Health inspection·July 20, 2023

F 0635 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 7/19/23 at 10:44 AM, Registered Nurse (RN) C confirmed there were no physician orders for the right arm sling for resident #15. She stated it was usually therapy staff that applied and removed the residents' slings. On 7/19/23 at 12:47 PM, Certified Nursing Assistant (CNA) D stated therapy staff applied and removed the resident slings. On 7/19/23 at 1:00 PM, the Therapy Director stated if a resident was admitted from the hospital with a sling, then nursing addressed it. If therapy received a referral, or if the sling was ordered for therapy, or if we recommend it, then we will address the resident's sling. On 7/19/23 at 1:36 PM, review of resident #15's admission physician orders with the DON revealed no physician orders to instruct staff in the care of resident's right arm sling. The DON validated there was no physician order for the sling. She stated new admission orders were checked by herself and the interim DON. She stated ultimately the DON was responsible for checking admission physician orders. Review of the facility's policy for Medication Orders revised on 7/23 showed documentation of medication orders includes entering a new order on the MAR and to ensure the new order is in the electronic MAR. Review of the Facility Assessment initiated January 2023 revealed the facility's main health care service was providing care for residents that were discharged from the hospital, and provide general care for therapy management of braces and splints. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106118 If continuation sheet Page 2 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Baldwin Park 2653 Lake Baldwin Lane Orlando, FL 32814 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure wound care and treatment services were provided for 1 of 1 resident reviewed for non-pressure related skin conditions from a total sample of 21 residents, (#3). Residents Affected - Few Findings: A review of the medical record revealed resident #3 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of stage 3 pressure wound of the sacrum, skin tear wound of the right elbow, anemia, cancel, and limitation of activities due to disability. The Minimum Data Set admission assessment with Assessment Reference Date 7/04/2023 noted the resident scored 15 out of 15 on the Brief Interview For Mental Status that indicated she was cognitively intact. The assessment showed the resident did not reject care, required extensive staff assistance for activities of daily living, had 1 stage 3 pressure wound that was present on admission, skin tears, and she received anticoagulant (blood thinner) and antibiotic medication for 2 of 7 days during the look back period. On 7/17/2023 at 12:53 PM, resident #3 was observed in her room lying in bed. There was a 3 by 3-inch adhesive bandage on her right arm/elbow that noted a date of 7/13. The resident said she had asked the nursing staff to see the nurse practitioner as she was concerned the bandage had not been changed since a week ago. Review of the Physician Wound Evaluation reports dated 7/06/2023 and 7/13/2023 showed the resident was evaluated for a full thickness skin tear of the right elbow. It was noted the wound care provider recommended wound treatment and dressing changes for a total of 30 days. The Order Summary Report showed physician's orders dated 7/14/23 that read, Cleanse right elbow wound with normal saline, pat dry, apply Xeroform gauze and cover with dry dressing every day shift and every 8 hours as needed for wound care. The Comprehensive Care Plan dated 7/08/23 for altered skin integrity related to a stage 3 pressure ulcer on her sacrum and a skin tear on her right elbow with risk for further alteration with interventions for staff to, Administer treatments as ordered and monitor for effectiveness . follow facility policies/protocols for the prevention/treatment of skin breakdown. During a joint observation on 7/17/2023 at 1:24 PM, Licensed Practical Nurse (LPN) B checked the dressing located on resident #3's right arm and acknowledged it was changed and dated 7/13/2023. LPN B checked resident #3's physician's orders and stated the dressing should have been changed at least once daily. LPN B explained she noticed a slight malodor and drainage from the wound when she earlier provided wound care treatment to the resident's right arm. She said the malodor was likely due to the dressing not being changed, and it was important for nurses to provide skin treatments ordered by physicians to prevent infection and complications. On 7/18/2023 at 3:14 PM, the Director of Nursing (DON) checked resident #3's medical record and acknowledged wound care orders to the right elbow was not written by the physician until 7/14/23. She explained LPN B informed her on 7/17/2023, the resident had not received wound care treatment for her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106118 