Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Baldwin Care Center during CMS and state inspections, most recent first.
Dish Machine Temperatures Below Required Sanitizing Levels: The facility did not ensure the dish machine was operating at required sanitizing temperatures. Although policy required wash temperatures of 120-140 degrees F and rinse temperatures of 140-160 degrees F, the dishwasher was observed reaching only 111 degrees F on wash and 119 degrees F on rinse, with the gauge never exceeding 119 degrees F. The DM reported the unit was a chemical sanitization dishwasher and that the booster heater had malfunctioned, and the NHA stated the company had not been aware the machine needed recalibration.
Pest control was not effective in the kitchen dry storage area. A surveyor observed sticky residue, debris, trash, and mouse droppings on and around dry storage shelves, and staff reported there were no pest control units in the kitchen or dry storage room. Maintenance later confirmed the droppings were mouse droppings and said there had been a recent mouse issue that staff thought was fixed.
Failure to provide required transfer/discharge notices and Ombudsman notification: the facility did not ensure that two residents or their representatives received notice of transfer or discharge, bed-hold policy information, or appeal rights, and did not notify the State LTC Ombudsman of an unplanned hospital transfer and an AMA discharge. The Social Worker stated she was unaware of the need to provide the required notices and Ombudsman notifications.
A resident with severe cognitive impairment had Gabapentin removed from its original unit dose packaging, placed in a labeled medication cup, and stored in a locked cupboard for about 2 hours before the scheduled dose time. An RN said this was done for convenience, and interviews showed the facility sometimes prepared meds ahead of time in labeled cups stored in locked areas instead of keeping them in the original identifiable packaging until administration.
Expired Aspirin was found in a medication storage room during observation with an RN. Four bottles of Aspirin 325 mg were expired, including unopened bottles and one opened bottle with remaining tablets. The RN said the medication had been used for a resident who was no longer in the facility and no other resident had needed Aspirin 325 mg since then. The DON stated she was not aware of the expired medications in storage.
Hand hygiene and peri-care infection control failures were observed during resident care. A CNA alternated feeding two residents with severe cognitive impairment without cleaning hands between residents, touched surfaces and another resident's wheelchair with bare hands, and resumed feeding without hand hygiene. Residents were not offered hand hygiene before meals, and during peri-care on one resident, a CNA did not change gloves or perform hand hygiene when moving from rectal care to frontal care, contrary to facility policy.
The facility failed to maintain professional standards for food service safety, affecting all residents. Staff did not change gloves or practice proper hand hygiene while handling food, leading to potential cross-contamination. Additionally, a layer of dust was observed on light fixtures above serving areas, indicating a lack of cleanliness. Despite acknowledgment from the Dietary Manager, these issues persisted.
The facility failed to establish a comprehensive Infection Control Program, leading to inadequate tracking of infectious outbreaks and non-compliance with hand hygiene and Enhanced Barrier Precautions (EBP). Staff did not adhere to proper hand hygiene during water passes, and personal protective equipment was not used during high-contact care activities. Communal equipment was not disinfected between uses, indicating systemic failures in infection prevention practices.
A resident with multiple health issues, including congestive heart failure, experienced significant weight fluctuations and a leg condition that required urgent care. The facility failed to notify the physician about these changes, as required by their policy. The DON confirmed the lack of notifications, and the NHA noted the system did not flag these changes.
A resident with multiple pressure injuries did not receive adequate care and prevention measures in a LTC facility. The resident was not repositioned as per the care plan, and necessary pressure-relieving devices were not used, leading to worsening of the injuries. Comprehensive weekly assessments were not conducted, and changes in the condition of the injuries were not communicated to the physician. Interviews with staff revealed a lack of awareness and implementation of necessary interventions.
A facility failed to maintain a medication error rate of 5% or less, resulting in a 7.14% error rate. An LPN administered insulin injections to a resident without verifying if the insulin was expired, as the pens were not labeled with the date opened or discard date. The facility's policy requires labeling to ensure proper discard timing, which was not followed.
