Metro West Nursing and Rehab Center
5900 Westgate Drive, Orlando, FL 32825 · Orange County · (407) 296-8164
120 certified beds, about 108 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1994
Certified for Medicaid Certified for Medicare
Overall
4 of 5
Health inspections
3 of 5
Staffing
3 of 5
Quality measures
5 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 105868 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on August 28, 2025, inspectors cited 6 health deficiencies (the Florida average is 7.1, the national average 9.2).
None of its 19 health citations since May 2022 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.68 hours per resident per day, against 3.82 across Florida and 3.86 nationally. Registered nurses accounted for 0.67 of those hours.
43.2% of nursing staff left within the year CMS measured (Florida average 41.4%).
CMS links it to Sovereign Healthcare Holdings, an affiliated group of 43 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
205/22
1102/24
608/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 19 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
14D
5E
0F
Potential for minimal harm
0A
0B
0C
August 28, 2025Standard inspection · 6 citations
- E Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to promote a dignified existence during dining for cognitively impaired residents in the special-focus dining area and failed to maintain dignity for one resident during transport through facility hallway, (#104), of a total sample of 43 residents.
- E Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures for medication administration were sustained.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain oxygen flow rates as ordered by the physician for 1 of 2 residents reviewed for respiratory care, of a total sample of 43 residents, (#111).
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased 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 43 residents, (#89).
- D Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine dental care services to 1 of 2 residents reviewed for dental care, (#101), of a total sample of 43 residents.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for 2 of 2 residents reviewed for discharge, (#127 and #126); and for 1 of 2 residents reviewed for hemodialysis, (# 100), of a total sample 43 residents.
February 22, 2024Standard inspection, Complaint inspection · 11 citations
- E Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interview, and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the residents or their representative for 2 of 3 residents reviewed for hospitalizations out of a total sample of 47 residents, (#28 and #52).
- E Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent medication administration error rate of 5% or greater for 4 of 4 residents sampled for medication administration, (#3, #41, #77, #204). There were 8 medication errors in 27 opportunities for a medication error rate of 27%.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, record review, and interview the facilty failed to ensure dishes and eating utensils were sanitized to prevent foodborne illness.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected use of a mobility device, (#5), use of corrective lens, (#24), and limitation in range of motion, (#66), for 3 of 32 residents reviewed for MDS accuracy, out of a total sample of 47 residents.
- D Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview, and record review, the facility failed to ensure completion and accuracy of Level I Preadmission Screening and Resident Reviews (PASARRs) on admission, and/or failed to make referrals for newly evident or possible mental disorders, to evaluate the need for specialized mental health services or alternate placement, for 3 of 3 residents reviewed for PASARRs, out of a total sample of 47 residents, (#24, #62 #34).
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary activities of daily (ADL) care related to personal hygiene and incontinence care for 1 of 4 residents reviewed for ADLs, out of a total sample of 47 residents, (#256).
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice related to physician-ordered dressing changes, for 2 of 3 residents reviewed for non-pressure skin conditions, (#59 & #256), and application of compression stockings to treat edema, for 1 of 2 residents reviewed for edema, (#6), out of a total sample of 47 residents.
- D Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services for splinting to maintain mobility and/or prevent worsening of contractures for 1 of 1 resident reviewed for limited range of motion, out of a total sample of 47 residents, (#66).
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and monitor a notable weight loss trend, and failed to provide meal portions as ordered to promote weight stability and/or weight gain for 1 of 4 residents reviewed for nutrition, out of a total sample of 47 residents, (#66).
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure transdermal medication patches were removed according to accepted professional nursing standards of practice for 1 of 2 residents observed for mood and behaviors out of a total sample of 47 residents, (#1).
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records accurately documented wound care treatments in accordance with professional standards of practice for 2 of 3 residents reviewed for non-pressure related skin conditions, out of a total sample of 47 residents, (#59 and #256).
May 12, 2022Standard inspection · 2 citations
- D Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and and record review, the facility failed to complete, encode and transmit a required Minimum Data Set (MDS) Discharge assessment for 1 of 5 residents reviewed for hospitalization, of a total sample of 42 residents (#28).
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review, the facility failed to provide a care plan meeting invitation, and failed to ensure participation of the resident and all required members of the interdisciplinary team (IDT) in the care plan meeting for 1 of 1 resident reviewed for care plans, out of the total sample of 42 residents (#94).
