cannula (NC) tubing unlabeled, which was required for infection control purposes. The resident, who had no speech and was dependent on others for care, was observed receiving oxygen via NC without a date label. The facility's Infection Prevention Nurse confirmed the NC should be labeled and changed weekly, but without labeling, staff could not determine when it was applied or due for change.
A facility failed to follow up on a pharmacist's medication regimen review (MRR) recommendation for a resident prescribed Cyclobenzaprine, identified as inappropriate for the elderly. The Director of Nursing admitted the oversight, noting that the MRR should have been sent to the prescribing physician for evaluation, as per facility policy.
A facility failed to offer a pneumococcal vaccine to a resident with COPD and diabetes, as per CDC guidelines. The resident had received previous pneumococcal vaccines, but the Infection Prevention Nurse did not inform the resident or their responsible party about the overdue PCV20 vaccine. This oversight was against the facility's policy, which requires offering vaccines per CDC recommendations.
The facility failed to include census information in daily shift staffing postings for three consecutive days, as required by policy. Interviews with the Lobby Receptionist and DON confirmed the omission, which could mislead residents and visitors and affect care quality.
Expired Food Items and Improper Sanitizer Testing in Kitchen
Penalty
Summary
The facility failed to follow proper food storage and sanitation practices in the kitchen. During observation, a bag of ground turkey meat dated 5/15/25 was found placed on top of an ice bag inside the kitchen freezer. The Director of Nutrition stated the ice machine had broken the night before and ice bags were being used for residents, and stated the turkey should not have been placed on top of the ice bag because the ice could be contaminated if the bag was not completely sealed. A kitchen staff member stated the frozen turkey could still be used and pointed out a second date of 11/25/25 on the bag, but the date did not specify whether it was the received date or the opened date. The Director of Nutrition later stated that if the food item had no clear use-by or best-by date, it should be discarded to ensure it was safe to eat. During the same kitchen observation, ten fruit cups and fourteen red pudding cups were found in the refrigerator with labels dated 1/26/26 for use at lunch the next day. The kitchen staff member stated the items were dated 1/26/26 because that was when they were made, while the Director of Nutrition stated the items were expired based on the label date and should have been thrown away. In the dry storage room, two containers of rice, including brown rice and [NAME] rice, were found with a best-by date of 1/6/26. The Director of Nutrition stated both rice items should be discarded because they could be expired. The dishwasher used test strips with an expiration date of 11/1/24 to measure the concentration of the sanitizing solution in the red bucket. The dishwasher stated they were not aware the strips were expired and explained the solution was used on kitchen countertops where clean utensils and serving spoons were kept. A later observation showed another staff member using a wet towel from the red bucket to clean food prep countertops and other kitchen areas. The Dietary Supervisor and Infection Prevention Nurse stated expired test strips could produce inaccurate results and that expired strips were not allowed because the sanitizing solution might not be properly disinfecting surfaces. The Infection Prevention Nurse also stated kitchen staff needed to ensure nothing in the kitchen was expired.
Infection Control Lapses With GT, IS, NC, and Foley Catheter Equipment
Penalty
Summary
Infection prevention and control procedures were not followed for four residents with devices or equipment in use. Resident 1, who had dysphasia, aphasia, severely impaired cognition, and was dependent on staff for multiple activities of daily living, had a gastrostomy tube line hanging on the side of the bed with the medication port left uncovered and dry brown crust visible inside. At the same time, Resident 1’s abdominal binder was observed with brown stains. The WCN stated the GT port should have a cap and that the dirty port and soiled binder could allow bacteria to grow and contribute to infection at the GT site. Resident 27, who had metabolic encephalopathy, dementia, and severely impaired cognition, used an incentive spirometer for breathing exercises. The IS mouthpiece was observed placed on the flat top surface of the resident’s nightstand on multiple observations. The IPN stated the mouthpiece should be kept in a bag to prevent infection and that the licensed nurse was responsible for keeping it away from dirty surfaces. The DON stated the mouthpiece should not touch the nightstand surface and should be stored in a plastic bag. Resident 43, who had respiratory failure with hypoxia, muscle weakness, and moderately impaired cognition, had an order for continuous oxygen via nasal cannula. The nasal cannula storage bag at the bedside was observed not dated on multiple occasions. The IPN stated the designated CNA should date and change the storage bag every seven days or as needed, and the DON stated the designated CNA should have dated the bag for infection control. Resident 61, who had a history including UTI and BPH and had an order for a Foley catheter for obstructive uropathy, had the catheter drainage bag observed touching the floor. The IPN stated the drainage bag should not touch the floor and should be held in a basin, and the DON stated all staff should ensure the drainage bag remained off the floor throughout the shift.
