Cycle 1
Health 2024-10-31 · Fire 2024-10-31
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Winter Park, FL
Westminster Winter Park
4-star overall rating with 2-star inspections with $81,276 in total fines with 4 recent health deficiencies
1111 S Lakemont Ave, Winter Park, FL
(407) 647-4083
Overall
4 / 5
CMS overall stars
Health inspections
2 / 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
80
Certified beds
Average residents
76
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Westminster Communities Of Florida
Operator or chain grouping
Approved since
1995-03-03
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
1.05
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.46
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
4.03
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.88
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
1.10
CMS adjusted RN staffing hours
Adjusted total hours
4.21
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,523
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.76
Baseline 20.16% · Performance 20.62% · Measure score 1.76 · Achievement 1.76 · Improvement 0
Healthcare-associated infections
0
Baseline 6.73% · Performance 8.51% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.22
Baseline 41.38% · Performance 38.27% · Measure score 6.22 · Achievement 6.22 · Improvement 1.38
Adjusted total nurse staffing
3.84
Baseline 4.25 hours · Performance 4.17 hours · Measure score 3.84 · Achievement 3.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.79% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 152 · Observed rate 11.18% · Lower 95% interval 7.9% |
| Discharge to community | 52.37% |
50.57%
1.8 pts better
|
No Different than the National Rate · Eligible stays 122 · Observed rate 50.82% · Lower 95% interval 44.83% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 150 · Denominator 150 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 150 |
| Discharge self-care score | 67.95% |
53.69%
14.3 pts better
|
Numerator 53 · Denominator 78 |
| Discharge mobility score | 48.72% |
50.94%
2.2 pts worse
|
Numerator 38 · Denominator 78 |
| Pressure ulcers or injuries, new or worsened | 1.33% |
2.29%
1 pts better
|
Numerator 2 · Denominator 150 · Adjusted rate 1.26% |
| Healthcare-associated infections requiring hospitalization | 8.51% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 106 · Observed rate 9.43% · Lower 95% interval 5.09% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 122 |
| Staff flu vaccination coverage | 68.94% |
42%
26.9 pts better
|
Numerator 111 · Denominator 161 |
| Discharge function score | 52.56% |
56.45%
3.9 pts worse
|
Numerator 41 · Denominator 78 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 65 · Denominator 65 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 51 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 13.95% |
25.2%
11.2 pts worse
|
Numerator 12 · Denominator 86 |
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 1.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
97.8%
1.7 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.3% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| 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 | 0.5% |
2.6%
2.1 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
3.7%
0.8 pts better
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.5% · Q3 0.0% · Q4 2.0% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
5.9%
3 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 0.0% · Q3 3.1% · Q4 0.0% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.5% |
15.7%
10.2 pts better
|
19.6%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 5.6% · Q3 0.0% · Q4 2.8% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.5% |
9.8%
4.3 pts better
|
16.7%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 4.0% · Q3 6.5% · Q4 5.1% · 4Q avg 5.5% · 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 | 8.8% |
11.7%
2.9 pts better
|
16.3%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
9.8%
3.5 pts worse
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 14.7% · Q3 3.4% · Q4 13.8% · 4Q avg 13.3% · 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 | 0.0% |
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 | 8.0% |
12.5%
4.5 pts better
|
19.8%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 15.4% · Q3 5.7% · Q4 0.0% · 4Q avg 8.0% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.1%
2.1 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.1% · Q3 3.7% · Q4 1.9% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
94.3%
4 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 98.5% · Q3 98.5% · Q4 99.3% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
9.3%
0.5 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 8.1% · Expected 10.3% · 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 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.8% |
94.7%
3.1 pts better
|
79.7%
18.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.3% |
26.2%
6.1 pts worse
|
23.9%
8.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.3% · Observed 28.9% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-30 · Fire 2023-03-30
10 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2021-05-20 · Fire 2021-05-20
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-03-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-03
D · Potential for more than minimal harm
2024-10-31
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-10-31
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-11-25
D · Potential for more than minimal harm
2024-10-31
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 2024-11-25
G · Actual harm
2024-06-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-06-03
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-06-03
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 2024-07-02
D · Potential for more than minimal harm
2024-06-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-02
J · Immediate jeopardy
2023-05-19
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-18
J · Immediate jeopardy
2023-05-19
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-06-18
F · Potential for more than minimal harm
2023-03-30
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 2023-04-30
F · Potential for more than minimal harm
2023-03-30
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-04-30
E · Potential for more than minimal harm
2023-03-30
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 2023-04-30
E · Potential for more than minimal harm
2023-03-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-30
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 2023-04-30
D · Potential for more than minimal harm
2023-03-30
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2023-04-30
E · Potential for more than minimal harm
2021-05-20
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 2021-06-18
D · Potential for more than minimal harm
2021-05-20
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 2021-06-18
D · Potential for more than minimal harm
2021-05-20
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 2021-06-18
C · Minimal harm
2021-05-20
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-06-18
Penalties and ownership
What sits behind the stars
$65,683
2024-06-03
Fine
Fine · fine $65,683
Fine
$7,796
2023-05-19
Fine
Fine · fine $7,796
Fine
$7,797
2023-05-19
Fine
Fine · fine $7,797
Fine
Ownership
Bell, William
Corporate Director · Individual
Debevoise, John
Corporate Director · Individual
Doddridge, Donald
Corporate Director · Individual
Dye, Stephen
Corporate Director · Individual
Early, Mary Ellen
Corporate Director · Individual
Faubel, Megan
Corporate Officer · Individual
Hennis, Garry
Corporate Officer · Individual
Hillenmeyer, John
Corporate Director · Individual
Hull, William
Corporate Director · Individual
Keith, Henry
Corporate Officer · Individual
Kuriakose, Joel
Operational/Managerial Control · Individual
Kutac, Kristin
Corporate Director · Individual
Lehman, Gary
Operational/Managerial Control · Individual
Maddux, Carlen
Corporate Director · Individual
Mock, Jeffrey
Corporate Director · Individual
Ramsey, John
Corporate Director · Individual
Shelley, Linda
Corporate Director · Individual
Westminster Services Inc
Operational/Managerial Control · Organization
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