Tag 0550 · Severity E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2025-09-28For-profit
Metro West Nursing and Rehab Center
5900 Westgate Drive, Orlando, FL 32825
(407) 296-8164 · Sovereign Healthcare Holdings
At a glance
CMS data snapshot: 2026-08-01 · Sources and limitations
| Ownership | For profit - Limited Liability company | Certified beds | 120 |
|---|---|---|---|
| Estimated occupancy | 90.2% | Latest inspection | 2025-08-28 |
County and Florida comparison
Navy: facility · Teal: county · Gray: Florida
Overall rating
Facility: 4 of 5
Health-inspection score
Facility: 38.0 points
Total nurse staffing
Facility: 3.68 hours/day
RN staffing
Facility: 0.67 hours/day
Staff turnover
Facility: 43.2%
Latest health deficiencies
Facility: 6 deficiencies
View data table
| Metric | Facility | County | Florida |
|---|---|---|---|
| Overall rating | 4 of 5 | 3 of 5 | 3 of 5 |
| Health-inspection score | 38.0 points | 50.9 points | 38.5 points |
| Total nurse staffing | 3.68 hours/day | 3.66 hours/day | 3.63 hours/day |
| RN staffing | 0.67 hours/day | 0.66 hours/day | 0.62 hours/day |
| Staff turnover | 43.2% | 41.7% | 41.8% |
| Latest health deficiencies | 6 deficiencies | 4.5 deficiencies | 6 deficiencies |
Comparisons describe CMS data; they are not recommendations.
Inspection history
2025-08-28
6 deficiencies
Highest severity: E
Immediate-jeopardy citations: 0
Tag 0867 · Severity E
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · Deficient, Provider has date of correction 2025-09-28Tag 0695 · Severity D
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2025-09-28Tag 0755 · Severity D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2025-09-28Tag 0790 · Severity D
Provide routine and 24-hour emergency dental care for each resident.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2025-09-28Tag 0842 · Severity D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2025-09-282024-02-22
11 deficiencies
Highest severity: E
Immediate-jeopardy citations: 0
Tag 0623 · Severity E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2024-03-22Tag 0759 · Severity E
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2024-03-22Tag 0812 · Severity E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction 2024-03-22Tag 0641 · Severity D
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2024-03-22Tag 0644 · Severity D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2024-03-22Tag 0677 · Severity D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-03-22Tag 0684 · Severity D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-03-22Tag 0688 · Severity 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.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-03-22Tag 0692 · Severity D
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2024-03-22Tag 0755 · Severity D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2024-03-22Tag 0842 · Severity D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2024-03-222022-05-12
2 deficiencies
Highest severity: D
Immediate-jeopardy citations: 0
Tag 0640 · Severity D
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2022-06-08Tag 0657 · Severity D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2022-06-08Staffing composition
2.25 hours/dayNurse aide
0.76 hours/dayLPN
0.67 hours/dayRN
- Total staffing
- 3.68 hours/day
- County median
- 3.66 hours/day
- Florida median
- 3.63 hours/day
- Weekend total
- 3.32 hours/day
- Staff turnover
- 43.2%
- RN turnover
- 52.0%
Reported averages, not a real-time staffing schedule.
Resident outcomes
Lower is generally better
Hospitalizations
2.0 per 1,000 dayssimilarFlorida: 2.1 per 1,000 days · County: 2.4 per 1,000 days20250101-20251231
Emergency-department visits
0.5 per 1,000 daysbetterFlorida: 1.0 per 1,000 days · County: 0.9 per 1,000 days20250101-20251231
Falls with major injury
2.4%worseFlorida: 2.2% · County: 2.1%2025Q2-2026Q1
Pressure ulcers
6.6%worseFlorida: 4.2% · County: 4.4%2025Q2-2026Q1
Urinary tract infections
0.3%unavailableFlorida: 0.0% · County: 0.3%2025Q2-2026Q1
Antipsychotic medication use
7.0%similarFlorida: 7.0% · County: 7.4%2025Q2-2026Q1
These group measures do not predict an individual resident’s experience.
Questions to ask
Use these prompts during a tour or phone call
What fall-prevention program is used, and how are families notified after a fall?
