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
Staffing
Hours and turnover
RN hours / resident day
2.69
Registered nurse staffing
LPN hours / resident day
0.05
Licensed practical nurse staffing
Aide hours / resident day
2.50
Nurse aide staffing
Weekend hours
4.57
Weekend nurse staffing
RN turnover
27%
Annual RN turnover
Total nurse turnover
22%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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#3
Westminster Winter Park
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4-star overall rating with 2-star inspections with $81,276 in total fines with 4 recent health deficiencies
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