Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Westminster Winter Park during CMS and state inspections, most recent first.
Two residents with respiratory and cardiac conditions did not receive oxygen therapy at the flow rates ordered by their physicians. One resident received 3.5 LPM instead of the prescribed 1 LPM, while another received 1.5 LPM instead of the ordered 2 LPM. Nursing staff confirmed they had not checked the oxygen settings as required, and leadership acknowledged the expectation to verify and administer oxygen according to physician orders.
A resident with no cognitive impairment, admitted with Parkinson's disease and osteoarthritis, expressed a preference for showers, as documented in their evaluation and CNA Kardex. Despite this, the resident did not receive showers for a month, only receiving bed baths. Staff interviews confirmed the resident's preference was communicated but not honored, and the DON acknowledged the oversight, contrary to facility policy.
A resident admitted for therapy did not receive a written summary of her Baseline Care Plan within the required 48-hour timeframe. Despite being admitted with multiple health conditions, the necessary signatures and provision of the care plan summary were delayed, contrary to the facility's policy. Staff interviews confirmed the delay and non-compliance with the policy.
A resident with intact cognition and a preference for family involvement was not included in care plan meetings, as documented in her MDS assessment. Despite the facility's policy supporting resident participation, there was no evidence of the resident or her family attending care plan meetings. Staff interviews revealed that the Social Services Director was responsible for invitations, but documentation was lacking, and the Assistant Director of Nursing could not confirm if invitations were extended.
Two residents in a LTC facility developed severe pressure injuries due to inadequate care and lack of timely interventions. One resident, with multiple health issues, suffered from worsening wounds and infections, leading to hospitalization and death. The facility failed to implement necessary preventative measures and did not communicate effectively with hospice services and family members. Another resident developed a Stage III pressure ulcer due to insufficient repositioning and care, highlighting the facility's failure to follow care plans and prevent skin breakdown.
The facility failed to provide adequate nursing staff, resulting in delayed medication administration and insufficient incontinence care for residents. Nurses were unable to complete medication passes on time due to split assignments across floors, while CNAs were unable to meet residents' needs for repositioning and incontinence care. Residents and their families reported concerns about call light response times and prolonged periods in soiled briefs, contributing to discomfort and potential health risks.
A long-term care facility failed to provide timely pharmaceutical services, affecting 25 residents. Medications scheduled for morning administration were given late, with some administered as late as noon. Nurses responsible for medication administration were overburdened with assignments across multiple floors, leading to delays. Despite the ongoing issue, nursing management was unaware and did not assist. The facility's policy required medications to be administered within a specific timeframe, which was not adhered to, resulting in a deficiency.
A resident with severe cognitive impairment developed a Stage III pressure ulcer, and the facility failed to notify the physician and family about the condition and subsequent surgical procedure. The resident's daughter, who was a joint POA, was not informed, despite the facility's policy requiring notification of such changes.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy as ordered by the physician for two residents with significant respiratory and cardiac conditions. For one resident with diagnoses including pneumonia, acute respiratory failure, COPD, and CHF, the physician's order specified oxygen at 1 liter per minute (LPM) via nasal cannula, with nurses required to check the delivery rate every shift. However, observations on two occasions revealed the resident was receiving 3.5 LPM, and both the registered nurse and assistant director of nursing confirmed the oxygen was not set according to the physician's order. The nurse admitted she had not checked the oxygen settings that day, despite being responsible for verifying the rate each time she entered the room. Another resident, with a history of cerebral infarction, hemiplegia, CHF, adult failure to thrive, and quadriplegia, had a physician's order for continuous oxygen at 2 LPM via nasal cannula. Observations showed the resident was receiving only 1.5 LPM on two separate occasions. The assigned LPN confirmed she had not checked the concentrator settings that day and verified the flow rate was below the ordered amount. The director of nursing stated that nurses were expected to check the oxygen flow rate at eye level at least every shift and ensure administration matched the physician's order. The facility's policy required oxygen to be administered as ordered by a physician, consistent with professional standards and the resident's care plan.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's right to choose their preferred bathing method, specifically showers, as indicated in their Resident Preferences Evaluation and CNA Kardex. The resident, who was admitted with diagnoses including Parkinson's disease and osteoarthritis, was assessed to have no cognitive impairment and expressed a preference for showers on specific days. Despite this, the resident did not receive any showers from the time of admission until a month later, receiving only bed baths on a few occasions. Interviews with the resident and staff revealed that the resident had communicated his preference for showers, but this was not honored. The RN acknowledged that the resident began to express dissatisfaction after two weeks without a shower, but no documentation was made. The DON confirmed the oversight and acknowledged that the resident's choices were not respected, which was contrary to the facility's policy on Activities of Daily Living that emphasizes honoring resident choices.
