Health inspection·January 22, 2026

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 interview, and record review, the facility failed to provide assessment, and notification of physician for a symptomatic resident having chest pain after cardiac surgery, for one of one resident reviewed for hospitalizations, out of a total sample of 21 residents, (#20).Findings: Residents Affected - Few Resident #20 was admitted to the facility from an acute care hospital on [DATE] following aortic heart valve repair surgery. She had diagnoses that included coronary artery disease (CAD), atrial fibrillation (A-Fib), pulmonary fibrosis, asthma, and generalized muscle weakness. Review of State Agency Form 3008 dated 10/29/25, revealed resident #20 was capable to make her own healthcare decisions and was transferred to the skilled care facility for continuation of care and rehabilitation services post aortic valve replacement. Review of resident #20's medical record revealed a care plan initiated on 10/30/25 for risk of cardiac complications related to diagnoses that included of A-Fib, CAD, arteriosclerotic heart disease, arrythmia, and post cardioversion. The goal was for the resident to have no symptoms of acute cardiac event and interventions included monitoring vitals and observation of the resident for symptoms of cardiac complications, such as chest pain, abnormal pulse, and abnormal blood pressure. The care plan did not specify what staff needed to do if the resident displayed cardiac complications. On 1/21/26 at 12:17 PM, resident #20 stated, via phone interview, that she was admitted to the facility for rehabilitation services and skilled nursing care after cardiac surgery. She said she believed the facility was not appropriate for the level of care that she required. Resident #20 recalled on the early morning of 10/30/25 she was not feeling well, and her heart rate was elevated. She said she informed the nurse and when her vitals were taken her blood pressure and heart rate were elevated. She said the nurse told her they would wait to see if the blood pressure came down on its own, but the nurse did not seem concerned. She stated she contacted her cardiologist, who recommended she go to the emergency room right away, so she called emergency services (EMS) 911 and was transferred to the hospital. She said she preferred not to return to the facility. Review of resident #20's vitals summary dated 1/22/26, revealed on 10/29/25 at 7:41 PM, her blood pressure (BP) was 123/62, heart rate (HR) 72, and oxygen saturations (O2 sats) on room air was 94%. On 10/30/25 at 10:50 AM, her BP was 150/100, HR 133, and O2 sats at 7:20 AM were 91%. Signs of a failing heart valve replacement were usually similar to those experienced prior to receiving a new valve. Some of the most common signs included: chest pain or discomfort, fainting or lightheadedness, rapid heartbeats, and shortness of breath. It was recommended for patients to call 911 immediately as these could be signs of a medical emergency, (retrieved from www.healthline.com on (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 106118 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 01/22/2026 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)