Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Metro West Nursing And Rehab Center during CMS and state inspections, most recent first.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the actions or events that led to this finding.
The facility experienced repeat deficiencies in pharmacy services and medical record accuracy due to insufficient auditing and oversight by the QAA/QAPI committee. Despite having a QAPI plan and ongoing performance improvement projects in other areas, leadership changes and high staff turnover contributed to a lack of sustained focus on previously identified issues, resulting in continued noncompliance.
A resident with multiple chronic conditions and severely impaired cognition was administered oxygen at a flow rate of 3 LPM instead of the physician-ordered 2 LPM. An LPN, new to the unit and covering for another staff member, did not verify the physician's order before setting the oxygen concentrator. The facility's policy and care plan required adherence to the prescribed flow rate, but this was not followed.
A resident with cardiovascular conditions received blood pressure medications outside of physician-ordered parameters, including instances where blood pressure or heart rate readings were below the specified thresholds or not documented. Multiple nurses administered the medications without adhering to the required parameters, and there was no documentation in the medical record to explain these actions. The DON confirmed that staff did not follow the physician's orders regarding medication administration.
A resident with multiple medical conditions and significant dental needs did not receive routine dental care as required. Although the care plan called for dental coordination, staff delayed arranging services due to uncertainty about payment while the resident was in a Medicaid pending status. The resident remained without needed dental care, despite being cognitively intact and expressing the need for dental attention.
The facility failed to ensure accurate and complete medical records for multiple residents, including discrepancies in documentation of changes in condition, discharge events, and ongoing care. For example, one resident's hospital transfer was inaccurately recorded, with forms completed by staff not present at the event and missing vital details. Another resident with a dialysis fistula had repeated documentation errors regarding blood pressure site, and weights were not consistently entered into the record. A third resident's change in condition and related interventions were incompletely documented, with missing entries for tests, physician notifications, and treatments. Staff and leadership acknowledged these documentation failures.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Repeat Deficiencies Due to Ineffective QAPI Oversight
Penalty
Summary
The facility failed to ensure that its Quality Assessment & Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) committee conducted effective performance improvement activities to sustain prior corrective measures related to medication administration. Despite having a QAPI plan that outlined regular review and revision of quality improvement processes, the facility did not maintain sufficient auditing and oversight, resulting in repeat deficiencies for pharmacy services (F755) and accuracy of medical records (F842) during the current survey, which had also been cited in the previous recertification survey. The QAPI plan required the committee to review data monthly and prioritize high-risk or problem-prone areas, but these processes were not adequately implemented to prevent recurrence of the deficiencies. Interviews with facility leadership, including the NHA, DON, and RNC, revealed that while the facility was actively working on other performance improvement projects, such as elopement and mechanical lift use, there was a lack of sustained focus on previously identified issues with medication administration and record accuracy. Leadership changes, high staff turnover, and insufficient follow-through by the leadership team were cited as contributing factors to the failure in maintaining improvements. The QAPI process did not continue effectively through these transitions, leading to ongoing noncompliance in the cited areas.
Failure to Maintain Physician-Ordered Oxygen Flow Rate
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease, atrial fibrillation, altered mental status, and chronic kidney disease was administered oxygen at a flow rate higher than the physician's order. The resident, who had severely impaired cognition, had an active physician's order for oxygen at 2 liters per minute (LPM) via nasal cannula. However, during observation, the oxygen concentrator was set at 3 LPM. The nurse assigned to the resident, who was new to the unit and covering for another staff member, initially believed the correct flow rate was 3 LPM and did not verify the physician's order before administering the oxygen. Upon review, the nurse acknowledged the error after checking the medical record and realizing the order was for 2 LPM. The Staff Development Coordinator and Director of Nursing both confirmed that nurses are expected to verify physician orders, and the facility's policy directs staff to set the oxygen flow rate as ordered by the physician. The care plan for the resident did not indicate any behaviors that would have led to refusal or adjustment of the oxygen flow rate.
