Deficiency Records for Baldwin Healthcare and Rehab Center, LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Baldwin Healthcare and Rehab Center, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-14 | 2023-03-09 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-05 | 2022-11-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-05 | 2022-11-11 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-10-05 | 2022-11-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-05 | 2022-11-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-05 | 2022-11-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-24 | 2022-11-11 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-10-24 | 2022-11-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-24 | 2022-11-11 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-11-02 | 2022-11-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-11-02 | 2022-11-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-02 | 2022-11-08 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-11-02 | 2022-11-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-02 | 2022-11-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-02 | 2022-11-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-02 | 2022-11-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-11-02 | 2022-11-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-02 | 2022-11-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-02 | 2022-11-08 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-29 | 2022-09-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-29 | 2022-09-16 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-22 | 2021-07-22 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-06-22 | 2021-07-22 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-06-22 | 2021-07-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-06-22 | 2021-07-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-22 | 2021-07-22 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-06-22 | 2021-07-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-22 | 2021-07-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-22 | 2021-07-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-22 | 2021-07-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-22 | 2021-07-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-22 | 2021-07-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-22 | 2021-07-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-22 | 2021-07-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-22 | 2021-07-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-22 | 2021-07-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-13 | 2021-06-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-05-13 | 2021-06-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-13 | 2021-06-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-13 | 2021-06-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-13 | 2021-06-25 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-08-19 | 2019-09-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-08-19 | 2019-09-23 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-08-19 | 2019-09-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-08-19 | 2019-09-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-19 | 2019-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-19 | 2019-09-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-08-19 | 2019-09-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-19 | 2019-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-19 | 2019-09-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-19 | 2019-09-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-19 | 2019-09-23 | N |