Dish Machine Temperatures Below Required Sanitizing Levels
Penalty
Summary
Food was not stored, prepared, and served in accordance with professional standards because the facility did not ensure the dish machine was operating at the required temperatures for sanitizing dishes. The facility policy titled, Dish Machine Operation, stated wash temperature should reach between 120-140 degrees F and rinse temperature should reach between 140-160 degrees F. The Dish Machine Temperature log for November 2025 showed the machine was unable to be temperature checked on November 26 because it was being repaired, and the log was blank for November 27 and 28. During observation, the dishwasher in the kitchen was labeled with minimum wash and rinse temperatures, but when Dietary Manager G washed dishes, the wash cycle reached only 111 degrees Fahrenheit and the rinse cycle reached only 119 degrees Fahrenheit, and the temperature gauge never exceeded 119 degrees Fahrenheit. The Dietary Manager stated the dishwasher was a chemical sanitization dishwasher and reported the booster heater had malfunctioned about a week earlier. The Dietary Manager also stated the thermometer would need to be recalibrated, and later the Nursing Home Administrator reported the company had not been aware the dishwasher needed recalibration. An invoice from the repair company stated the water going in was 200 degrees and coming out was 152 degrees, but the facility gauge read 120 degrees out, so the facility was going to get a new thermometer changed out.
Pest Control Program Not Effective in Kitchen Dry Storage Area
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of rodents, with the potential to affect all 30 residents. During a kitchen tour, the surveyor observed sticky residue, debris, and trash on the floor under the dry storage shelves in the dry storage room. The Dietary Manager stated there did not appear to be pest control units in the kitchen or dry storage room, and Maintenance later reported the kitchen did not have pest control units, saying there was only a unit outside the back kitchen door that was not observed by the surveyor. When the surveyor returned to the dry storage room, the floor had been swept, but a mouse dropping was observed on a cardboard box on the first shelf close to the floor and additional mouse droppings were seen in the corner near the door. Maintenance then entered with a pest control unit in hand and, after being shown the droppings, identified them as mouse droppings. Maintenance stated there had been an issue a few weeks earlier and live traps had been set, and that staff thought the issue had been fixed.
Failure to Provide Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility did not ensure that residents or their representatives received required notice before transfer or discharge, including notice of bed-hold policy and appeal rights, and did not send a copy of the discharge notice to the Office of the State Long Term Care Ombudsman for 2 of 2 residents reviewed, R7 and R39. The facility policies titled Notice of Bedhold Policies, Notice of Transfer/Discharge, and Notification of Ombudsman stated that residents and/or their representatives are to be informed of transfer or discharge, bed-hold policies, resident rights to appeal, and that the Ombudsman is to be notified of unplanned transfers or discharges. R7 was transferred to the hospital following a fall with head injury, and the facility did not provide a copy of the bed-hold notice or transfer notice, and did not inform the State Long Term Care Ombudsman. R39 was discharged against medical advice, and the facility did not inform the State Long Term Care Ombudsman of the discharge. During interview, the Social Worker stated she was unable to provide documentation because she was unaware of the need to provide notice of transfer and Ombudsman notification for R7, or to provide Ombudsman notification for R39's discharge.
Medication removed from original packaging and stored before scheduled administration
Penalty
Summary
The facility did not follow best standards of practice when administering medication for one resident with severe cognitive impairment. The resident had a BIMS score of 3/15 and was ordered Gabapentin 100 mg to be given at 10:00 AM daily. During surveyor observation, an RN removed the Gabapentin tablet from its original identifiable unit dose packaging received from the pharmacy, placed it into a medication cup, labeled the cup with the resident’s name, medication, dose, date, time, and initials, and stored it in a locked medication cupboard outside the resident’s room for later administration. The surveyor observed that the medication had been prepared about 2 hours before the scheduled administration time. The RN stated this was done for convenience because the medication carts with computers were separate from where medications were stored for residents. Record review confirmed the MAR and physician order matched for the 10:00 AM Gabapentin dose, and the RN later documented the medication as administered at 10:00 AM. Interviews with another RN and the DON showed the facility’s practice included preparing medications ahead of time by removing them from original packaging and storing them in labeled cups in locked areas, although the DON stated medications should be administered at the scheduled time.
