Westminster Winter Park: Oxygen Delivery Failure - FL
The inspection, conducted August 12, 2025, centered on a single resident identified in records as Resident 4. The physician's order was clear: 2 liters per minute, continuous oxygen. What the resident was actually receiving was 1.5 liters per minute, a 25 percent shortfall that had gone undetected.
LPN B, as the nurse is identified in the inspection report, confirmed to inspectors that she had not checked the oxygen concentrator yet that day to verify the resident was receiving the prescribed rate. When she went to the room to check, inspectors watched her stand over the machine and try to read the flow rate from above rather than at eye level. The flow meter on an oxygen concentrator is a vertical tube with a floating ball inside; reading it from above rather than straight on produces an inaccurate reading. The nurse was not reading it correctly.
The concentrator was set to 1.5 liters per minute.
The Director of Nursing told inspectors that afternoon that nurses were supposed to check oxygen liter flow rates at eye level at least every shift. She said nurses were expected to verify the physician's order and administer exactly what was ordered. She went further than that: good nursing practice, she said, was to check every time a nurse rounded on a resident, not just once per shift.
LPN B had not done it once.
The facility's own oxygen administration policy, revised as recently as May 2025, states that oxygen is administered consistent with professional standards of practice and under physician orders. The policy existed. The Director of Nursing knew what the standard was. The nurse who was responsible for Resident 4 that day had not followed either.
The gap between 1.5 and 2 liters per minute is not trivial in the context of why a physician orders supplemental oxygen in the first place. A concentrator set below the ordered rate means a resident whose lungs or heart or circulation requires supplemental support is not receiving the level of support their doctor determined they needed. How long the concentrator had been set incorrectly, and how many shifts had passed without anyone checking, the inspection report does not say.
The violation was cited at a level of minimal harm or potential for actual harm, meaning inspectors found no documented injury to Resident 4 as a result. That determination reflects the regulatory framework inspectors work within, not a conclusion that nothing could have gone wrong. The resident was receiving oxygen at a rate below what a physician prescribed, and no nurse had verified the equipment was working as ordered before inspectors arrived and prompted the check.
Westminster Winter Park is a continuing care retirement community in Orange County. The inspection was conducted in response to a complaint.
Resident 4 was still in the room when LPN B finally checked the concentrator. The machine had been running, delivering less than what was ordered, and the nurse tasked with that resident's care had not looked at it once that shift.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westminster Winter Park from 2025-08-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 27, 2026 · Our methodology
WESTMINSTER WINTER PARK in WINTER PARK, FL was cited for violations during a health inspection on August 12, 2025.
The inspection, conducted August 12, 2025, centered on a single resident identified in records as Resident 4.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.