Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Care Center during CMS and state inspections, most recent first.
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.
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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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 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 | — | 0 | 0 |
| Park View Home | 3.9 mi | — | 3 | 0 |
| Spring Valley Health And Rehab Center | 9.8 mi | — | 13 | 0 |
| Glenhaven | 12.2 mi | — | 16 | 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 August 2026) and official state health department websites.