Incomplete Informed Consent for Mirtazapine
Penalty
Summary
The facility failed to obtain a signed informed consent from Resident 59’s responsible party before administering Mirtazapine 7.5 mg for depression with poor PO intake. Resident 59 was admitted and later readmitted with diagnoses including COPD and depression, and the H&P dated 12/19/2025 stated the resident did not have the capacity to make medical decisions. The active order summary dated 12/27/2025 included Mirtazapine 7.5 mg by mouth once daily, and the MDS dated 12/29/2025 described severely impaired cognition and dependence in ADLs. The care plan for antidepressant medication initiated on 12/29/2025 directed staff to educate the resident, family, or caregivers about the risks, benefits, and side effects of antidepressant drugs. However, a record review on 1/29/2026 showed the informed consent for Mirtazapine 7.5 mg was not signed by Resident 59 or the resident’s RP. During interview, RN 1 stated the form was signed only by the nurse who received the order and that the resident, family, or RP was required to sign it; the DON also stated the consent was not signed and was incomplete. The facility policy stated the physician or licensed practitioner is responsible for obtaining informed consent from the resident or the resident’s representative.
Delayed Ombudsman Notification for Resident Transfer
Penalty
Summary
The facility failed to provide the Notice of Proposed Transfer/Discharge to the Ombudsman in a timely manner for one sampled resident. Resident 57 was initially admitted to the facility and later readmitted with diagnoses including metabolic encephalopathy and lack of coordination. The resident’s MDS dated 12/24/2025 showed severely impaired cognition and dependence on staff for eating, oral hygiene, personal hygiene, toileting hygiene, showering/bathing, and transferring. On 1/4/2026, the physician ordered the resident transferred to General Acute Care Hospital 2 for evaluation, and the SBAR documented the transfer was due to congestion and distress. The NPTD dated 1/4/2026 showed the resident’s responsible party was notified that day, but the copy for the Ombudsman was not provided until 1/13/2026. During interviews, LVN 1 stated the NPTD should be faxed to the Ombudsman after a resident is transferred, ideally within a day, because the Ombudsman needs to know the transfer reason and the resident’s whereabouts. The Social Service Director acknowledged the notice was sent late and stated it should have been faxed the following business day. The DON stated the SSD should fax the NPTD within 24 hours of transfer because that is the regulation, and said it was not acceptable to fax it on 1/13/2026 for a transfer that occurred on 1/4/2026. The facility policy stated the NPTD should be provided to the Ombudsman when practicable.
Failure to Complete Significant Change MDS After Readmission With Indwelling Catheter
Penalty
Summary
The facility failed to complete a Significant Change MDS assessment for a resident who was readmitted from the hospital with an indwelling catheter. The resident’s admission record showed diagnoses including polyneuropathy, UTI, bipolar disorder, depression, obstructive and reflux uropathy, and anxiety disorder. The resident’s MDS indicated cognitive intactness and dependence for toileting hygiene, lower body dressing, and chair/bed-to-chair transfer, and it did not indicate an indwelling catheter at that time. Nursing progress notes showed the resident was sent to the hospital for abdominal pain, and the Admission/Readmission/Initial Assessment documented that the resident returned to the facility with an indwelling catheter. Physician orders and the TAR confirmed the catheter was ordered and monitored. The resident’s later MDS indicated an indwelling catheter, but the medical record from May 2025 through January 2026 did not show that a Significant Change MDS was completed. During interview, the MDS Coordinator stated she believed the catheter did not affect ADLs, but after reviewing the RAI Manual, acknowledged that a significant change assessment should have been completed because the resident returned with a significant decline from baseline.
