Orlando, FL

Metro West Nursing And Rehab Center

3-star overall rating with 3-star inspections with 6 recent health deficiencies

5900 Westgate Drive, Orlando, FL

(407) 296-8164

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

113

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Sovereign Healthcare Holdings

Operator or chain grouping

Approved since

1994-10-21

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

43 facilities

Chain averages 4 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.67

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.82

Licensed practical nurse staffing · state 0.79 · national 0.87

Aide hours / resident day

2.23

Nurse aide staffing · state 2.34 · national 2.35

Total nurse hours

3.73

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.49

RN + LPN hours · state 1.52 · national 1.54

Weekend hours

3.43

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.41

Weekend registered nurse coverage · state 0.53 · national 0.47

Physical therapist

0.11

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.66

CMS adjusted RN staffing hours

Adjusted total hours

3.66

CMS adjusted total nurse staffing hours

Case-mix index

1.39

Higher values indicate more complex resident acuity

RN turnover

57%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

51%

Annual nurse turnover · state 42% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,967

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

37.95

Composite VBP score used to determine payment impact.

Payment multiplier

0.9911

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.15

Baseline 23.26% · Performance 20.98% · Measure score 3.15 · Achievement 0.97 · Improvement 3.15

Healthcare-associated infections

6.49

Baseline 8.14% · Performance 5.94% · Measure score 6.49 · Achievement 6.33 · Improvement 6.49

Total nurse turnover

3.35

Baseline 55.12% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 1.19

Adjusted total nurse staffing

2.20

Baseline 3.75 hours · Performance 3.70 hours · Measure score 2.20 · Achievement 2.20 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.58%	10.72% 0.9 pts worse	No Different than the National Rate · Eligible stays 200 · Observed rate 14.5% · Lower 95% interval 8.59%
Discharge to community	52.53%	50.57% 2 pts better	No Different than the National Rate · Eligible stays 176 · Observed rate 41.48% · Lower 95% interval 43.71%
Medicare spending per beneficiary	0.89	1.02 0.1 pts better
Drug regimen review with follow-up	96.43%	95.27% 1.2 pts better	Numerator 189 · Denominator 196
Falls with major injury	0.51%	0.77% 0.3 pts better	Numerator 1 · Denominator 196
Discharge self-care score	36.51%	53.69% 17.2 pts worse	Numerator 46 · Denominator 126
Discharge mobility score	37.3%	50.94% 13.6 pts worse	Numerator 47 · Denominator 126
Pressure ulcers or injuries, new or worsened	2.04%	2.29% 0.2 pts better	Numerator 4 · Denominator 196 · Adjusted rate 1.5%
Healthcare-associated infections requiring hospitalization	5.94%	7.12% 1.2 pts better	No Different than the National Rate · Eligible stays 124 · Observed rate 4.84% · Lower 95% interval 3.99%
Staff COVID-19 vaccination coverage	100%	8.2% 91.8 pts better	Numerator 5 · Denominator 5
Staff flu vaccination coverage	20.89%	42% 21.1 pts worse	Numerator 47 · Denominator 225
Discharge function score	40.48%	56.45% 16 pts worse	Numerator 51 · Denominator 126
Transfer of health information to provider	74.42%	95.95% 21.5 pts worse	Numerator 96 · Denominator 129
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	10.71%	25.2% 14.5 pts worse	Numerator 12 · Denominator 112

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.0	2.1 0.1 pts better	1.9 0.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.8	1.2 0.4 pts better	1.8 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.2%	97.8% 0.4 pts better	93.4% 4.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	99.2% 0.8 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	1.5%	2.6% 1.1 pts better	3.3% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 1.3% · Q4 2.3% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	6.1%	3.7% 2.4 pts worse	11.4% 5.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 10.3% · Q3 4.8% · Q4 8.6% · 4Q avg 6.1%
Percentage of long-stay residents who lose too much weight	3.0%	5.9% 2.9 pts better	5.4% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 6.5% · Q3 0.0% · Q4 2.3% · 4Q avg 3.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	13.8%	15.7% 1.9 pts better	19.6% 5.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 7.9% · Q3 10.6% · Q4 9.1% · 4Q avg 13.8%
Percentage of long-stay residents who received an antipsychotic medication	9.0%	9.8% 0.8 pts better	16.7% 7.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 8.2% · Q3 10.4% · Q4 7.7% · 4Q avg 9.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	18.1%	11.7% 6.4 pts worse	16.3% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 22.0% · Q3 26.1% · 4Q avg 18.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.9%	9.8% 2.1 pts worse	14.9% 3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 5.9% · Q3 4.5% · Q4 7.5% · 4Q avg 11.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.4% 0.4 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.9%	0.8% 0.1 pts worse	1.7% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 0.0% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	15.6%	12.5% 3.1 pts worse	19.8% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 24.1% · Q3 11.8% · Q4 1.4% · 4Q avg 15.6%
Percentage of long-stay residents with pressure ulcers	6.8%	5.1% 1.7 pts worse	5.1% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.3% · Q3 5.5% · Q4 7.0% · 4Q avg 6.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	96.8%	94.3% 2.5 pts better	81.7% 15.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 91.4% · Q2 97.9% · Q3 98.4% · Q4 99.5% · 4Q avg 96.8%
Percentage of short-stay residents who had an outpatient emergency department visit	6.2%	9.3% 3.1 pts better	12.0% 5.8 pts better	Short Stay · 20240701-20250630 · Adjusted 6.2% · Observed 6.9% · Expected 12.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.9%	1.5% 1.4 pts worse	1.6% 1.3 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 4.3% · Q3 3.1% · Q4 1.4% · 4Q avg 2.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	94.7% 5.3 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	30.5%	26.2% 4.3 pts worse	23.9% 6.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 30.5% · Observed 34.3% · Expected 26.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-28 · Fire 2025-08-28

6 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-02-22 · Fire 2024-02-22

11 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-05-12 · Fire 2022-05-12

2 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-08-28

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-09-28

E · Potential for more than minimal harm 2025-08-28

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2025-09-28

D · Potential for more than minimal harm 2025-08-28

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-09-28

D · Potential for more than minimal harm 2025-08-28

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-09-28

D · Potential for more than minimal harm 2025-08-28

F790 · Quality of Life and Care Deficiencies

Health

Provide routine and 24-hour emergency dental care for each resident.

Corrected 2025-09-28

D · Potential for more than minimal harm 2025-08-28

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-09-28

E · Potential for more than minimal harm 2024-02-22

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-03-22

E · Potential for more than minimal harm 2024-02-22

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-03-22

E · Potential for more than minimal harm 2024-02-22

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-03-22