Metro West Nursing And Rehab Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

52.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 176 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 50.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 115 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.54 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 25% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 120 beds and averages 108.2 residents a day — about 90% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.68 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.67 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.32 hrs/resident/day on weekends vs 3.83 on weekdays — 13% thinner on weekends. RN hours go from 0.80 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.

• Potential for harm · E2025-08-28 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings: 1. Resident #123 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including aphasia (loss of speech), hemiplegia and hemiparesis (partial paralysis) following cerebral infarction affecting right dominant side, dysphagia (trouble swallowing) and unspecified dementia. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 8/26/25 revealed resident #123 had a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated she had moderate cognitive impairment. The assessment indicated resident #123 required supervision or touching assistance for eating. 2. Resident #76 was admitted to the facility on [DATE] with…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-28 · tag F0867 — failed to act on quality-improvement findings — pattern
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based 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. Findings:A review of the facility's QAPI plan revised October 2024, stated for their purpose, that it provided guidance for their overall quality improvement program and that the Administrator would ensure that the QAPI plan was reviewed minimally on an annual basis by the QAA committee and conduct at least one distinct performance improvement project annually. Ongoing revisions would be made to the plan, as the need arose, to reflect current practices within the center. The revisions would be made by the QAA committee.Their QAPI plan included the policies and procedures used to Identify and use Data to monitor our performance Establish goals and thresholds for our performance measurement Utilize resident, staff and family input Identify and prioritize problems and opportunities for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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).Findings:Review of the medical record revealed resident #111 was admitted to the facility on [DATE] from the hospital. Her diagnoses included chronic obstructive pulmonary disease, unspecified atrial fibrillation, altered mental status and chronic kidney disease. Review of the quarterly Minimum Data Set assessment with reference date 8/16/25 revealed resident #111's cognition was severely impaired. Resident #111's Order Summary Report showed an active physician's order for oxygen (O2) at 2 liters per minute (LPM) via nasal cannula dated 4/12/25. The medical record further revealed a care plan initiated on 2/29/24 that indicated the resident was to be administered oxygen via nasal cannula as ordered by the physician. The care plan did not indicate resident #111 had any behaviors of refusals…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-28 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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).Findings: Resident #89 was admitted to the facility on [DATE] with diagnoses including nonrheumatic mitral valve insufficiency, heart failure, essential hypertension and personal history of transient ischemic attack and cerebral infarction (stroke). Review of the Minimum Data Set (MDS) significant change assessment with assessment reference date (ARD) of 6/07/25 revealed resident #89's active diagnoses included anemia, heart failure and hypertension. Review of the electronic medical record (EMR) revealed resident #89 had a physician order for Amlodipine Besylate 10 milligrams (mg) to be given one time a day for hypertension. The order included parameters to hold the medication if resident #89's systolic blood pressure was below 110 millimeters of mercury (mmHg), diastolic…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-28 · tag F0790 — failed to provide dental care — isolated
  Provide routine and 24-hour emergency dental care for each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings:Review of the medical record revealed resident #101, a [AGE] year-old female was admitted to the facility from an acute care hospital on 5/30/25 with diagnoses that included bipolar disorder, major depressive disorder recurrent, dysphagia (difficulty swallowing), hypotension (low blood pressure), hypertension (high blood pressure), and abdominal tenderness.The Modified Minimum Data Set admission 5-day Comprehensive Assessment with an Assessment Reference Date of 6/07/25 noted resident #101 scored 15 out of 15 on the Brief Interview for Mental Status which indicated she was cognitively intact and did not reject evaluation or care. Section L (Dental) was modified on 8/28/25 to indicate the resident had, obvious or likely cavity or broken natural teeth.The Care Plan Report included a focus initiated on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-28 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings: 1. Resident #127 was admitted to the facility on [DATE] and discharged to the hospital on 7/11/25. His diagnoses included syncope and collapse, cerebral cysts, dementia, anxiety and seizures. A review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment with assessment reference date 7/11/25 revealed resident #127 had a Brief Interview for Mental Status Score of 9/15 which meant his cognition was moderately impaired. On 8/26/25 at 3:56 PM, the Director of Nursing (DON) explained the Change in Condition (CIC) form in resident #127's record dated 7/12/25 at 7:00 AM. According to the CIC form, it indicated the resident was discharged to the hospital on 7/12/25 for low oxygen however, on the census line in resident…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-02-22 · tag F0623 — pattern
  Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings: 1. Resident #28 was admitted to the facility on [DATE] with diagnoses including quadriplegia, intracranial injury with loss of consciousness, thrombocytopenia, encephalopathy, and gastrostomy malfunction. Review of the resident's medical record revealed a nursing progress dated 02/16/24 that noted the resident's gastrostomy tube was displaced. He was transferred to the hospital on 2/17/24 by non-emergency transportation for replacement. As of 02/22/24, the resident remained in the hospital but was expected to return to the facility. The medical record did not contain a Notification of Transfer or Discharge form for the hospitalization. 2. Resident #52 was admitted to the facility on [DATE] with diagnoses including calculus of ureter,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-02-22 · tag F0759 — failed to keep medication error rate low — pattern
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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%. Findings: 1. Resident #41 was admitted to the facility on [DATE] with diagnoses that included hypertension, schizophrenia, major depressive disorder, and type II diabetes mellitus. On 02/21/24 at 9:21 AM, Registered Nurse (RN) G, was by her medication cart preparing to administer morning diabetic medications. She stated it was her regular process to obtain blood sugars and administer insulin to all diabetic residents on her assignment first before administering all other medications. She stated that resident #41's morning blood sugar was 238 and he had orders for Novolog injection solution 5 units before meals as well as Novolog injection solution per sliding scale give 5 units for blood sugars between 201 and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-02-22 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and interview the facilty failed to ensure dishes and eating utensils were sanitized to prevent foodborne illness. Findings: On 2/19/24 at 10:33 AM, Dietary Aide A was observed at the dishmachine, washing the breakfast dishes. The Aide stated the dishmachine was low temperature and utilized a chlorine base chemical for sanitation. A minimum of 50 parts per million (PPM) for the sanitizer level was required. She explained she tested the sanitizer solution with a test strip, when she started washing the dishes, and the sanitizer was at 75 ppm. A rack of dishes came out of the machine and the Dietary Technician used a test strip to determine if the chemical sanitation solution was at the appropriate level. After she swabbed the dishes with the test strip, the test strip remained white in color instead of turning purple indicating none or less than minimum level of sanitizer. The Dietary Technician ran several racks of dishes through the dish machine and each was swabbed with a test strip. The sanitizer solution could not be detected. After several…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-02-22 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: 1. Review of the medical record revealed resident #5 was admitted to the facility on [DATE] with diagnoses including right lower leg fracture, falls, generalized muscle weakness, and abnormal gait. Review of resident #5's MDS admission assessment with assessment reference date (ARD) of 1/19/24, Section GG - Functional Abilities and Goals, revealed she had functional limitation in range of motion due to impairment of one lower extremity. The document indicated the resident did not use any mobility devices during the 7-day look back period. On 2/22/24 at 4:54 PM, the Licensed Practical Nurse (LPN) MDS Coordinator confirmed resident #5 was admitted to the facility with a cast on her right…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to SOVEREIGN HEALTHCARE HOLDINGS — 43 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 31 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $663K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in FL