MDS Did Not Accurately Reflect Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected that Resident 51 had an indwelling urinary catheter. Resident 51 was admitted with diagnoses including polyneuropathy, UTI, bipolar disorder, depression, obstructive and reflux uropathy, and anxiety disorder. The admission/readmission initial assessment documented that the resident had an indwelling catheter present for obstructive uropathy, and the physician's orders showed an indwelling catheter from 5/18/2025 to 1/22/2026. Review of multiple MDS assessments showed inconsistent documentation of the catheter status: one MDS did not indicate an indwelling catheter, while later MDS assessments did indicate one. During interview and record review, the MDS Coordinator stated that the MDS for 6/24/2025 was not properly documented and that no modification to the MDS was submitted or done. The facility policy titled MDS Error Calculation stated that if an error is found in an accepted record, procedures must be implemented to modify or deactivate the information in the system within 14 days from discovery of the error.
Missing Physician Order for Incentive Spirometer Use
Penalty
Summary
The facility failed to obtain a physician's order for the use of an incentive spirometer for one resident. Resident 27 was admitted with diagnoses including metabolic encephalopathy and dementia, and the H&P stated the resident could make needs known but could not make medical decisions. The MDS indicated severely impaired cognition and the resident required varying levels of assistance with eating, oral hygiene, toilet hygiene, personal hygiene, bed-to-chair transferring, and bathing. During multiple observations, the incentive spirometer mouthpiece was found placed on the resident's nightstand, and the resident stated it was used daily for breathing exercises. The Infection Preventionist Nurse identified the device as being for breathing exercises and later confirmed there was no physician's order for its use in the active order summary report. The IPN stated there should have been a physician's order before the device was provided, and the DON stated the licensed nurse should have obtained the order prior to starting the treatment because it was standard nursing practice. The facility policy on incentive spirometers stated to obtain a physician's order as needed, and the professional standard of care policy required services to be performed in accordance with accepted professional standards, safety, and regulatory compliance.
Improper LALM Setting and Missing Physician Order
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was deficient for one sampled resident with diabetes mellitus, dementia, severely impaired cognition, and dependence on staff for multiple activities of daily living. The resident had eight pressure ulcers and was using a pressure reducing device for bed. The care plan identified use of a low air loss mattress (LALM) for skin management, and the order summary showed a physician order for staff to monitor the LALM function and setting every shift starting 1/28/2026. During observations on 1/27/2026, the resident was lying on the LALM and the mattress weight setting was 200 lbs, while the resident's recorded weight was 134 lbs. The wound care nurse stated the setting was not appropriate for the resident's weight and that the mattress should be set according to the resident's weight or preference, with no documentation showing the responsible party preferred the 200 lb setting. The wound care nurse and DON also stated there should have been a physician order for the use of the LALM before it was placed in use, but the order was not present until 1/28/2026.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility Administrator (ADM) and Director of Nursing (DON) failed to report an injury of unknown origin (IUO) involving a resident to the appropriate authorities, including the State Survey Agency (SSA) and adult protective services (APS), within the required timeframe of 24 hours. The facility's policy and procedure on abuse, neglect, exploitation, or misappropriation reporting and investigating mandates such incidents be reported promptly. This failure was identified for one of two sampled residents, who had a small skin discoloration under the right lower eye, and the cause of the injury could not be determined due to the resident's inability to communicate. The resident in question had been admitted with diagnoses including unspecified intellectual disabilities and generalized muscle weakness, and was assessed to have severely impaired cognition, requiring significant assistance with daily activities. On the day of the incident, the resident was noted to be agitated and attempting to hit staff, and later was found to have redness under the right eye. The Licensed Vocational Nurse (LVN) and a Certified Nurse Assistant (CNA) both observed the resident rubbing their eyes aggressively, but neither witnessed any fall or impact that could have caused the discoloration. The LVN reported the incident to the resident's sister and the DON, but the incident was not reported to external authorities as required. Interviews with the DON and ADM revealed that they recognized the incident as an IUO and acknowledged that it should have been reported to the department of public health, local law enforcement, and the ombudsman. The facility's policy, revised in November 2024, clearly states that all injuries of unknown source should be reported immediately, but this protocol was not followed in this case. The failure to report the IUO in a timely manner had the potential to allow similar incidents to occur without appropriate investigation and intervention, compromising resident safety.