Expired Aspirin Found in Medication Storage Room
Penalty
Summary
Drugs and biologicals were not maintained in accordance with accepted professional principles because expired medications were left in a medication storage room. During observation with the RN, four bottles of Aspirin 325 mg were found expired in one of two medication storage rooms: two unopened bottles expired in June 2025, one opened bottle with about half of the tablets remaining expired in June 2025, and one unopened bottle expired in August 2025. The RN stated the Aspirin had been used for a resident who was in the facility during June 2025, but that resident was no longer in the facility and no other resident since then had required Aspirin 325 mg. The DON was interviewed and stated she was not aware of the expired medications in storage.
Hand hygiene and peri-care infection control failures
Penalty
Summary
The facility did not maintain infection prevention practices during feeding assistance for two residents, both of whom had severe cognitive impairment and required substantial to maximum assistance with feeding. R32 had a BIMS score of 0 and R17 had a BIMS score of 3. During dining observations, a CNA alternated spoon-feeding both residents while using bare hands and did not perform hand hygiene between residents. The CNA also touched body surfaces of both residents and did not clean hands between alternating feedings. During the same dining observations, the CNA was seen pouring water from a pitcher into a glass at the kitchenette counter, touching the counter, pitcher, water glass, and another resident's wheelchair with bare hands, then resuming feeding without hand hygiene. The CNA also wiped one resident's mouth with a napkin using bare hands, set the napkin on the table, and then assisted the other resident with feeding without cleaning hands. On another observation, the CNA assisted one resident to drink from a glass by holding the straw with bare hands and then proceeded to assist the other resident with feeding without performing hand hygiene first. The report also states that residents were served breakfast without being offered hand hygiene beforehand, and no hand hygiene product was available at the table for residents to use themselves. In a separate observation, a CNA performing peri-care on R17 removed a soiled incontinent product but did not change gloves or perform hand hygiene before moving between rectal care and frontal genital care, despite facility policy requiring glove changes and hand hygiene after removing soiled products and between cleansing the genital and anal areas. The CNA acknowledged the expectation to change gloves and perform hand hygiene when moving from contaminated to clean areas, and the DON stated the expectation was to perform frontal peri-care before posterior care and to remove gloves and perform hand hygiene in between clean and dirty areas.
Deficiencies in Food Service Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, impacting all 39 residents. Observations revealed that staff did not practice proper hand hygiene while distributing food. Utility Aide I was seen handling meal tickets, food items, and utensils with the same pair of gloves without changing them, leading to potential cross-contamination. Similarly, Dietary Aide M was observed touching meal tickets and ready-to-eat food items with the same gloves, failing to change them throughout the food service. These actions were contrary to the facility's policy on glove use, which mandates changing gloves after touching contaminated surfaces and washing hands after glove removal. Additionally, the facility did not maintain cleanliness in the food serving areas. A layer of dust was noted on light fixtures above the serving areas, visible from 15 feet away, and located over open containers of food. Despite the Dietary Manager's acknowledgment of the issue and the ongoing efforts to prevent staff from touching papers while serving food, the dust remained unaddressed. Interviews with staff confirmed that maintenance was responsible for cleaning the light fixtures, but the dust buildup indicated a lack of regular cleaning.
Inadequate Infection Control and Hygiene Practices
Penalty
Summary
The facility failed to establish a comprehensive Infection Control Program, which resulted in inadequate tracking and management of infectious outbreaks, such as Norovirus and COVID-19. The surveyor found that the facility's infection control logs were incomplete and inconsistent, lacking critical information such as the start and end dates of outbreaks, testing details, and the implementation of precautions. The Director of Nursing (DON) was unable to provide the necessary documentation and was unaware of the requirement to document such information, indicating a lack of understanding and implementation of proper infection control protocols. Additionally, the facility's staff did not adhere to proper hand hygiene practices, as observed during a water pass by a Utility Aide (UA). The UA failed to change gloves or perform hand hygiene between handling clean and used water pitchers, potentially spreading infections among residents. This non-compliance with the facility's hand hygiene policy highlights a significant gap in staff training and adherence to infection prevention measures. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with specific medical conditions, such as wounds and indwelling medical devices. Observations revealed that staff did not wear the required personal protective equipment (PPE) during high-contact care activities, such as assisting with toileting or emptying catheter bags. Furthermore, communal equipment like mechanical lifts was not disinfected between uses, increasing the risk of cross-contamination. These deficiencies demonstrate a systemic failure in the facility's infection prevention and control practices, affecting the safety and well-being of all residents.