If continuation sheet Page 3 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Baldwin Park 2653 Lake Baldwin Lane Orlando, FL 32814 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 right elbow for 4 days. Level of Harm - Minimal harm or potential for actual harm On 7/19/2023 at 11:58 AM, the DON said resident #3 had a skin tear wound on her right arm when she was admitted from the hospital, and the wound doctor evaluated her on 7/06/2023 and noted treatment orders. She explained the orders should have been implemented on 7/06/2023, but they were missed by a nurse who assisted with wound care rounds. She said orders were entered 7 days later on 7/14/2023. Residents Affected - Few Review of the facility's policy titled Wound Treatment Management dated July 2023 read, 6. c. The facility will follow specific physician orders for providing wound care. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. The Facility assessment dated [DATE], pages 5 and 6 read, 'PART 2: Services and Care We Offer Based on our Residents' Needs . Skin Integrity Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106118 If continuation sheet Page 4 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Baldwin Park 2653 Lake Baldwin Lane Orlando, FL 32814 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to demonstrate the effectiveness of a Performance Improvement Plan related to wound care for 1 of 1 resident reviewed for non-pressure skin-condition out of a total sample of 21 residents, (#3). Residents Affected - Some Findings: Cross reference to F684 On 7/20/23 at 5:03 PM, the facility's Administrator stated the Quality Assessment and Assurance(QAA) committee looked at the reported trends in skin care, and had informal communication with residents, and team members. He stated the Performance Improvement Plan (PIP) is what the team could do immediately to address system changes, and which monitoring tools could be used to ensure changes are implemented. He stated every a PIP has to have a measurable tool. He explained the Director of Nursing (DON) had brought wound care to the forefront and submitted weekly reports starting about 2 months ago. He added, Wound care was discussed in May 2023 and the PIP was started in June 2023 for wound treatment plans, treatment supplies, new admission treatment orders, weekly wound documentation, and wound care consults. Review of the facility's PIP for Weekly Wound Assessments, Initiation of Treatments, Treatment Supply Implementation revealed based on a compliance audit, staff are not in compliance for following wound treatment protocol, wound care consults ., and documentation. The audit to be completed, to establish baseline education needs and ongoing opportunities include new admission treatment initiation, weekly wound documentation, and wound care consults. The action step started on 6/1/23 showed identify the number of residents with wounds in need of weekly documentation, consults, and initiation of treatments upon admission. On 7/20/22 at 5:55 PM, a request was made to review the facility's audits, in-service education covered with nursing staff, and signature pages. The DON stated there was no education yet and education would be starting on 8/01/23 for nursing staff. She provided copies of the physician weekly wound round notes dated 6/1/23 through 7/14/23. She stated this is what was used for audits. The forms revealed the resident's name, dressing in place, room number, wound location, treatment, facility acquired, or community acquired, and status of improved or resolved. Observation of the form did not show new admission treatment initiation or wound care consults performance measures by/from direct care staff. On 7/20/23 at 6:25 PM, the administrator stated every PIP in place had a measurable tool. He stated they were setting a baseline of where we are and where we want to be, from a monthly perspective, it is done on a monthly basis. The DON explained an audit was to identify the residents that needed to be seen were seen for that week. She stated that wound treatments were entered in the electronic health record when the wound rounds were done to make sure the resident had a treatment in place, and documentation was in place. The facility failed to demonstrate the effectiveness of the PIP started on 6/1/23. The facility did not provide documentation of education to staff regarding action steps initiated on 6/1/23 for consults and initiation of treatments upon admission. The facility provided no audit forms showing new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106118 If continuation sheet Page 5 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Baldwin Park 2653 Lake Baldwin Lane Orlando, FL 32814 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some admission treatment initiation, wound care consults, elements audited, evidence of accuracy, compliance, and the survey team investigation