Non-Functioning Call Light in Bathroom
Penalty
Summary
The facility failed to ensure that a functioning call light system was available in one of the three sampled bathrooms, specifically Bathroom Room 1. During an observation and interview with a Certified Nursing Assistant (CNA 1), it was noted that the call light button in BR 1 did not remain activated when pressed. CNA 1 acknowledged that the malfunctioning call light posed a risk, as staff would not be alerted if a resident required assistance in the bathroom. Further interviews with the Maintenance Worker and the Director of Nursing (DON) confirmed the issue, with both acknowledging that the call light button should remain activated when pressed. The facility's policy and procedure on answering call lights, revised in October 2010, requires staff to promptly report defective call lights to the nurse supervisor. However, this protocol was not effectively followed, leading to the deficiency.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, which could lead to delayed care or lack of necessary assistance. Resident 12, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, was assessed as high risk for falls. Despite the care plan indicating that the call light should be within easy reach, observations showed that the call light was hanging on the left side rail, out of reach. The Infection Prevention Nurse confirmed that the call light needed to be accessible for emergencies or assistance. Resident 23, diagnosed with paraplegia, also had a care plan that required the call light to be within easy reach. However, during an observation, the call light was found hanging on the left side rail, and the resident confirmed it was unreachable. The Infection Prevention Nurse reiterated the necessity for the call light to be accessible. Similarly, Resident 7, with intervertebral disc disorder and epilepsy, had a call light that was found on the floor, and the Licensed Vocational Nurse acknowledged it should be placed close to the resident. Resident 9, who had metabolic encephalopathy and hemiplegia, was also affected by this deficiency. The call light was found under the bed, tangled and inaccessible. The Licensed Vocational Nurse stated it should be within reach. The Director of Nursing confirmed that call lights should be placed next to the resident's strong arm to ensure timely assistance. The facility's policy indicated that call lights should be within easy reach and answered promptly, which was not adhered to in these cases.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information regarding Advance Directives (AD) for two residents, which is a violation of their own Policy and Procedure (P&P) titled Advance Directives. Resident 11 was admitted with diagnoses including dependence on supplemental oxygen and gastrostomy status, and was noted to have severely impaired cognition for daily decision making. During a review of Resident 11's medical records, it was found that there was no Advance Directive Acknowledgement Form in the chart, which the Social Services Director (SSD) acknowledged should have been initiated upon admission. Similarly, Resident 25, who was admitted with essential hypertension and gastrostomy status, also had severely impaired cognition and required total dependence for daily activities. A review of Resident 25's chart revealed the absence of an Advance Directive Acknowledgement Form, which the SSD confirmed was necessary. The Director of Nursing (DON) also stated that the form needed to be in the resident's chart to identify the resident's preferences. The facility's P&P requires that residents be provided with information about their rights to accept or refuse treatment and to formulate an advance directive upon admission, which was not adhered to in these cases.