Failure to Provide Timely Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the Baseline Care Plan within the required 48-hour timeframe for a resident admitted for therapy. The resident, an elderly female with multiple diagnoses including sepsis and atrial fibrillation, was admitted on 10/24/24. Despite being at the facility for several days, she reported not receiving any therapy and was unaware of her care plan. The Baseline Care Plan was initiated on the day of admission, but the necessary signatures and provision of a copy to the resident were delayed until 10/28/24, which was not in compliance with the facility's policy. Interviews with facility staff, including the MDS Coordinator, ADON/UM, and DON, confirmed the delay in completing the Baseline Care Plan process. The MDS Coordinator acknowledged the lapse in adhering to the 48-hour guideline, while the ADON/UM and DON confirmed the delay in providing the written summary and obtaining the resident's signature. The facility's policy, revised in 7/2023, mandates that a Baseline Care Plan be developed within 48 hours of admission, with a written summary provided to the resident, which was not followed in this case.
Failure to Involve Resident in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and/or their representative were invited or involved in the development of their care plan. This deficiency was identified for one resident out of a sample of 29. The resident, an elderly female with intact cognition, expressed that she had not attended any care plan meetings and was unaware of the details of her care. The resident's preference for family involvement in care discussions was documented in her Minimum Data Set (MDS) assessment, yet there was no evidence of her or her family's participation in care plan meetings. Interviews with facility staff revealed that the Social Services Director was responsible for inviting residents and their families to care plan meetings through various means, including telephone calls and emails. However, documentation in the resident's physical chart did not indicate the resident or her family attended the meetings. The Assistant Director of Nursing acknowledged the lack of documentation and could not confirm if the resident or her family were invited. Despite a family member stating they attended a meeting via telephone, there was no record of this in the medical documentation. The facility's policy emphasized resident participation in care planning, but there was no explanation documented for the lack of involvement in this case.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to prevent the development and worsening of pressure injuries for two residents. Resident #7, who had multiple health conditions including diabetes and a Stage III sacral pressure ulcer, developed additional pressure injuries while in the facility. The facility did not implement necessary preventative measures such as regular turning, repositioning, and prompt incontinence care. Despite the family's requests for more aggressive treatment and diagnostic testing, the facility did not order necessary lab work or consult with specialists in a timely manner. The resident's condition deteriorated, leading to severe infections and hospitalization, where it was confirmed that the wounds were avoidable with proper care. Resident #5, who had severe cognitive impairment and was dependent on staff for most activities, developed a Stage III pressure ulcer on her coccyx during her stay. The facility's records showed a lack of timely assessment and intervention when the wound was first identified. The wound worsened significantly within a short period, indicating that the facility did not follow through with appropriate care plans and interventions to prevent further skin breakdown. Observations revealed that the resident was left in a wheelchair for extended periods without repositioning or the use of positioning devices, contributing to the development of the pressure ulcer. The facility's failure to provide adequate care and timely interventions for pressure injuries resulted in actual harm to the residents. The lack of cohesive care planning and communication among facility staff, hospice services, and family members further exacerbated the situation. The facility did not ensure that the necessary preventative measures and treatments were in place, leading to the worsening of the residents' conditions and, in the case of Resident #7, eventual death.
