SNF
WESTMINSTER BALDWIN PARK
CCN: 106118 · ORLANDO, FL 32814 · Orange County
CCRC
Overview
- Address
- 2653 LAKE BALDWIN LANE, ORLANDO, FL 32814
- Phone
- 4076214100
- Certified beds
- 40
- Avg daily residents
- 18 (46% of beds filled)
- Ownership
- Non-profit (church-affiliated)
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 2018-02-16
- Setting
- Urban
5 /5
★★★★★
CMS Overall Rating
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 5.24 | 4.79 | 4.22 | ≥ 3.48 | |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 2.69 | 0.84 | 2.17 | ≥ 0.55 | |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 0.05 | 1.06 | 0.04 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 2.50 | 2.89 | 2.01 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 2.74 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.10 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Total nurse (weekend)
4.57
hrs / resident / day
RN (weekend)
2.06
hrs / resident / day
Total nurse (adjusted, weekend)
3.69
hrs / resident / day
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Total nursing staff turnover
21.7%
annual
RN turnover
27.3%
annual
Administrators departed
0
last 12 months
Resident acuity
Nursing Case-Mix Index
1.70
higher acuity than avg
Case-Mix Index Ratio
1.23
facility / state ratio
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2024-12-11 | 1 | 1 | 0 | 4 | 1 | 4 |
| Cycle 2/3 (prior) | 2023-07-20 | 4 | 4 | 0 | 20 | 1 | 20 |
Total weighted health score
8.0
lower is better
Deficiencies (15)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
15 D/E/F Actual harm — potential for minor
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0880 | Provide and implement an infection prevention and control program. | D | 2024-12-11 | 2025-01-02 |
| 0635 | Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | D | 2023-07-20 | 2023-08-24 |
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | 2023-07-20 | 2023-08-24 |
| 0865 | Have a plan that describes the process for conducting QAPI and QAA activities. | E | 2023-07-20 | 2023-08-24 |
| 0880 | Provide and implement an infection prevention and control program. | D | 2023-07-20 | 2023-08-24 |
| 0578 | 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. | E | 2022-01-20 | 2022-02-20 |
| 0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | 2022-01-20 | 2022-02-20 |
| 0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | E | 2022-01-20 | 2022-02-20 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2022-01-20 | 2022-02-20 |
| 0661 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | D | 2022-01-20 | 2022-02-20 |
| 0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | 2022-01-20 | 2022-02-20 |
| 0693 | 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. | D | 2022-01-20 | 2022-02-20 |
| 0695 | Provide safe and appropriate respiratory care for a resident when needed. | D | 2022-01-20 | 2022-02-20 |
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | 2022-01-20 | 2022-02-20 |
| 0758 | 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. | D | 2022-01-20 | 2022-02-20 |
Financial Health (FY 2024)
Payer mix (share of resident days)
Medicare 77.6% Medicaid 4.5% Other 17.9%
Operating performance
Total Margin
-12.5%
Occupancy Rate
55.4%
Cost per Resident Day
$230
Revenue & costs
Net Patient Revenue
$4.7M
Total Costs
$1.9M
Net Income
-$1.1M
Balance sheet
Total Assets
$77.9M
Total Liabilities
$38.1M
Fund Balance
$39.7M
Current Ratio
0.04
Source: CMS SNF Cost Report (FY 2024). Cost report data lags by ~2 years.