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Florida | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.68 | 3.82 | 3.86 |
| Registered nurses | 0.67 | 0.73 | 0.69 |
| All nursing staff on weekends | 3.32 | 3.49 | 3.42 |
| Nurse aides | 2.25 | ||
| Licensed practical nurses | 0.76 | ||
| Nursing staff turnover (share who left in a year) | 43.2% | 41.4% | 45.8% |
| Registered nurse turnover | 52.0% | 46.0% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.85 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.83 on weekdays and 3.32 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.3% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.67 in April to June 2025 to 3.68 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.68 | 0.67 | 3.83 | 3.32 | 0.3% | 0 of 90 | 108 |
| Oct to Dec 2025 | 3.73 | 0.72 | 3.88 | 3.35 | 0.0% | 0 of 92 | 107 |
| Jul to Sep 2025 | 3.73 | 0.67 | 3.84 | 3.43 | 2.0% | 0 of 92 | 113 |
| Apr to Jun 2025 | 3.67 | 0.66 | 3.80 | 3.34 | 2.5% | 0 of 91 | 112 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Florida, Jan to Mar 2026 | 3.76 | 0.70 | 3.90 | 3.44 | 1.1% | 0.2% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Florida | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 3.3 | 8.7 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.3 | 0.7 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.4 | 2.5 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.6 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 7.7 | 9.5 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.6 | 4.5 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 7.0 | 8.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 33.8 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 7.1 | 9.1 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.0 | 2.1 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.5 | 1.1 | 1.8 |
Owners and operators
Legal business name: SOVEREIGN HEALTHCARE OF METRO WEST LLC. CMS links this home to Sovereign Healthcare Holdings, a group of 43 nursing homes averaging 3.7 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Sovereign Healthcare Holdings LLC | Direct ownership interest | Organization | 05/19/2009 | |
| Mangine, John | Direct ownership interest | Individual | 12/31/2015 | |
| Berkadia Commercial Mortgage LLC | 5% or greater security interest | Organization | 09/15/2014 | |
| Fl Metro West Holdings LLC | 5% or greater security interest | Organization | 05/19/2009 | |
| Health Services Properties LLC | 5% or greater security interest | Organization | 05/19/2009 | |
| Bell, Charles | Managing control - governing body | Individual | 09/15/2016 | |
| Chery, Dawn | Managing control - governing body | Individual | 06/08/2017 | |
| Kaar, Susan | Managing control - governing body | Individual | 10/01/2003 | |
| Southern Healthcare Management LLC | Operational/managerial control | Organization | 05/19/2009 | |
| Britton, Mark | Operational/managerial control | Individual | 10/19/2023 | |
| Cronquist, Royce | Operational/managerial control | Individual | 02/01/2018 | |
| Mangine, John | Operational/managerial control | Individual | 01/01/2025 | |
| Melton, Donald | Operational/managerial control | Individual | 02/15/2009 | |
| Notermann, William | Operational/managerial control | Individual | 01/01/2025 | |
| Stoutjesdijk, Wendy | Operational/managerial control | Individual | 05/20/2025 | |
| Notermann, Brenda | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 08/28/2025 | |
| Fl Metro West Holdings LLC | Adp of the SNF | Organization | 05/19/2009 | |
| Forvis Mazars LLP | Adp of the SNF | Organization | 01/01/2025 | |
| Health Services Properties LLC | Adp of the SNF | Organization | 05/19/2009 | |
| Southern Healthcare Management LLC | Adp of the SNF | Organization | 10/03/2025 | |
| Sovereign Healthcare Disbursements LLC | Adp of the SNF | Organization | 05/19/2009 | |
| Bell, Charles | Adp of the SNF | Individual | 09/15/2016 | |
| Britton, Mark | Adp of the SNF | Individual | 10/19/2023 | |
| Chery, Dawn | Adp of the SNF | Individual | 06/08/2017 | |
| Cronquist, Royce | Adp of the SNF | Individual | 02/01/2018 | |
| Kaar, Susan | Adp of the SNF | Individual | 10/01/2003 | |
| Kelly, Michelle | Adp of the SNF | Individual | 02/01/2018 | |
| Mangine, John | Adp of the SNF | Individual | 12/31/2015 | |
| Melton, Donald | Adp of the SNF | Individual | 02/15/2009 | |
| Notermann, William | Adp of the SNF | Individual | 01/01/2025 | |
| Stoutjesdijk, Wendy | Adp of the SNF | Individual | 05/20/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 6 problems in this area, most recently on August 28, 2025: "Provide safe and appropriate respiratory care for a resident when needed."
- When is the care plan meeting, and can family attend it?Inspectors cited 6 problems in this area, most recently on August 28, 2025: "Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 3 problems in this area, most recently on August 28, 2025: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 2 problems in this area, most recently on August 28, 2025: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.32 hours per resident per day, below the Florida average of 3.49.
- How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.
Other nursing homes nearby
- Solaris Healthcare Windermere Orlando, 2.6 mi · 5 of 5 stars · 4 citations
- Guardian Care Nursing & Rehabilitation Center Orlando, 3 mi · 2 of 5 stars · 18 citations
- Courtyards of Orlando Care Center and Rehab Orlando, 3.2 mi · 2 of 5 stars · 22 citations
- Orlando Health Center for Rehabilitation Ocoee, 3.8 mi · 4 of 5 stars · 9 citations
- Lake Bennet Center for Rehabilitation & Healing Ocoee, 4.4 mi · 3 of 5 stars · 16 citations
- Orlando Health and Rehabilitation Center Orlando, 4.6 mi · 1 of 5 stars · 66 citations
- Vivo Healthcare West Orange Ocoee, 4.9 mi · 2 of 5 stars · 17 citations
- South Orange Health and Rehabilitation Center Orlando, 5.1 mi · 5 of 5 stars · 15 citations
Florida contacts for a concern about a nursing home
These are the official offices in Florida. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Florida Agency for Health Care Administration, Long Term Care Services Unit, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Florida Long-Term Care Ombudsman Program, 1-888-831-0404. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: FloridaHealthFinder, where Florida publishes its own records on licensed homes.
Common questions
- What is Metro West Nursing and Rehab Center's Medicare star rating?
- CMS rates Metro West Nursing and Rehab Center 4 out of 5 stars overall, with 3 for health inspections, 3 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Metro West Nursing and Rehab Center get at its last inspection?
- 6 health deficiencies at the standard inspection on August 28, 2025. The Florida average is 7.1.
- Has Metro West Nursing and Rehab Center been fined?
- CMS lists no fines in the last three years.
- Does Metro West Nursing and Rehab Center accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Metro West Nursing and Rehab Center?
- CMS lists 31 owners and managers, and links the home to Sovereign Healthcare Holdings. Legal business name: SOVEREIGN HEALTHCARE OF METRO WEST LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.