Staffing Deficiencies Lead to Delayed Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient licensed nurses on the 7:00 AM to 3:00 PM shift to meet medication administration needs for residents on both the 1st and 2nd floors. Observations revealed that nurses were unable to complete the administration of scheduled medications on time due to split assignments across floors. Registered Nurse (RN) E and Licensed Practical Nurse (LPN) C were responsible for administering medications to residents on both floors, which led to delays in medication administration. The Director of Nursing (DON) acknowledged the staffing was based on census and not on the acuity of residents, which contributed to the issue. The facility also failed to ensure sufficient Certified Nursing Assistants (CNAs) to meet the person-centered needs for repositioning and incontinence care for several residents. Resident #5, who was totally dependent on staff for toileting hygiene and at risk for pressure ulcers, was observed in her wheelchair for extended periods without being repositioned or provided with incontinence care. Her daughter expressed concerns about the lack of timely care, particularly on weekends, which resulted in the resident remaining in soiled briefs for extended periods. Similarly, resident #2, who required substantial assistance for bathing and toileting hygiene, reported issues with call light response and timely incontinence care. The resident stated that she was often left unchanged from the morning until bedtime, leading to discomfort and potential health risks. Resident #7's family also raised concerns about inadequate care, including delayed incontinence care and lack of repositioning, which they believed contributed to the development of pressure ulcers. The facility's grievance log confirmed these complaints, highlighting the ongoing staffing issues and their impact on resident care.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to provide timely pharmaceutical services for 25 out of 27 residents reviewed for medication administration. Observations revealed that medications scheduled for 8:00 AM and 9:00 AM were administered late, with some being given as late as 12:00 PM. Registered Nurse (RN) E and Licensed Practical Nurse (LPN) C were responsible for administering these medications, and both confirmed that the late administration was not an isolated incident but an ongoing issue. The nurses' assignments were split between multiple floors and hallways, contributing to the delay in medication administration. RN E and LPN C both acknowledged the difficulty in completing medication administration within the required timeframe of one hour before and one hour after the scheduled time. Despite being aware of the issue, the Unit Managers and Assistant Directors of Nursing did not assist with the morning medication administration task. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were not aware of the ongoing problems with medication administration until informed by the surveyors. The facility's policy and procedure for medication administration, dated July 2023, required medications to be administered within 60 minutes prior to or after the scheduled time unless otherwise ordered by the physician. However, the Medication Administration Audit Report revealed multiple instances where residents did not receive their medications within this timeframe. The facility's failure to adhere to its own policies and procedures resulted in a deficiency in providing timely pharmaceutical services to its residents.
Failure to Notify Family and Physician of Pressure Ulcer and Procedure
Penalty
Summary
The facility failed to notify the physician and resident representatives of a change in condition for a resident who developed a Stage III pressure ulcer and underwent a surgical procedure. The resident, an elderly female with severe cognitive impairment and multiple health issues, was admitted to the facility and later developed a pressure ulcer on her coccyx. Despite the facility's policy requiring notification of changes in status, there was no evidence that the physician or the resident's family were informed of the newly identified wound. The Assistant Director of Nursing (ADON) confirmed that the nurse who identified the wound did not notify the physician or family, and the ADON herself did not notify the family even after becoming aware of the wound. The resident's medical record showed that her husband, who lived out-of-state, was informed about the surgical procedure, but her daughter, who was also a joint Power of Attorney and emergency contact, was not informed. The daughter discovered the new mattress during a visit and assumed there was a skin concern but was unaware of the pressure ulcer or the surgical debridement. The ADON mentioned that residents signed a Consent to Treat form upon admission, questioning if further consent was necessary for the procedure. The facility's policy clearly stated the need for notification in such cases, which was not adhered to in this instance.
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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.
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Nursing homes near Winter Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alwyn C Cashe State Veterans Nursing Home | 0.5 mi | ★★★★★ | 6 | 2 |
| Parkview Rehabilitation Center At Winter Park | 1 mi | ★★★★★ | 0 | 0 |
| Westminster Baldwin Park | 1.1 mi | ★★★★★ | 8 | 0 |
| Avante At Orlando Inc | 1.2 mi | ★★★★★ | 3 | 0 |
| Mayflower Healthcare Center | 1.6 mi | ★★★★★ | 0 | 0 |
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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.