Ownership & Corporate Structure
Owner / manager organizations (1)
| Organization | Role | Association |
|---|---|---|
| PRESBYTERIAN RETIREMENT COMMUNITIES, INC. | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 10/29/2014 |
Owner / manager individuals (20)
| Name | Role | Association |
|---|---|---|
| HENNIS, GARRY | OPERATIONAL/MANAGERIAL CONTROL | since 09/21/2011 |
| KEITH, HENRY | OPERATIONAL/MANAGERIAL CONTROL | since 09/23/1992 |
| LEHMAN, GARY | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2017 |
| YELKEN, JUSTIN | OPERATIONAL/MANAGERIAL CONTROL | since 04/10/2023 |
| DEBEVOISE, JOHN | CORPORATE DIRECTOR | since 01/01/2025 |
| DODDRIDGE, DONALD | CORPORATE DIRECTOR | since 01/01/2025 |
| DYE, STEPHEN | CORPORATE DIRECTOR | since 01/01/1997 |
| EARLY, MARY ELLEN | CORPORATE DIRECTOR | since 01/01/2025 |
| HILLENMEYER, JOHN | CORPORATE DIRECTOR | since 01/01/2024 |
| HULL, WILLIAM | CORPORATE DIRECTOR | since 01/01/2025 |
| KEITH, HENRY | CORPORATE DIRECTOR | since 09/23/1992 |
| KUTAC, KRISTIN | CORPORATE DIRECTOR | since 01/01/2025 |
| MADDUX, CARLEN | CORPORATE DIRECTOR | since 01/01/2025 |
| MOCK, JEFFREY | CORPORATE DIRECTOR | since 01/01/2025 |
| RAMSEY, JOHN | CORPORATE DIRECTOR | since 01/01/2025 |
| SHELLEY, LINDA | CORPORATE DIRECTOR | since 01/01/2025 |
| DODDRIDGE, DONALD | CORPORATE OFFICER | since 01/01/2025 |
| HENNIS, GARRY | CORPORATE OFFICER | since 09/21/2011 |
| HILLENMEYER, JOHN | CORPORATE OFFICER | since 01/01/2024 |
| KEITH, HENRY | CORPORATE OFFICER | since 09/23/1992 |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- Yes
- Hospital-based
- No
- Resident / family council
- None
- Sprinkler systems
- Yes
- Abuse citation flag
- No
Methodology & sources
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows. - Skilled Nursing Facility Cost Report (
snf-cost-report), vintage 2024, downloaded 2026-04-14 , 14,120 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 112 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Cost Report | Cost per Resident Day ($) | $230 | metrics.cost_per_resident_day |
| Cost Report | Current Ratio | 0.04 | metrics.current_ratio |
| Cost Report | fiscal_year | 2,024 | fiscal_year |
| Cost Report | Medicaid Day Share (%) | 4.5% | metrics.medicaid_day_share |
| Cost Report | Medicare Day Share (%) | 77.6% | metrics.medicare_day_share |
| Cost Report | Net Income ($) | $-1,057,749 | metrics.net_income |
| Cost Report | Net Patient Revenue ($) | $4,675,557 | metrics.net_patient_revenue |
| Cost Report | Occupancy Rate (%) | 55.4% | metrics.occupancy_rate |
| Cost Report | Total Assets ($) | $77,864,598 | metrics.total_assets |
| Cost Report | Total Costs ($) | $1,859,906 | metrics.total_costs |
| Cost Report | Total Fund Balances ($) | $39,739,360 | metrics.fund_balance |
| Cost Report | Total Liabilities ($) | $38,125,238 | metrics.total_liabilities |
| Cost Report | Total Margin (%) | -12.5% | metrics.total_margin |
| Provider Information | Abuse Icon | N | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 0.04240 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 2.01116 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 2.16946 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 4.22301 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 3.68635 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 18.3 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 1.06309 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.88924 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.83795 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 4.79028 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 4.22213 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | — | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | — | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | — | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | — | Chain Average Staffing Rating |
| Provider Information | Chain ID | — | Chain ID |
| Provider Information | Chain Name | — | Chain Name |
| Provider Information | City/Town | ORLANDO | City/Town |
| Provider Information | CMS Certification Number (CCN) | 106118 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | Y | Continuing Care Retirement Community |
| Provider Information | County/Parish | Orange | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 2018-02-16 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 5 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 28.5666 | Latitude |
| Provider Information | Legal Business Name | PRESBYTERIAN RETIREMENT COMMUNITIES, INC. | Legal Business Name |
| Provider Information | Location | 2653 LAKE BALDWIN LANE,ORLANDO,FL,32814 | Location |
| Provider Information | Long-Stay QM Rating | — | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | 2 | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -81.325 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | N | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 0 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 40 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | — | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | — | Number of Facilities in Chain |
| Provider Information | Number of Fines | 0 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.69698 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 1.23180 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 5 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | Non profit - Church related | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 2653 LAKE BALDWIN LANE | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | WESTMINSTER BALDWIN PARK | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 470 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 5 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 4 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 0 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 1 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 1 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2024-12-11 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 4 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 1 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 4 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2023-07-20 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 20 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 0 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 20 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 4 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 2.06000 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 27.3 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 2.74426 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 0.05260 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 2.49526 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.09740 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 2.69166 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 5.23952 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | 5 | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | — | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | Special Focus Status |
| Provider Information | Staffing Rating | 5 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | FL | State |
| Provider Information | Telephone Number | 4076214100 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 0.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 4.57368 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 0 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 21.7 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 8.000 | Total Weighted Health Survey Score |
| Provider Information | Urban | Y | Urban |
| Provider Information | With a Resident and Family Council | None | With a Resident and Family Council |
| Provider Information | ZIP Code | 32814 | ZIP Code |