Failure to Notify Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to consult with a physician regarding changes in the condition of a resident, identified as R3, who was admitted with multiple diagnoses including heart failure, dementia, type 2 diabetes, major depressive disorder, hypertension, and congestive heart failure. On a specific date, an LPN observed R3's right leg to be red, shiny, and with open, weeping wounds, while R3 complained of pain. Despite these observations, there was no immediate consultation with a physician. R3 and a family member decided to seek urgent care independently, where R3 was diagnosed with cellulitis and prescribed antibiotics. Additionally, the facility did not notify the physician about significant weight fluctuations in R3, which were critical given R3's congestive heart failure. The facility's policy required physician notification for a weight gain of 3 pounds in one day or 5 pounds in three days. However, there was no documentation of physician notification for R3's weight gain on two occasions. The Director of Nursing confirmed the absence of such notifications, and the Nursing Home Administrator acknowledged that the system in place did not flag these weight changes.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, identified as R4, who was at risk for pressure injuries. R4, who was admitted with multiple pressure injuries and had a history of paraplegia, was not repositioned as per the care plan, and the necessary pressure-relieving devices were not utilized. Observations revealed that R4's feet were not elevated, and the ankles were in direct contact with the bed, increasing the risk of pressure injuries. Despite the care plan's instructions to reposition R4 every two hours and elevate the heels, these measures were not consistently implemented. The facility also failed to conduct comprehensive weekly assessments of R4's pressure injuries, as required by their policy and professional standards. The surveyor noted that from March to July, there were no comprehensive assessments documented, and changes in the condition of R4's pressure injuries were not communicated to the physician. This lack of documentation and communication led to a deterioration in R4's condition, with some pressure injuries increasing in size and severity without appropriate medical intervention. Interviews with facility staff, including the LPN and DON, revealed a lack of awareness and implementation of necessary interventions to prevent further deterioration of R4's pressure injuries. The staff admitted to not using devices like Podus boots to relieve pressure on R4's ankles and acknowledged that the air mattress was not provided in a timely manner. The facility's failure to adhere to its own policies and professional guidelines contributed to the inadequate care provided to R4, resulting in worsening pressure injuries.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by a 7.14% error rate observed during a medication administration task. Specifically, two errors were noted out of 28 medication opportunities. The errors involved the administration of insulin injections without verifying whether the insulin was expired. This affected one resident who was observed for medication administration. The facility's policy on insulin administration requires staff to check the date the medication was first opened and the expiration date, which was not adhered to in this instance. During the observation, an LPN administered two insulin injections to a resident using insulin pens that were not labeled with the date opened or discard date. The LPN acknowledged that the pens should have been labeled to ensure proper discard timing. Despite this, the LPN proceeded to administer the insulin without verifying the pens' opened or discard dates. The Director of Nursing confirmed that the facility's policy mandates labeling insulin pens with the date opened to track when they should be discarded, and acknowledged that the LPN should have discarded the pens if the dates were unknown.
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Illustrative
What surveyors actually found near you
We read the 102 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baldwin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hammond Health Services | 3.5 mi | ★★★★★ | 3 | 0 |
| Park View Home | 3.9 mi | ★★★★★ | 3 | 0 |
| Spring Valley Health And Rehab Center | 9.8 mi | ★★★★★ | 13 | 0 |
| Glenhaven | 12.2 mi | ★★★★★ | 18 | 0 |
| Kinnic Health And Rehabilitation Center | 13.2 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.