Inaccurate MDS Coding for Resident Discharges and Diagnoses
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to incorrect reporting to the Centers for Medicare and Medicaid Services (CMS). Resident 16 was discharged to a Skilled Nursing Facility (SNF) but was incorrectly coded in the Minimum Data Set (MDS) as being discharged to home or community. Additionally, Resident 16's MDS inaccurately indicated an active diagnosis of Post-Traumatic Stress Disorder (PTSD), despite the resident and the facility's Minimum Data Set Nurse (MDSN) confirming there was no such diagnosis. This error was attributed to a mistake by a previous MDSN. Similarly, Resident 55 was discharged to an SNF, but their MDS was incorrectly coded as discharged to home/community. The facility's Social Services Director and the MDSN both confirmed the error, acknowledging that the MDS should have accurately reflected the discharge to an SNF. These inaccuracies in the MDS assessments resulted in incorrect information being reported to CMS, potentially affecting the residents' care interventions.
Failure to Implement Safety Measures for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents. For Resident 7, the facility did not pad the bilateral 1/4 siderails as ordered by the physician, despite the resident's severe cognitive impairment and seizure disorder. Observations confirmed that the siderails were not padded, and interviews with the LVN and DON corroborated the need for padding to prevent harm during seizure activity. The facility's policy on bed safety emphasized the importance of additional safety measures for residents at higher risk of injury, which was not adhered to in this case. For Resident 53, the facility did not position the floor mat close enough to the bed, nor was the bed lowered to its lowest position, as required for fall risk management. Resident 53 had a high fall risk score and required substantial assistance for mobility. Observations showed the bed was in a high position, and the floor mat was two feet away from the bed's edge, which was confirmed by an LVN. The LVN acknowledged that the current setup would not prevent injury if the resident fell, as the mat was not positioned to cushion a fall effectively. The facility's policy on fall risk assessment highlighted the need to address environmental factors contributing to falls, which was not followed in this instance. These deficiencies in adhering to physician orders and facility policies for safety measures had the potential to result in accidents and hazards for the residents involved. The lack of proper implementation of safety interventions for both residents indicates a failure to provide adequate supervision and a safe environment, as required by the facility's own policies and procedures.
Failure to Provide Proper Gastrostomy Tube Care
Penalty
Summary
The facility failed to provide necessary care and services for the gastrostomy tube (GT) sites of three residents, as ordered by the physician and indicated in their care plans. Resident 1, who was admitted with a gastrostomy, hemiplegia, and hemiparesis, had a care plan that required the GT stoma to be cleansed with normal saline, patted dry, and covered with a T-drain sponge dressing daily. However, during an observation, the resident's GT stoma was found uncovered and the skin around it was red, indicating a failure to follow the physician's orders and care plan. Resident 36, who had diagnoses including dysphagia, gastrostomy, and dementia, was observed to have their GT tubing hanging with the end exposed and not capped. This was contrary to the facility's policy, which required the tubing to be capped when not in use to prevent contamination and infection. The Licensed Vocational Nurse (LVN) acknowledged that the tubing should have been capped, and the Director of Nursing (DON) confirmed the necessity of capping to prevent bacterial entry. Resident 26, with diagnoses including gastrostomy and diabetes mellitus, had a physician's order for continuous water infusion via GT at 40ml/hr for 20 hours. However, the LVN failed to start the water infusion as ordered, leaving the resident without the necessary hydration. The LVN admitted to not being aware of the order and acknowledged the importance of following it to prevent dehydration and maintain resident safety. The DON reiterated the need to adhere to physician orders to ensure adequate hydration and quality of care.