revealed non-compliance with wound care treatment not being provided as ordered for resident #3 after PIP start date of 6/1/23. Review of the facility's Quality Assurance & Performance Improvement (QAPI) Plan dated 2023 revealed guiding principle number 6 which showed the organization set goals for performance and measures progress towards those goals. Feedback, data systems and monitoring will include using performance indicators to monitor a wide range of care process and outcomes, and reviewing findings against benchmarks and /or goals the facility has established for performance. Review of the Facility assessment dated [DATE], revealed the facility provides general care for skin integrity and specific care or practices for pressure injury prevention, and care, skin care, and wound care (surgical, other skin wounds). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106118 If continuation sheet Page 6 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Baldwin Park 2653 Lake Baldwin Lane Orlando, FL 32814 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper infection control practices of items stored in the medication cart and failed to disinfect a rubber septum before piercing the medication bottle for administration of insulin for 1 of 1 resident out of a total sample of 6 residents during medication administration pass observation, (#6). Residents Affected - Few Findings: 1. Review of the medical record revealed resident #6 was admitted to the facility on [DATE], with diagnoses of osteoarthritis right hip, type 2 diabetes, prosthetic heart valve, and chronic kidney disease. On 7/17/23 at 12:18 PM, during a medication observation pass with Registered Nurse (RN) A, on the 100 unit, RN A removed Humalog injection solution bottle from the medication cart to be administered subcutaneously to resident #6. RN A then proceeded to pierce the rubber septum of the Humalog insulin bottle with the insulin syringe and withdrew 5 units of insulin from the bottle. RN A did not disinfect the rubber septum of the insulin bottle before withdrawing the 5 units of Humalog insulin. A physician order dated 6/28/23 read, Humalog insulin solution 100 units/milliliter inject 5 units subcutaneously before meals and at bedtime. RN A then proceeded to resident #6's room, and prepared to give the resident the insulin injection. She cleansed the resident's left arm with an alcohol pad, removed the cap from the insulin syringe to administer the 5 units of Humalog insulin, and was stopped by the surveyor. After exiting resident #6's room with RN A, she acknowledged she did not clean the rubber septum on the Humalog insulin bottle before withdrawing the insulin. She stated, sorry, yes, am aware the bottle is to be wiped, disinfected before withdrawing the insulin medication. 2. On 7/17/23 at 11:27 AM, 7/17/23 at 12:02 PM, 7/17/23 at 12:18 PM, and 7/17/23 at 1:14 PM, a clear water bottle and a black drinking cup was noted inside the large drawer of the medication cart on the 100 unit. RN A said, yes, my water bottle and cup inside the medication cart. She acknowledged the personal water bottle and drinking cup should not be inside the medication cart along with residents' medications. She explained she was an agency nurse and could not remember the last time she received education in the facility about infection control. On 7/11/23 at 1:07 PM, the Assistant Director of Nursing (ADON) validated insulin rubber septum should be disinfected before withdrawal of the medication. She stated, it is my understanding that it is best practice, and there should not be any drinks inside the medication cart. On 7/17/23 at 2:22 PM, Director of Nursing (DON) explained that no personal items of staff should be in the medication carts. Review of healthcare staffing education of proper injections techniques and documentation signed by RN A on 1/01/23 revealed infection control and prevention emphasize the importance of infection control measures to minimize the risk of healthcare-associated infections. This includes proper hand washing, wearing gloves, using sterile equipment, and following aseptic techniques during injection administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106118 If continuation sheet Page 7 of 8 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106118 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Westminster Baldwin Park 2653 Lake Baldwin Lane Orlando, FL 32814 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Review facility Policy Administration of Injections with a revision date of 6/21/23 showed aseptic technique is used when preparing and administrating all injections. It is a practice to prevent contamination includes disinfecting the rubber septum of a vial with alcohol before inserting any devise (i.e. needle) into the vial. This also applies when a new vial is opened. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106118 If continuation sheet Page 8 of 8