01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-04-15 | 4 | 2026-04-15 | 7 |
| Cycle 2 | 2024-06-12 | 11 | 2024-06-12 | 12 |
| Cycle 3 | 2022-10-05 | 5 | 2022-10-05 | 10 |
CMS CCN 1753382026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Baldwin Healthcare & Rehab Center, Llc
1223 Orchard Lane · Baldwin City, KS 66006 · Douglas County
Certified beds60CMS provider file
Recent citation rows49current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
49 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 12 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-15 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-15 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2026-05-08 · complaint2026-04-15 · HEALTHF0851Severity C · widespread; potential for minimal harm
Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-15 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-05-082026-04-15 · FIREK0161Severity F · widespread; potential for more than minimal harm
Construction Deficiencies
Use approved construction type or materials.
Correction field: Deficient, Provider has date of correction · 2026-06-122026-04-15 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-06-292026-04-15 · FIREK0293Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2026-06-122026-04-15 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-06-232026-04-15 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2026-06-292026-04-15 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2026-06-232026-04-15 · FIREK0920Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2026-06-122024-09-24 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-10-11 · complaint2024-06-12 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-06-28 · complaint2024-06-12 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2024-06-28 · complaint2024-06-12 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2024-06-28 · complaint2024-06-12 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-06-28 · complaint2024-06-12 · HEALTHF0689Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-06-28 · complaint2024-06-12 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2024-06-28 · complaint2024-06-12 · HEALTHF0732Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2024-06-28 · complaint2024-06-12 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2024-06-28 · complaint2024-06-12 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-06-28 · complaint2024-06-12 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-06-28 · complaint2024-06-12 · FIREK0161Severity E · pattern; potential for more than minimal harm
Construction Deficiencies
Use approved construction type or materials.
Correction field: Deficient, Provider has date of correction · 2024-07-242024-06-12 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2024-07-2403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- MIDWEST RECOVER-CARE LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/28/2025
- MRCMM LLCOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/28/2025
- BHNV 2 LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/28/2025
- KANSAS SNF HOLDINGS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/28/2025
- MAD FAMILY HOLDINGS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/28/2025
- NATR TRUSTOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/28/2025
- RARMNA HOLDINGS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/28/2025
- RATR TRUSTOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/28/2025
- RECOVER-CARE HEALTHCARE LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/28/2025
- RNR HOLDINGS LLCOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/28/2025
- WETR TRUSTOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/28/2025
- GOLDSTEIN, AVROHOMIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/28/2025
- MARGULIES, ZISHAIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 02/28/2025
- MRC SNF MANAGEMENT LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2017
- AKKULUGARI, SHYAMIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/28/2025
- BELVEAL, MEGANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/07/2022
- EDWARDS, AMANDAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/28/2025
- MARGULIES, ZISHAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/28/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.43per resident day
RN hours0.56per resident day
Weekend nurse hours3.19per resident day
Staff turnover46.7%CMS reported field
06 / LOCAL RECORDS
Open the Kansas ledger →Other published facilities nearby
No second facility in the same city met the directory rule.