Cycle 1
Health 2024-10-17 · Fire 2024-10-17
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Altamonte Springs, FL
Harborview Health Center West Altamonte
2-star overall rating with 2-star inspections with $18,106 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1099 West Town Parkway, Altamonte Springs, FL
(407) 865-8000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Harborview Health Systems
Operator or chain grouping
Approved since
1994-02-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
21 facilities
Chain averages 2 overall / 2 health / 3 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.67
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.55
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.33
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
3.71
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,172
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9860
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.77
Baseline 20.01% · Performance 21.08% · Measure score 0.77 · Achievement 0.77 · Improvement 0
Healthcare-associated infections
4.77
Baseline 8.52% · Performance 6.66% · Measure score 4.77 · Achievement 3.92 · Improvement 4.77
Total nurse turnover
4.27
Performance 46.24% · Measure score 4.27 · Achievement 4.27 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.41
Baseline 4.05 hours · Performance 3.76 hours · Measure score 2.41 · Achievement 2.41 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.5% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 10.89% · Lower 95% interval 7.01% |
| Discharge to community | 33.39% |
50.57%
17.2 pts worse
|
Worse than the National Rate · Eligible stays 72 · Observed rate 23.61% · Lower 95% interval 24.82% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 92.78% |
95.27%
2.5 pts worse
|
Numerator 90 · Denominator 97 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 97 |
| Discharge self-care score | 36.51% |
53.69%
17.2 pts worse
|
Numerator 23 · Denominator 63 |
| Discharge mobility score | 31.75% |
50.94%
19.2 pts worse
|
Numerator 20 · Denominator 63 |
| Pressure ulcers or injuries, new or worsened | 3.09% |
2.29%
0.8 pts worse
|
Numerator 3 · Denominator 97 · Adjusted rate 2.49% |
| Healthcare-associated infections requiring hospitalization | 6.66% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 6% · Lower 95% interval 3.57% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 2.65% |
42%
39.4 pts worse
|
Numerator 6 · Denominator 226 |
| Discharge function score | 34.92% |
56.45%
21.5 pts worse
|
Numerator 22 · Denominator 63 |
| Transfer of health information to provider | 84.85% |
95.95%
11.1 pts worse
|
Numerator 28 · Denominator 33 |
| Transfer of health information to patient | 92% |
96.28%
4.3 pts worse
|
Numerator 23 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 3.13% |
25.2%
22.1 pts worse
|
Numerator 2 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.2 |
2.1
1.1 pts worse
|
1.9
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
99.2%
1.4 pts worse
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
2.6%
1.4 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 5.1% · Q3 3.3% · Q4 4.4% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
3.7%
3 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 0.3% |
5.9%
5.6 pts better
|
5.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.1% |
15.7%
3.6 pts better
|
19.6%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 14.1% · Q3 12.7% · Q4 10.4% · 4Q avg 12.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.7% |
9.8%
6.1 pts better
|
16.7%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 4.2% · Q3 1.8% · Q4 3.6% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.6% |
11.7%
5.9 pts worse
|
16.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 14.5% · Q3 18.3% · Q4 4.6% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.2% |
9.8%
8.4 pts worse
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.8% · Q2 19.0% · Q3 13.9% · Q4 8.3% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.4%
0.3 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.9% · Q3 0.0% · Q4 1.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
0.8%
1 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 1.4% · Q3 0.0% · Q4 1.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
12.5%
13.3 pts worse
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 29.2% · Q3 24.6% · Q4 16.5% · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
5.1%
0.2 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 9.4% · Q3 0.8% · Q4 3.1% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
94.3%
0.3 pts worse
|
81.7%
12.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 93.0% · Q3 91.9% · Q4 95.3% · 4Q avg 94.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
9.3%
2.4 pts worse
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 11.9% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
1.5%
2.3 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.3% · Q3 1.9% · Q4 1.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.7% |
94.7%
6 pts worse
|
79.7%
9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.6% |
26.2%
11.4 pts worse
|
23.9%
13.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.6% · Observed 40.3% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-09 · Fire 2023-03-09
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-04-08 · Fire 2021-04-08
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-17
E · Potential for more than minimal harm
2024-10-17
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-17
F · Potential for more than minimal harm
2023-03-09
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-03-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-09
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-03-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-31
F · Potential for more than minimal harm
2021-04-08
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2021-05-07
F · Potential for more than minimal harm
2021-04-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-05-07
E · Potential for more than minimal harm
2021-04-08
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2021-05-07
Inspection history
Recent health citations
G · Actual harm
2024-10-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-17
G · Actual harm
2024-10-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-17
E · Potential for more than minimal harm
2024-10-17
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-17
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-10-17
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-11-17
D · Potential for more than minimal harm
2024-05-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-22
G · Actual harm
2023-03-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-14
Penalties and ownership
What sits behind the stars
$9,053
2024-10-17
Fine
Fine · fine $9,053
Fine
$9,053
2024-10-17
Fine
Fine · fine $9,053
Fine
Ownership
Harborview West Altamonte Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Cl 2022 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
De 2021 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Fl 7 Nursing And Rehab Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Griffin, Maria
Operational/Managerial Control · Individual
Leibowitz, Chaim
Operational/Managerial Control · Individual
Nuriel, Gabriel
Operational/Managerial Control · Individual
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