Tallahassee, FL

Westminster Oaks

5-star overall rating with 5-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

4449 Meandering Way, Tallahassee, FL

(850) 878-1136

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

112

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Westminster Communities Of Florida

Operator or chain grouping

Approved since

1993-10-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

8 facilities

Chain averages 4 overall / 4 health / 5 staffing / 5 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

0.75

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.57

Licensed practical nurse staffing · state 0.79 · national 0.87

Aide hours / resident day

2.43

Nurse aide staffing · state 2.34 · national 2.35

Total nurse hours

3.75

All reported nurse hours · state 3.86 · national 3.89

Licensed hours

1.32

RN + LPN hours · state 1.52 · national 1.54

Weekend hours

3.48

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.55

Weekend registered nurse coverage · state 0.53 · national 0.47

Physical therapist

0.12

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.80

CMS adjusted RN staffing hours

Adjusted total hours

4.00

CMS adjusted total nurse staffing hours

Case-mix index

1.28

Higher values indicate more complex resident acuity

RN turnover

19%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

26%

Annual nurse turnover · state 42% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,156

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

Performance score

27.65

Composite VBP score used to determine payment impact.

Payment multiplier

0.9846

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.80

Baseline 20.56% · Performance 21.06% · Measure score 0.80 · Achievement 0.80 · Improvement 0

Healthcare-associated infections

0

Baseline 6.61% · Performance 8.36% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

7.35

Baseline 44.14% · Performance 33.65% · Measure score 7.35 · Achievement 7.35 · Improvement 4.94

Adjusted total nurse staffing

2.92

Baseline 3.91 hours · Performance 3.91 hours · Measure score 2.92 · Achievement 2.92 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.05%	10.72% 1.3 pts worse	No Different than the National Rate · Eligible stays 194 · Observed rate 10.82% · Lower 95% interval 8.86%
Discharge to community	53.05%	50.57% 2.5 pts better	No Different than the National Rate · Eligible stays 192 · Observed rate 52.08% · Lower 95% interval 46.04%
Medicare spending per beneficiary	1.34	1.02 0.3 pts worse
Drug regimen review with follow-up	97.35%	95.27% 2.1 pts better	Numerator 110 · Denominator 113
Falls with major injury	0.88%	0.77% 0.1 pts worse	Numerator 1 · Denominator 113
Discharge self-care score	64.47%	53.69% 10.8 pts better	Numerator 49 · Denominator 76
Discharge mobility score	39.47%	50.94% 11.5 pts worse	Numerator 30 · Denominator 76
Pressure ulcers or injuries, new or worsened	0.88%	2.29% 1.4 pts better	Numerator 1 · Denominator 113 · Adjusted rate 0.98%
Healthcare-associated infections requiring hospitalization	8.36%	7.12% 1.2 pts worse	No Different than the National Rate · Eligible stays 123 · Observed rate 8.13% · Lower 95% interval 5.41%
Staff COVID-19 vaccination coverage	1.38%	8.2% 6.8 pts worse	Numerator 2 · Denominator 145
Staff flu vaccination coverage	66.38%	42% 24.4 pts better	Numerator 152 · Denominator 229
Discharge function score	55.26%	56.45% 1.2 pts worse	Numerator 42 · Denominator 76
Transfer of health information to provider	74.07%	95.95% 21.9 pts worse	Numerator 20 · Denominator 27
Transfer of health information to patient	86.79%	96.28% 9.5 pts worse	Numerator 46 · Denominator 53
Resident COVID-19 vaccinations up to date	33.87%	25.2% 8.7 pts better	Numerator 21 · Denominator 62

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.8	2.1 0.7 pts worse	1.9 0.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.0 · Expected 1.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.6	1.2 0.4 pts worse	1.8 0.2 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.7%	97.8% 1.9 pts better	93.4% 6.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7%
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	3.1%	2.6% 0.5 pts worse	3.3% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 1.2% · Q3 3.8% · Q4 2.4% · 4Q avg 3.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.7%	3.7% 2 pts better	11.4% 9.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 1.4% · Q4 1.4% · 4Q avg 1.7%
Percentage of long-stay residents who lose too much weight	4.7%	5.9% 1.2 pts better	5.4% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 4.5% · Q3 0.0% · Q4 5.5% · 4Q avg 4.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	13.0%	15.7% 2.7 pts better	19.6% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 13.0% · Q3 14.3% · Q4 12.2% · 4Q avg 13.0%
Percentage of long-stay residents who received an antipsychotic medication	12.1%	9.8% 2.3 pts worse	16.7% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 8.3% · Q3 16.3% · Q4 15.7% · 4Q avg 12.1% · 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	17.7%	11.7% 6 pts worse	16.3% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 12.8% · Q3 19.8% · Q4 19.3% · 4Q avg 17.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	4.5%	9.8% 5.3 pts better	14.9% 10.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.6% · Q3 3.0% · Q4 8.8% · 4Q avg 4.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.9%	0.4% 0.5 pts worse	1.0% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 0.0% · Q4 1.1% · 4Q avg 0.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 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 new or worsened bowel or bladder incontinence	8.6%	12.5% 3.9 pts better	19.8% 11.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.4% · Q3 11.1% · Q4 13.4% · 4Q avg 8.6%
Percentage of long-stay residents with pressure ulcers	2.3%	5.1% 2.8 pts better	5.1% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.7% · Q3 2.5% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.7%	94.3% 3.4 pts better	81.7% 16 pts better	Short Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 97.7% · Q3 98.3% · Q4 97.5% · 4Q avg 97.7%
Percentage of short-stay residents who had an outpatient emergency department visit	9.6%	9.3% 0.3 pts worse	12.0% 2.4 pts better	Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 8.3% · Expected 9.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.0%	1.5% 0.5 pts better	1.6% 0.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.7% · Q3 0.9% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	94.9%	94.7% 0.2 pts better	79.7% 15.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 94.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	14.8%	26.2% 11.4 pts better	23.9% 9.1 pts better	Short Stay · 20240701-20250630 · Adjusted 14.8% · Observed 10.7% · Expected 17.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-14 · Fire 2025-08-14

2 health deficiencies

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

6 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 2 Health 2024-05-22 · Fire 2024-05-22

2 health deficiencies

Top issue: Administration (1 deficiency)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Cycle 3 Health 2023-07-27 · Fire 2023-07-27

0 health deficiencies

No concentrated health issue counts in this cycle.

4 fire-safety deficiencies

D · Potential for more than minimal harm 2025-08-14

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 2025-09-19

D · Potential for more than minimal harm 2025-08-14

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-09-19

D · Potential for more than minimal harm 2024-05-22

F851 · Administration Deficiencies

Health

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Corrected 2024-06-23

D · Potential for more than minimal harm 2024-05-22

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2024-06-23

Penalties and ownership

What sits behind the stars

Ownership

Bell, Scott

Operational/Managerial Control · Individual

0% 2 facilities 2022-08-01

Bell, William