Cycle 1
Health 2025-06-05 · Fire 2025-06-05
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Clearwater, FL
Westchester Gardens Health & Rehabilitation
4-star overall rating with 3-star inspections with 9 recent health deficiencies
3301 N Mcmullen Booth Rd, Clearwater, FL
(727) 785-8335
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
111
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Goodman Group
Operator or chain grouping
Approved since
1989-09-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
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
0.81
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.92
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
3.98
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,734
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.59% · Performance 25.01% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.37% · Performance 9.14% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.30
Baseline 45.63% · Performance 54.26% · Measure score 2.30 · Achievement 2.30 · Improvement 0
Adjusted total nurse staffing
2.01
Baseline 4.05 hours · Performance 3.65 hours · Measure score 2.01 · Achievement 2.01 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.47% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 463 · Observed rate 10.37% · Lower 95% interval 9% |
| Discharge to community | 59.67% |
50.57%
9.1 pts better
|
Better than the National Rate · Eligible stays 481 · Observed rate 56.76% · Lower 95% interval 55.12% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 89.18% |
95.27%
6.1 pts worse
|
Numerator 371 · Denominator 416 |
| Falls with major injury | 0.72% |
0.77%
0.1 pts better
|
Numerator 3 · Denominator 416 |
| Discharge self-care score | 68.24% |
53.69%
14.5 pts better
|
Numerator 217 · Denominator 318 |
| Discharge mobility score | 54.4% |
50.94%
3.5 pts better
|
Numerator 173 · Denominator 318 |
| Pressure ulcers or injuries, new or worsened | 0.96% |
2.29%
1.3 pts better
|
Numerator 4 · Denominator 416 · Adjusted rate 1.02% |
| Healthcare-associated infections requiring hospitalization | 9.14% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 296 · Observed rate 8.45% · Lower 95% interval 6.48% |
| Staff COVID-19 vaccination coverage | 67.1% |
8.2%
58.9 pts better
|
Numerator 104 · Denominator 155 |
| Staff flu vaccination coverage | 84.97% |
42%
43 pts better
|
Numerator 147 · Denominator 173 |
| Discharge function score | 60.38% |
56.45%
3.9 pts better
|
Numerator 192 · Denominator 318 |
| Transfer of health information to provider | 98.9% |
95.95%
3 pts better
|
Numerator 90 · Denominator 91 |
| Transfer of health information to patient | 99.64% |
96.28%
3.4 pts better
|
Numerator 277 · Denominator 278 |
| Resident COVID-19 vaccinations up to date | 15.38% |
25.2%
9.8 pts worse
|
Numerator 34 · Denominator 221 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.2
1 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.1 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
97.8%
1.8 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| 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 | 0.4% |
2.6%
2.2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 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 who lose too much weight | 5.1% |
5.9%
0.8 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 9.3% · Q3 8.2% · Q4 0.0% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.4% |
15.7%
2.3 pts better
|
19.6%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 16.4% · Q3 8.0% · Q4 11.4% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.8% |
9.8%
6 pts better
|
16.7%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.9% · Q3 3.9% · Q4 2.1% · 4Q avg 3.8% · 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 | 12.1% |
11.7%
0.4 pts worse
|
16.3%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 18.4% · Q3 21.1% · Q4 0.0% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.5% |
9.8%
3.3 pts better
|
14.9%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 9.8% · Q3 8.7% · Q4 4.8% · 4Q avg 6.5% · 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 | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.1% |
12.5%
4.6 pts worse
|
19.8%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 19.5% · Q3 17.4% · Q4 18.7% · 4Q avg 17.1% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
5.1%
2.4 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 6.4% · Q3 7.4% · Q4 9.5% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.3% |
9.3%
3 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 5.6% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.3% · Q2 0.5% · Q3 0.9% · Q4 0.6% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.2% |
94.7%
4.5 pts better
|
79.7%
19.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.8% |
26.2%
10.6 pts worse
|
23.9%
12.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.8% · Observed 30.4% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-06 · Fire 2023-04-06
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-06-25 · Fire 2021-06-25
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
C · Minimal harm
2023-04-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-03
E · Potential for more than minimal harm
2025-06-05
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 2025-07-05
E · Potential for more than minimal harm
2025-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
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 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-05
D · Potential for more than minimal harm
2025-06-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-07-05
D · Potential for more than minimal harm
2023-07-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-17
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-04-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-01
E · Potential for more than minimal harm
2021-06-25
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-07-25
D · Potential for more than minimal harm
2021-06-25
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 2021-07-25
D · Potential for more than minimal harm
2021-06-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-07-25
D · Potential for more than minimal harm
2021-06-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-07-25
Penalties and ownership
What sits behind the stars
Ownership
Benson, Randall
5% Or Greater Indirect Ownership Interest · Individual
John B. Goodman 2006 Irrv Grantor Tr
5% Or Greater Indirect Ownership Interest · Organization
Salmen, Thomas
5% Or Greater Indirect Ownership Interest · Individual
South Dakota Trust Company, LLC
5% Or Greater Indirect Ownership Interest · Organization
Weichert, James
5% Or Greater Indirect Ownership Interest · Individual
Wilson, Mark
5% Or Greater Indirect Ownership Interest · Individual
Grossman, Beverly
5% Or Greater Indirect Ownership Interest · Individual
Benson, Randall
General Partnership Interest · Individual
Benson, Randall
Limited Partnership Interest · Individual
Benson, Randall
Corporate Officer · Individual
Beverly N. Grossman Revocable Trust
5% Or Greater Direct Ownership Interest · Organization
Beverly N. Grossman Revocable Trust
Limited Partnership Interest · Organization
Edinger, Craig
Corporate Officer · Individual
Grossman, Beverly
Limited Partnership Interest · Individual
Jbge Westchester Inc
General Partnership Interest · Organization
John B. Goodman 2006 Irrv Grantor Tr
5% Or Greater Direct Ownership Interest · Organization
John B. Goodman 2006 Irrv Grantor Tr
General Partnership Interest · Organization
John B. Goodman 2006 Irrv Grantor Tr
Limited Partnership Interest · Organization
Knacke, Clinton
Corporate Officer · Individual
Olson, Denise
Corporate Officer · Individual
Reed, Travis
W-2 Managing Employee · Individual
Salmen, Thomas
General Partnership Interest · Individual
Salmen, Thomas
Limited Partnership Interest · Individual
South Dakota Trust Company, LLC
General Partnership Interest · Organization
South Dakota Trust Company, LLC
Limited Partnership Interest · Organization
The Goodman Group Properties LLC
5% Or Greater Direct Ownership Interest · Organization
The Goodman Group Properties LLC
Limited Partnership Interest · Organization
Weichert, James
General Partnership Interest · Individual
Weichert, James
Limited Partnership Interest · Individual
Weichert, James
Corporate Director · Individual
Werner Ventures Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Werner Ventures Limited Partnership
Limited Partnership Interest · Organization
Westchester Gardens Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Wilson, Mark
General Partnership Interest · Individual
Wilson, Mark
Limited Partnership Interest · Individual
Nearby options
Other facilities in reach
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Palm Garden Of Clearwater
Clearwater, FL
2-star overall rating with 1-star inspections with $17,345 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Aviata At Countryside
Palm Harbor, FL
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Aviata At Oldsmar
Oldsmar, FL
2-star overall rating with 1-star inspections with $36,659 in total fines with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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