Cycle 1
Health 2024-12-11 · Fire 2024-12-11
1 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Orlando, FL
Westminster Baldwin Park
5-star overall rating with 5-star inspections with 1 recent health deficiencies
2653 Lake Baldwin Lane, Orlando, FL
(407) 621-4100
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
18
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2018-02-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
2.69
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.05
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.50
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
5.24
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
2.74
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
4.57
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
2.06
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
2.17
CMS adjusted RN staffing hours
Adjusted total hours
4.22
CMS adjusted total nurse staffing hours
Case-mix index
1.70
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,514
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9970
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.16
Baseline 25.81% · Performance 22.59% · Measure score 3.16 · Achievement 0 · Improvement 3.16
Healthcare-associated infections
5.41
Baseline 7.55% · Performance 6.22% · Measure score 5.41 · Achievement 5.41 · Improvement 4.71
Total nurse turnover
4.61
Baseline 45.10% · Performance 44.83% · Measure score 4.61 · Achievement 4.61 · Improvement 0
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.78% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 304 · Observed rate 10.86% · Lower 95% interval 8.41% |
| Discharge to community | 57.59% |
50.57%
7 pts better
|
Better than the National Rate · Eligible stays 328 · Observed rate 53.35% · Lower 95% interval 51.72% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98.19% |
95.27%
2.9 pts better
|
Numerator 163 · Denominator 166 |
| Falls with major injury | 1.2% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 166 |
| Discharge self-care score | 78% |
53.69%
24.3 pts better
|
Numerator 39 · Denominator 50 |
| Discharge mobility score | 58% |
50.94%
7.1 pts better
|
Numerator 29 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 166 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.22% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 164 · Observed rate 4.88% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 87 |
| Staff flu vaccination coverage | 86.46% |
42%
44.5 pts better
|
Numerator 83 · Denominator 96 |
| Discharge function score | 84% |
56.45%
27.5 pts better
|
Numerator 42 · Denominator 50 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 51 · Denominator 51 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 113 · Denominator 113 |
| Resident COVID-19 vaccinations up to date | 9.09% |
25.2%
16.1 pts worse
|
Numerator 8 · Denominator 88 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
94.3%
4.7 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 98.1% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
9.3%
2 pts worse
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.3% · Observed 10.9% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.4% · Q3 1.4% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
26.2%
2.7 pts better
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 23.1% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-20 · Fire 2023-07-20
4 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-01-20 · Fire 2022-01-20
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-02
E · Potential for more than minimal harm
2023-07-20
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-07-20
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-07-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-07-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-24
E · Potential for more than minimal harm
2022-01-20
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-02-20
E · Potential for more than minimal harm
2022-01-20
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 2022-02-20
E · Potential for more than minimal harm
2022-01-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-02-20
D · Potential for more than minimal harm
2022-01-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-02-20
D · Potential for more than minimal harm
2022-01-20
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 2022-02-20
D · Potential for more than minimal harm
2022-01-20
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-02-20
D · Potential for more than minimal harm
2022-01-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-02-20
D · Potential for more than minimal harm
2022-01-20
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-02-20
D · Potential for more than minimal harm
2022-01-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-02-20
D · Potential for more than minimal harm
2022-01-20
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 2022-02-20
Penalties and ownership
What sits behind the stars
Ownership
Presbyterian Retirement Communities, Inc.
5% Or Greater Direct Ownership Interest · Organization
Debevoise, John
Corporate Director · Individual
Doddridge, Donald
Corporate Director · Individual
Doddridge, Donald
Corporate Officer · Individual
Dye, Stephen
Corporate Director · Individual
Early, Mary Ellen
Corporate Director · Individual
Hennis, Garry
Operational/Managerial Control · Individual
Hennis, Garry
Corporate Officer · Individual
Hillenmeyer, John
Corporate Director · Individual
Hillenmeyer, John
Corporate Officer · Individual
Hull, William
Corporate Director · Individual
Keith, Henry
Operational/Managerial Control · Individual
Keith, Henry
Corporate Director · Individual
Keith, Henry
Corporate Officer · Individual
Kutac, Kristin
Corporate Director · Individual
Lehman, Gary
Operational/Managerial Control · Individual
Maddux, Carlen
Corporate Director · Individual
Mock, Jeffrey
Corporate Director · Individual
Ramsey, John
Corporate Director · Individual
Shelley, Linda
Corporate Director · Individual
Yelken, Justin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Alwyn C Cashe State Veterans Nursing Home
Orlando, FL
1-star overall rating with 2-star inspections with abuse icon flag with $68,731 in total fines with 11 recent health deficiencies
#2
Avante At Orlando Inc
Orlando, FL
3-star overall rating with 3-star inspections with 5 recent health deficiencies
#3
Westminster Winter Park
Winter Park, FL
4-star overall rating with 2-star inspections with $81,276 in total fines with 4 recent health deficiencies
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