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Metro West Nursing and Rehab Center
5900 Westgate Drive, Orlando, FL 32825 · CMS Certification Number (CCN) 105868
At a glance
- CMS overall rating
- ★★★★☆ 4 of 5
- Health inspection citations
- 19 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 2 from complaints)
- Fire safety citations
- 0
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- August 28, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Florida average | U.S. average |
|---|---|---|---|
| Overall | ★★★★☆ 4 of 5 | 3.3 | 3 |
| Health inspections | ★★★☆☆ 3 of 5 | 2.9 | 2.8 |
| Staffing | ★★★☆☆ 3 of 5 | 3.3 | 2.9 |
| Quality measures | ★★★★★ 5 of 5 | 4.2 | 3.6 |
| Long-stay quality | ★★★★★ 5 of 5 | Not published | Not published |
| Short-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | August 28, 2025 | 6 | 6 | 0 |
| Cycle 2 | February 22, 2024 | 11 | 11 | 2 |
CMS weighted health inspection score: 38 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
19 health citations across 3 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
August 28, 2025: 6 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/28/2025 |
| D | F-0842 | 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 | Standard | Deficient, Provider has date of correction Corrected 09/28/2025 |
| D | F-0790 | Provide routine and 24-hour emergency dental care for each resident. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/28/2025 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/28/2025 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/28/2025 |
| E | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 09/28/2025 |
February 22, 2024: 11 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | 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 | Standard | Deficient, Provider has date of correction Corrected 03/22/2024 |
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/22/2024 |
| E | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/22/2024 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/22/2024 |
| D | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/22/2024 |
| D | F-0688 | 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 | Standard | Deficient, Provider has date of correction Corrected 03/22/2024 |
| D | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/22/2024 |
| D | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 03/22/2024 |
| D | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/22/2024 |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/22/2024 |
| E | F-0623 | 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 | Standard | Deficient, Provider has date of correction Corrected 03/22/2024 |
May 12, 2022: 2 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0657 | 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 | Standard | Deficient, Provider has date of correction Corrected 06/08/2022 |
| D | F-0640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 06/08/2022 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Fire safety inspections
No fire safety citations published for this facility in the CMS Fire Safety Deficiencies file.
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Staffing
| Measure | This facility | Florida average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.68 | 3.82 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.67 | 0.73 | 0.69 |
| LPN/LVN hours per resident per day | 0.76 | Not published | Not published |
| Nurse aide hours per resident per day | 2.25 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.32 | Not published | Not published |
| RN hours per resident per day, weekends | 0.37 | Not published | Not published |
| Total nursing staff turnover (%) | 43.2 | 41.4 | 45.8 |
| Registered nurse turnover (%) | 52 | Not published | Not published |
| Administrators who have left | 1 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Facility details
- Legal business name
- Sovereign Healthcare of Metro West LLC
- Ownership type
- For profit - Limited Liability company
- Chain
- Sovereign Healthcare Holdings (43 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 120
- Average residents per day
- 108.2
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Both
- First approved for Medicare/Medicaid
- October 21, 1994
- County/parish
- Orange
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Owners and managers reported to CMS
31 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| SOVEREIGN HEALTHCARE HOLDINGS LLC | DIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MANGINE, JOHN | DIRECT OWNERSHIP INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BERKADIA COMMERCIAL MORTGAGE LLC | 5% OR GREATER SECURITY INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| FL METRO WEST HOLDINGS LLC | 5% OR GREATER SECURITY INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| HEALTH SERVICES PROPERTIES LLC | 5% OR GREATER SECURITY INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BELL, CHARLES | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CHERY, DAWN | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KAAR, SUSAN | MANAGING CONTROL - GOVERNING BODY | Individual | NOT APPLICABLE | undefined undefined, NaN |
| SOUTHERN HEALTHCARE MANAGEMENT LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BRITTON, MARK | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CRONQUIST, ROYCE | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MANGINE, JOHN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MELTON, DONALD | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NOTERMANN, WILLIAM | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STOUTJESDIJK, WENDY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NOTERMANN, BRENDA | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| FL METRO WEST HOLDINGS LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| FORVIS MAZARS LLP | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| HEALTH SERVICES PROPERTIES LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| SOUTHERN HEALTHCARE MANAGEMENT LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| SOVEREIGN HEALTHCARE DISBURSEMENTS LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BELL, CHARLES | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BRITTON, MARK | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CHERY, DAWN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CRONQUIST, ROYCE | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KAAR, SUSAN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| KELLY, MICHELLE | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MANGINE, JOHN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MELTON, DONALD | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| NOTERMANN, WILLIAM | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| STOUTJESDIJK, WENDY | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026
Check it yourself
- Medicare Care Compare: Metro West Nursing and Rehab Center. Full inspection reports, quality measures and staffing.
- AHCA licensed health care facility complaint form. The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 25, 2026. Not a ranking or endorsement.