Inspection Reports for
Westminster Baldwin Park
2645 Lake Baldwin Lane, Orlando, FL 32814, Orlando, FL, 32814
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 11, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to infection prevention and control practices at the facility.
Findings
The facility failed to practice appropriate infection control during medication administration for 1 of 3 residents reviewed, specifically failing to perform hand hygiene after glove removal and equipment cleaning, contrary to facility policy and CDC guidelines.
Deficiencies (1)
F 0880: The facility failed to implement proper infection prevention and control during medication administration by not performing hand hygiene after glove removal and cleaning equipment, risking cross-contamination.
Report Facts
Residents reviewed for medication administration: 18
Residents with infection control issue: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) A | Observed failing to perform hand hygiene after glove removal during medication pass | |
| Director of Nursing | Stated expectation for staff to perform hand hygiene after glove removal and equipment cleaning |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
State-compiled inspection summary page showing an initial licensure inspection conducted on 2024-09-19 with no deficiencies found.
Findings
The initial licensure inspection found no deficiencies.
Report Facts
Inspections on page: 1
Inspection Report
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
Inspection details for healthcare facility including multiple survey dates and deficiencies
Findings
No deficiencies were found during the inspection on 2024-09-19.
Report Facts
Total inspections: 1
Inspection Report
Routine
Deficiencies: 4
Date: Jul 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to admission physician orders, wound care treatment, infection control practices, and the effectiveness of the facility's Quality Assurance and Performance Improvement (QAPI) activities.
Findings
The facility failed to obtain admission physician orders for glucose monitoring and sling care for some residents, did not provide wound care treatment as ordered for a resident with a skin tear, failed to demonstrate effectiveness of a wound care Performance Improvement Plan, and did not follow proper infection control practices during insulin administration.
Deficiencies (4)
F0635: The facility failed to obtain admission physician orders for glucose monitoring for resident #6 and for care of a sling for resident #15.
F0684: The facility failed to ensure wound care and treatment services were provided as ordered for resident #3 with a non-pressure skin condition.
F0865: The facility failed to demonstrate the effectiveness of a Performance Improvement Plan related to wound care for resident #3.
F0880: The facility failed to ensure proper infection control practices by not disinfecting the insulin vial septum before medication withdrawal and allowing personal items in the medication cart during medication administration for resident #6.
Report Facts
Residents reviewed: 21
Medication administration observation sample: 6
Blood sugar monitoring instances: 74
PIP start date: Jun 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in infection control deficiency related to insulin administration |
| LPN B | Licensed Practical Nurse | Acknowledged wound care dressing issues for resident #3 |
| Director of Nursing | Director of Nursing (DON) | Responsible for checking admission physician orders and acknowledged deficiencies in wound care and infection control |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Validated infection control practices regarding insulin vial disinfection |
| Therapy Director | Therapy Director | Explained therapy staff roles related to sling care for resident #15 |
| Certified Nursing Assistant D | Certified Nursing Assistant | Stated therapy staff applied and removed resident slings |
| Registered Nurse C | Registered Nurse | Confirmed no physician orders for sling care for resident #15 |
| Facility Administrator | Administrator | Discussed QAPI and Performance Improvement Plan effectiveness |
Inspection Report
Routine
Deficiencies: 10
Date: Jan 20, 2022
Visit Reason
Routine inspection of Westminster Baldwin Park nursing home to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including inaccurate documentation of advanced directives, failure to notify physician and family of change in resident condition, incomplete baseline care plan reviews, failure to follow wound care orders, inadequate discharge summaries, insufficient assistance with activities of daily living, improper administration of tube feeding fluids, failure to administer oxygen as ordered, improper medication administration outside physician parameters, and lack of justification for continued use of psychotropic medication.
Deficiencies (10)
F 0578: The facility failed to ensure the medical record accurately reflected Advanced Directives related to Do Not Resuscitate Order for 1 of 1 resident reviewed.
F 0580: The facility failed to notify the physician and resident representative of signs and symptoms of a skin infection for 1 of 1 resident reviewed.
F 0655: The facility failed to ensure baseline care plan summaries were reviewed with resident or representative for 7 of 30 newly admitted residents.
F 0656: The facility failed to follow physician orders for wound treatment as directed in the comprehensive care plan for 1 of 1 resident reviewed.
F 0661: The facility failed to provide a discharge summary including diagnoses, course of illness, therapy, and pertinent results for 1 of 1 resident reviewed.
F 0677: The facility failed to provide assistance with fingernail care for 1 of 1 resident reviewed for activities of daily living.
F 0693: The facility failed to follow Registered Dietitian's recommendations for fluid administration for 1 of 1 resident reviewed for tube feeding.
F 0695: The facility failed to ensure oxygen was administered as ordered for 1 of 1 resident reviewed for respiratory care.
F 0755: The facility failed to administer blood pressure medication according to physician ordered parameters for 1 of 5 residents reviewed for unnecessary medications.
F 0758: The facility failed to ensure physician justification for continued use of psychotropic medication (Clonazepam) on a PRN basis for 1 of 5 residents reviewed.
Report Facts
Residents reviewed: 26
Residents with baseline care plan deficiencies: 7
Days Propranolol administered outside parameters: 9
Water flush volume: 375
Water flush ordered volume: 500
Oxygen flow rate: 5
Heart rate parameter: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Nurse Supervisor | Acknowledged oxygen tubing was not in place for resident #12 and confirmed medication administration errors |
| RN B | Registered Nurse | Confirmed oxygen administration issues and medication administration outside parameters for resident #11 |
| DON | Director of Nursing | Acknowledged multiple deficiencies including medication errors, care plan issues, and lack of physician justification |
| CNA A | Certified Nursing Assistant | Responsible for ADL care but failed to provide nail care for resident #11 |
| Pharmacy Consultant | Consultant Pharmacist | Reviewed medication regimens and acknowledged lack of identification of irregularities |
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