Failure to Follow Physician-Ordered Parameters for Blood Pressure Medications
Penalty
Summary
The facility failed to administer blood pressure medications according to physician-ordered parameters for a resident with multiple cardiovascular diagnoses, including heart failure and hypertension. The resident had specific orders for Amlodipine Besylate and Lisinopril, both with instructions to hold the medication if systolic blood pressure was below 110 mmHg, diastolic blood pressure was below 60 mmHg, or heart rate was less than 60 bpm. Over a 59-day period, documentation showed that four nurses administered these medications outside of the specified parameters on several occasions, and one nurse gave the medications without considering the parameters at all. The Medication Administration Record (MAR) indicated that the resident received blood pressure medications on multiple days when blood pressure or heart rate readings were below the ordered thresholds or not documented at all. Review of the resident's progress notes for the relevant period revealed no documentation explaining why the medications were administered outside of the physician's parameters. During interviews, a registered nurse acknowledged administering the medications outside of the parameters and was unable to provide documentation of rechecked blood pressure readings. The Director of Nursing also confirmed that the medications were given outside of the physician's orders and stated that staff are expected to follow such parameters.
Failure to Provide Routine Dental Care Due to Payor Source Uncertainty
Penalty
Summary
A deficiency occurred when the facility failed to provide routine dental care services to a resident who was admitted with multiple medical conditions, including bipolar disorder, major depressive disorder, dysphagia, hypotension, hypertension, and abdominal tenderness. The resident was cognitively intact and did not refuse care. Upon admission and subsequent assessments, the resident was noted to have obvious or likely cavities or broken natural teeth, and her care plan included coordination for dental care and transportation as needed. Despite these documented needs, the resident reported that arrangements for dental care had not been made, and observation confirmed she had only six remaining teeth, with multiple missing and discolored teeth. Interviews with facility staff revealed that the Social Services Director was aware of the resident's need for dental services but had not arranged care due to uncertainty about payment, as the resident was in a private pay/Medicaid pending status. The contracted dental provider's records showed the resident was listed but had not received or been scheduled for an annual assessment. The DON stated that all residents should have access to dental services regardless of payor source, and the facility was responsible for providing these services. However, the necessary dental care was not provided in a timely manner, resulting in a failure to meet the resident's dental care needs.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for multiple residents, as evidenced by discrepancies and omissions in documentation related to changes in condition, discharge events, and ongoing care. For one resident with a history of syncope, cerebral cysts, dementia, anxiety, and seizures, there were conflicting records regarding the date and circumstances of hospital discharge. The Change in Condition (CIC) form contained inaccurate dates and vital signs, and lacked documentation of the actual event that led to the resident's transfer. Interviews revealed that the nurse who completed the CIC form was not present during the incident and completed the form as a late entry based on secondhand information. The assigned nurse did not document the event, and there was confusion among staff regarding who was responsible for the documentation. The Director of Nursing (DON) and other staff acknowledged the inaccuracies and incompleteness of the medical record for this resident. Another resident, dependent on hemodialysis and with severe cognitive impairment, had physician orders specifying that blood pressure should not be taken on the arm with an arteriovenous (AV) fistula. Despite this, the medical record showed that nurses documented blood pressure readings from the restricted arm on numerous occasions over several months. Staff attributed these entries to data entry errors, but the documentation remained inaccurate. Additionally, weights for this resident were not entered into the medical record after a certain date, despite being available from other staff, resulting in incomplete records. The facility did not have a policy addressing the accuracy of medical record documentation. A third resident, admitted with fractures and atrial fibrillation, experienced a change in condition that was not accurately or completely documented in the medical record. Incident reports described symptoms such as shortness of breath, sweating, and functional decline, with staff interventions including vital sign checks, COVID-19 testing, and physician notifications. However, the electronic medical record lacked documentation of the COVID-19 test, some vital signs, physician notifications, and interventions such as supplemental oxygen administration. There were also inconsistencies between incident reports and the medical record regarding the timing and details of the resident's decline and the response by staff. The DON confirmed that there were gaps in the resident's medical record, failing to provide a full account of the change in condition and staff interventions.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 189 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orlando
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Solaris Healthcare Windermere | 2.6 mi | ★★★★★ | 0 | 0 |
| Guardian Care Nursing & Rehabilitation Center | 3 mi | ★★★★★ | 0 | 0 |
| Courtyards Of Orlando Care Center And Rehab | 3.2 mi | ★★★★★ | 5 | 0 |
| Orlando Health Center For Rehabilitation | 3.8 mi | ★★★★★ | 0 | 0 |
| Lake Bennet Center For Rehabilitation & Healing | 4.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.