Suggested because of: falls major injuryHow does the care team prevent and treat pressure injuries?
Suggested because of: pressure ulcersHow will the care plan be developed, reviewed, and shared with our family?
Suggested because of: general care planning
Facility Details
- County
- Orange County
- Certified beds
- 120
- Average daily residents
- 108.2
- Ownership
- For profit - Limited Liability company
- Provider type
- Medicare and Medicaid
- In hospital
- No
- Date certified
- 1994-10-21
- CCN
- 105868
Staffing Data
| Reported measure | Value |
|---|---|
| Nurse aide hours | 2.2451 |
| Lpn hours | 0.7607 |
| Rn hours | 0.67408 |
| Reported total hours | 3.67988 |
| Weekend total hours | 3.31831 |
| Weekend rn hours | 0.37193 |
| Adjusted total hours | 3.66354 |
| Total turnover percent | 43.2 |
| Rn turnover percent | 52 |
| Administrators left | 1 |
Hours are per resident per day; turnover values are percentages. Missing values are not zero.
Penalties & Enforcement
$0.00Total fines
0Number of fines
0Payment denials
No matching penalties in the supplied CMS records.
Totals reflect the supplied CMS records, not a lifetime total.
Citations
6Health citations
0Fire safety citations
Health counts describe the latest rating cycle. Fire counts cover supplied fire-safety records.
Serious Deficiencies
FL counts scope/severity G–L as serious deficiencies. Immediate jeopardy is J–L; these are not interchangeable.
0
Ownership & Operators
| Name | Role | Share |
|---|---|---|
| SOVEREIGN HEALTHCARE HOLDINGS LLC | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE |
| MANGINE, JOHN | DIRECT OWNERSHIP INTEREST | NOT APPLICABLE |
| BERKADIA COMMERCIAL MORTGAGE LLC | 5% OR GREATER SECURITY INTEREST | NOT APPLICABLE |
| FL METRO WEST HOLDINGS LLC | 5% OR GREATER SECURITY INTEREST | NOT APPLICABLE |
| HEALTH SERVICES PROPERTIES LLC | 5% OR GREATER SECURITY INTEREST | NOT APPLICABLE |
| BELL, CHARLES | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE |
| CHERY, DAWN | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE |
| KAAR, SUSAN | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE |
| SOUTHERN HEALTHCARE MANAGEMENT LLC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| BRITTON, MARK | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| CRONQUIST, ROYCE | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| MANGINE, JOHN | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| MELTON, DONALD | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| NOTERMANN, WILLIAM | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| STOUTJESDIJK, WENDY | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| NOTERMANN, BRENDA | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | NOT APPLICABLE |
| FL METRO WEST HOLDINGS LLC | ADP OF THE SNF | NOT APPLICABLE |
| FORVIS MAZARS LLP | ADP OF THE SNF | NOT APPLICABLE |
| HEALTH SERVICES PROPERTIES LLC | ADP OF THE SNF | NOT APPLICABLE |
| SOUTHERN HEALTHCARE MANAGEMENT LLC | ADP OF THE SNF | NOT APPLICABLE |
| SOVEREIGN HEALTHCARE DISBURSEMENTS LLC | ADP OF THE SNF | NOT APPLICABLE |
| BELL, CHARLES | ADP OF THE SNF | NOT APPLICABLE |
| BRITTON, MARK | ADP OF THE SNF | NOT APPLICABLE |
| CHERY, DAWN | ADP OF THE SNF | NOT APPLICABLE |
| CRONQUIST, ROYCE | ADP OF THE SNF | NOT APPLICABLE |
| KAAR, SUSAN | ADP OF THE SNF | NOT APPLICABLE |
| KELLY, MICHELLE | ADP OF THE SNF | NOT APPLICABLE |
| MANGINE, JOHN | ADP OF THE SNF | NOT APPLICABLE |
| MELTON, DONALD | ADP OF THE SNF | NOT APPLICABLE |
| NOTERMANN, WILLIAM | ADP OF THE SNF | NOT APPLICABLE |
| STOUTJESDIJK, WENDY | ADP OF THE SNF | NOT APPLICABLE |
Helpful resources
Educational information, not medical or legal advice. Data & methodology