Failure to Attempt Alternatives Before Siderail Installation
Penalty
Summary
The facility failed to attempt the use of appropriate alternatives to siderails before their installation for two residents, placing them at risk for entrapment and injury. Resident 39, who was admitted with diagnoses including depression and a compression fracture, had intact cognition and required varying levels of assistance with daily activities. Despite this, there was no documented evidence that alternatives to siderails were attempted before their installation. The Registered Nurse Supervisor (RNS) acknowledged that other options, such as a trapeze, should have been considered to prevent the risk of entrapment and injury. Similarly, Resident 9, who was admitted with conditions such as metabolic encephalopathy and hemiplegia, had severely impaired cognition and was dependent on assistance for most activities. The resident had an order for bilateral 1/4 siderails for bed mobility, but the RNS confirmed that no alternatives were attempted before their installation. The resident's contracture of upper extremities rendered the siderails ineffective for turning and repositioning. The facility's Director of Nursing (DON) also stated that least restrictive alternatives should have been attempted prior to the installation of siderails, as per the facility's policy.
Improper Setup of LAL Mattress for Resident
Penalty
Summary
The facility failed to ensure that a Low Air Loss (LAL) mattress was set up accurately based on a resident's weight, which is crucial for the prevention, treatment, and management of pressure injuries. The resident, who was admitted with chronic obstructive pulmonary disease and diabetes mellitus, had a history of pressure injuries and was dependent on assistance for toileting hygiene and transfers. Despite the resident's actual weight being 162 lbs, the LAL mattress was set at 280 lbs, as observed during two separate instances. This discrepancy was confirmed by a Licensed Vocational Nurse, who acknowledged that the mattress should be set according to the resident's weight to prevent pressure injuries. The Treatment Nurse also confirmed that the LAL mattress should be adjusted per the manufacturer's recommendations to provide proper relief of pressure points. The facility's policy indicated that individuals at risk for pressure ulcers should be placed on appropriate support surfaces. However, the failure to adjust the mattress according to the resident's weight posed a potential risk for the development of pressure injuries. The Proactive Operation Manual for the LAL mattress also supported the need for weight-based adjustments to ensure effective pressure relief.
Failure to Maintain Foley Catheter Tubing
Penalty
Summary
The facility failed to provide necessary care and services for a resident with a Foley catheter, as per the facility's Policy and Procedure on catheter care. The deficiency was identified during an observation and interview with the Treatment Nurse, where it was noted that the resident's Foley catheter tubing was kinked at the connection point. This kink in the tubing could potentially lead to backflow of urine and increase the risk of urinary tract infections (UTIs). The Treatment Nurse acknowledged that the tubing should be straight and free from kinks to prevent such complications. The resident involved had a history of urinary tract infection and chronic kidney disease and was dependent on staff for personal hygiene and toileting. The facility's Director of Nursing confirmed that the catheter tubing should be clear and straight to allow urine to flow freely and prevent backup. The facility's policy, revised in September 2014, also indicated that residents should be checked frequently to ensure the catheter and tubing are free of kinks. Despite these guidelines, the facility did not adhere to its own procedures, leading to the identified deficiency.
Failure to Label and Cap IV Site
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of intravenous (IV) fluids for a resident, identified as Resident 157. The resident was admitted with osteomyelitis and a left foot amputation and had an order for Ceftriaxone IV to treat the infection. During an observation, it was noted that the IV site on the resident's right forearm was not labeled or dated, and the IV tubing port was neither capped nor covered. This oversight was confirmed during interviews with the Registered Nurse Supervisor and the Director of Nursing, who both acknowledged the importance of labeling and dating the IV site and covering the IV tubing port to prevent infection. The facility's policies and procedures, which were reviewed, indicated that the dressing on the IV site should include the date, time, and initials of the nurse who started the IV, as well as details about the catheter. Additionally, the policy stated that the IV tubing should have a sterile end cap when disconnected. The failure to follow these procedures had the potential to result in an infection for Resident 157, as the necessary precautions to maintain sterility and track the IV site usage were not implemented.
