Westminster Baldwin Park

In the surveyor’s words

From the most serious findings on record at Westminster Baldwin Park, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF865Jul 20, 2023

  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). 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. […]

• No harm, potential for more than minimal, patternF578Jan 20, 2022

  Based on interview and record review, the facility failed to ensure the medical record accurately reflected Advanced Directives related to Do Not Resuscitate Order (DNRO) over a four month period, for 1 of 1 resident reviewed for Advanced Directives of a total sample of 26 residents, (#12). Findings: Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) significant change assessment with assessment reference date of [DATE] revealed resident #12 had a Brief Interview for Mental Status score of 8 which indicated she had moderate cognitive impairment. […]

• No harm, potential for more than minimal, patternF655Jan 20, 2022

  Based on interview and record review the facility failed to ensure baseline care plan summaries were reviewed with resident or resident representative for 7 of 30 newly admitted residents out of a total sample of 26 residents, ( #127, #125, #126, #128, #2, #19, and #174). Findings: 1. Resident #127 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the medical record revealed a Clinical Admission Evaluation was signed and dated on 1/05/22 by the Assistant Director of Nursing (ADON 100 hall). A Baseline Care Plan could not be found in the electronic or paper medical record. On 1/20/22 at 3:16 PM, the Medical Records Director stated the new residents did not have a baseline care plan but they had an assessment. […]

• No harm, potential for more than minimal, patternF755Jan 20, 2022

  Based on interview and record review, the facility failed to administer blood pressure medication according to physician ordered parameters for 1 of 5 residents reviewed for unnecessary medications of a total sample of 26 residents, (#11). Findings: Resident #11 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], [CONDITION(S)] [CONDITION(S)], Congestive Heart Failure, hypertension and Peripheral Vascular Disease. Review of the Minimum Data Set admission assessment with assessment reference date of 12/27/21 revealed resident #11 had medically complex conditions. Review of the Order Summary Report for January 2022 revealed resident #11 had a physician order for [MEDICATION(S)] 10 milligrams (mg) to be given two times a day for hypertension. […]

• No harm, potential for more than minimal, isolatedF684Jan 22, 2026

  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: 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. […]