Cycle 1
Health 2024-06-12 · Fire 2024-06-12
10 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Baldwin City, KS
Baldwin Healthcare & Rehab Center, LLC
5-star overall rating with 4-star inspections with 10 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
1223 Orchard Lane, Baldwin City, KS
(785) 594-6492
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Recover-Care Healthcare
Operator or chain grouping
Approved since
1995-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing
LPN hours / resident day
0.52
Licensed practical nurse staffing
Aide hours / resident day
2.50
Nurse aide staffing
Weekend hours
3.35
Weekend nurse staffing
RN turnover
40%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.2
1.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.8%
8.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
4.4%
3.9 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
5.6%
2.3 pts better
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.7% |
5.0%
0.7 pts worse
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.6% |
23.2%
5.6 pts better
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 3.6% |
19.8%
16.2 pts better
|
16.7%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.7% |
18.4%
2.3 pts worse
|
16.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.7% |
18.8%
5.1 pts better
|
14.9%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
1.8%
0.5 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.1%
3.1 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
23.2%
2.6 pts worse
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
4.6%
2.1 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
75.6%
17.3 pts better
|
81.7%
11.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.6% |
11.7%
8.9 pts worse
|
12.0%
8.6 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.8% |
73.5%
24.3 pts better
|
79.7%
18.1 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.6% |
23.0%
5.4 pts better
|
23.9%
6.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-05 · Fire 2022-10-05
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2021-05-13 · Fire 2021-05-13
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-24
F · Potential for more than minimal harm
2024-06-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-09
F · Potential for more than minimal harm
2024-06-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-24
F · Potential for more than minimal harm
2024-06-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-24
F · Potential for more than minimal harm
2024-06-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-24
F · Potential for more than minimal harm
2024-06-12
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-08-02
F · Potential for more than minimal harm
2024-06-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-06-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-06-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-06-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-06-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-24
E · Potential for more than minimal harm
2024-06-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-24
F · Potential for more than minimal harm
2022-10-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-11-08
F · Potential for more than minimal harm
2022-10-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-11-08
F · Potential for more than minimal harm
2022-10-05
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-11-08
F · Potential for more than minimal harm
2022-10-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-08
F · Potential for more than minimal harm
2022-10-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-11-08
F · Potential for more than minimal harm
2022-10-05
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-11-08
F · Potential for more than minimal harm
2022-10-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-08
E · Potential for more than minimal harm
2022-10-05
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-11-08
E · Potential for more than minimal harm
2022-10-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-08
E · Potential for more than minimal harm
2022-10-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-08
F · Potential for more than minimal harm
2021-05-13
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2021-07-22
F · Potential for more than minimal harm
2021-05-13
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2021-07-22
F · Potential for more than minimal harm
2021-05-13
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2021-07-22
F · Potential for more than minimal harm
2021-05-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-07-22
F · Potential for more than minimal harm
2021-05-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-22
F · Potential for more than minimal harm
2021-05-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-07-22
F · Potential for more than minimal harm
2021-05-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-07-22
F · Potential for more than minimal harm
2021-05-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-07-22
E · Potential for more than minimal harm
2021-05-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-07-22
E · Potential for more than minimal harm
2021-05-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-07-22
E · Potential for more than minimal harm
2021-05-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-07-22
E · Potential for more than minimal harm
2021-05-13
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2021-07-22
E · Potential for more than minimal harm
2021-05-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-07-22
D · Potential for more than minimal harm
2021-05-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-07-22
D · Potential for more than minimal harm
2021-05-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-07-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-24
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-06-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-06-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-12
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-06-28
C · Minimal harm
2024-06-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-06-28
J · Immediate jeopardy
2023-03-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-09
F · Potential for more than minimal harm
2022-10-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-10-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-10-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-10-05
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-11-11
D · Potential for more than minimal harm
2022-10-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-11
D · Potential for more than minimal harm
2021-05-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-06-25
D · Potential for more than minimal harm
2021-05-13
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2021-06-25
D · Potential for more than minimal harm
2021-05-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-06-25
D · Potential for more than minimal harm
2021-05-13
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-06-25
D · Potential for more than minimal harm
2021-05-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-06-25
Penalties and ownership
What sits behind the stars
Ownership
Midwest Recover-Care LLC
5% Or Greater Direct Ownership Interest · Organization
Kansas SNF Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Mad Family Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Margulies, Zisha
5% Or Greater Indirect Ownership Interest · Individual
Margulies, Zisha
Corporate Officer · Individual
Margulies, Zisha
W-2 Managing Employee · Individual
Natr Trust
5% Or Greater Indirect Ownership Interest · Organization
Rarmna Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Ratr Trust
5% Or Greater Indirect Ownership Interest · Organization
Recover-Care Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Rnr Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Wetr Trust
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Wellsville Manor
Wellsville, KS
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Medicalodges Eudora
Eudora, KS
1-star overall rating with 1-star inspections with abuse icon flag with $14,901 in total fines with 23 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Rock Creek Of Ottawa
Ottawa, KS
2-star overall rating with 2-star inspections with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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