Failure to Label Nasal Cannula Tubing for Resident
Penalty
Summary
The facility staff failed to label the nasal cannula (NC) tubing for a resident, identified as Resident 41, who was dependent on supplemental oxygen. Resident 41 was readmitted to the facility with diagnoses including dependence on supplemental oxygen and dysphagia. The Minimum Data Set (MDS) indicated that Resident 41 had no speech, rarely/never understood others, and was dependent on others for personal hygiene and transfers. The Order Summary Report (OSR) specified that Resident 41 was ordered oxygen at two liters per minute via NC continuously for shortness of breath. During an observation, it was noted that Resident 41 was receiving oxygen via NC, but the tubing was not labeled with the date of application. The facility's Infection Prevention Nurse (IPN) confirmed that the NC should be labeled with the date it was applied and changed weekly for infection control purposes. Without labeling, staff would not know when the NC was applied or when it was due to be changed, potentially leading to infection.
Failure to Address Pharmacist's Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to follow up on the pharmacist's medication regimen review (MRR) recommendations for a resident prescribed Cyclobenzaprine, a muscle relaxant. The MRR identified Cyclobenzaprine as an inappropriate drug therapy for the elderly due to its anticholinergic and sedative side effects, which are poorly tolerated by the geriatric population. Despite this, there was no documentation in the resident's medical record indicating that the MRR recommendation had been addressed by the prescribing physician. The Director of Nursing (DON) acknowledged that the MRR for the resident's Cyclobenzaprine use should have been followed up by sending the recommendation to the prescribing physician for evaluation. The DON admitted that this step was missed and stated that the facility's policy requires the pharmacist's monthly MRR to be acted upon within 3 to 5 days, with follow-up calls to the physician if no response is received within 24 hours. The facility's policy emphasizes collaboration with the interdisciplinary team to minimize adverse consequences and potential risks associated with medications.
Failure to Administer Pneumococcal Vaccine per CDC Guidelines
Penalty
Summary
The facility failed to offer a pneumococcal vaccine to a resident, identified as Resident 10, in accordance with the Centers for Disease Control and Prevention (CDC)'s recommended schedule guidelines. Resident 10, who was admitted with chronic obstructive pulmonary disease (COPD) and diabetes mellitus, had previously received the PPSV23 pneumococcal vaccine in 2014 and the Prevnar13 pneumococcal vaccine in 2019. According to the CDC's guidelines, Resident 10 was eligible to receive the PCV20 pneumococcal vaccine more than five years after the last Prevnar13 dose, which was due in February 2024. The Infection Prevention Nurse (IPN) acknowledged during an interview that they had missed informing Resident 10 or their responsible party about the overdue pneumococcal vaccine. This oversight was contrary to the facility's policy and procedure, which mandates offering pneumococcal vaccines to all residents unless contraindicated, unknown, or refused, following CDC recommendations. The failure to update Resident 10's vaccination status left the resident at risk of pneumococcal disease, which could lead to pneumonia and potential hospitalization.
Failure to Include Census Information in Daily Staffing Postings
Penalty
Summary
The facility failed to include the census information on the daily shift staffing postings for three consecutive recertification days. This omission was identified during a review of the facility's daily shift staffing postings dated 11/19/2024, 11/20/2024, and 11/21/2024. The postings included the name of the facility, the date, type and category of nursing staff, and the projected and actual hours worked, but lacked the resident census at the beginning of each shift. This information is crucial to ensure that there is adequate staffing to meet the needs of the residents. Interviews with the Lobby Receptionist and the Director of Nursing confirmed that the daily shift staffing postings should include the census information. The facility's policy and procedure, revised in July 2016, also indicated that the resident census should be recorded on the Nursing Staff Directly Responsible for Residents Care form for each shift. The failure to include this information could mislead residents and visitors and potentially affect the quality of nursing care provided.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Temple City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Santa Anita Convalescent Hospital | 0.2 mi | ★★★★★ | 17 | 0 |
| Temple City Healthcare | 1.2 mi | ★★★★★ | 10 | 0 |
| Arcadia Care Center | 1.3 mi | ★★★★★ | 34 | 0 |
| Rosemead Healthcare Center | 1.6 mi | ★★★★★ | 25 | 0 |
| San Marino Healthcare Center | 1.7 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.