Harborview Health Center West Altamonte

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.

33.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 72 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 38.8% 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 80 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 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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 116 beds and averages 110.4 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. 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 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 3.29 hrs/resident/day on weekends vs 3.67 on weekdays — 10% thinner on weekends. RN hours go from 0.82 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 33% is below the national median of 45%.

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 more than at the previous inspection — worsening. 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 13 most serious are shown; the remaining 6 are one tap away and print in full.

• Actual harm · G2024-10-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  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 immediate and thorough nursing assessment and treatment services related to burns for 1 of 2 residents, (#27), and failed to obtain an order for treatment and date a treatment dressing for 1 of 2 residents reviewed for pressure wounds, (#84), of a total sample of 37 residents. The facility's failure to ensure a complete and timely assessment including accurate identification of burns resulted in actual harm. Resident #27 was transferred to a higher level of care initially for treatment and was transferred again to another hospital with a specialized burn unit. Resident #27 was admitted to the stepdown trauma unit with second degree burns to her left arm, left hand, abdomen and left thigh. She remained there for 5 days. Findings: Cross reference F689 and F813 1. Resident #27 was admitted to the facility on [DATE] with diagnoses to include left sided hemiplegia and hemiparesis, type 2 diabetes mellitus with diabetic neuropathy…

  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
• Actual harm · Gcited before2024-10-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  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 prevent an avoidable accident for a resident by not checking the temperature of microwaved noodles provided by staff for 1 of 2 residents reviewed for accidents, of a total sample of 37 residents, (#27). The facility's failure to provide a policy and ensure all staff were educated regarding the heating and reheating of resident food resulted in actual harm. Resident #27 was transferred to a higher level of care, then transferred again to another hospital with a specialized burn unit. Resident #27 was admitted to the stepdown trauma unit with second degree burns to her left arm, left hand, abdomen and left thigh. She remained in the hospital for 5 days. Findings: Cross reference F684 and F813 Resident #27 was admitted to the facility on [DATE] with diagnoses to include left sided hemiplegia and hemiparesis (one sided weakness and paralysis), type 2 diabetes mellitus with diabetic neuropathy (diabetic nerve damage), and contracture of the left hand. The…

  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
• Actual harm · Gcited before2023-03-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  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 develop and implement appropriate interventions to include provision of adequate supervision to prevent a fall with major injury for 1 of 1 resident reviewed for accidents, of a total sample of 31 residents, (#11). The facility's failure to increase supervision for a resident with a history of repeated falls resulted in actual harm for resident #11. Findings: Review of the medical record revealed resident #11 was admitted to the facility on [DATE] with diagnoses including seizures, dementia, anxiety, and hypertension. He was hospitalized on [DATE] after a fall with major injury and readmitted from the hospital on [DATE] with additional diagnoses of traumatic subdural hemorrhage, repeated falls, weakness and paralysis of the left side and visiospatial deficit and spatial neglect following a stroke. A subdural hemorrhage is bleeding between the covering and surface of the brain that is often the result of a severe head injury. Compression of the brain…

  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 · F2026-04-08 · tag F0867 — failed to act on quality-improvement findings — widespread
  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 implementation of their Quality Assurance and Performance Improvement (QAPI) program by failing to obtain feedback and data to identify issues and concerns with facility systems, as well as opportunities for improvement.Findings:Cross Reference F580, F655, F656, F842In a joint interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 4/08/26 at 4:53 PM, the NHA stated he had only been at the facility for two days and had not been part of any QAPI meetings. The DON expressed she had started last year in June of 2025. The NHA and DON acknowledged the concerns related to notification of change in condition for residents, incomplete and inaccurate baseline care plans, incomplete comprehensive care plans that did not include respiratory care, and incomplete/inaccurate medical records. The DON stated she was not aware of the concerns and there were no active Performance Improvement Plans (PIP) related to these concerns. She explained during morning clinical meetings, each department head…

  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 · D2026-04-08 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 interview, and record review, the facility failed to ensure the resident's representative was informed of a change in condition for 2 of 2 residents reviewed for change in condition, (#1, and #4), and failed to notify the physician of the change in condition which had the potential to delay medical evaluation and treatment for 1 of 2 residents reviewed for notification of changes, (#4) .Findings: 1. Resident #1 was initially admitted to the facility on [DATE] from an acute care hospital with diagnoses that included metabolic encephalopathy (abnormal brain function), dysphagia (trouble swallowing), diabetes, sepsis, congestive heart failure, acute kidney failure, and adult failure to thrive. She was hospitalized on [DATE] due to a difficulty to arouse and labored breathing. Resident #1 returned to the facility on [DATE] with diagnoses of COVID-19, pneumonia, and acute respiratory failure. Review of the Agency for Healthcare Administration (AHCA) Long Term Care Medicaid Transfer form 3008, dated [DATE],…

  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 · D2026-04-08 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  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 the baseline care plan was effectively implemented to include a plan for staff to provide effective and person-centered care, for 2 of 2 residents reviewed for respiratory care, (#1, and #3), and failed to ensure the resident or representative received a summary of the baseline care plan with the required information, for 1 of 2 residents reviewed for baseline care plans, (#1), of a total sample of 4 residents. Findings: 1. Resident #1 was initially admitted to the facility on [DATE] from an acute care hospital with diagnoses that included metabolic encephalopathy (brain dysfunction), diabetes, congestive heart failure, acute kidney failure, and adult failure to thrive. She was hospitalized on [DATE] due to a difficulty to arouse and labored breathing. Resident #1 returned to the facility on [DATE] with diagnoses of Coronavirus 2019 (COVID-19), pneumonia, and acute respiratory failure. Review of the Agency for Healthcare Administration (AHCA)…

  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 · D2026-04-08 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  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 develop and implement a comprehensive care plan to address oxygen use which placed the resident at risk for potential respiratory complications, for 1 of 1 residents reviewed for Comprehensive Assessment, of a total sample of 4 residents, (#2).Findings: Resident #2 was admitted to the facility on [DATE]. admission diagnoses included end stage liver disease, hepatocellular carcinoma (liver cancer), diastolic congestive heart disease, chronic obstructive pulmonary disease (COPD), diabetes, and hypertension. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #2 required oxygen therapy and had a Brief Interview for Mental Status score of 15/15, which indicated she was cognitively intact. The assessment specified the resident required full assistance from staff with toileting, hygiene, and transfers. Review of resident #2's medical record revealed physician orders dated 12/23/25 for oxygen two liters per minute…

  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 · D2026-04-08 · 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 interview, and record review, the facility failed to maintain complete, accurate, and consistent clinical records, compromising the reliability of the clinical record and the ability to ensure appropriate assessment, treatment, and continuity of care for 2 of 2 residents reviewed for resident records, of a total sample of 4 residents, (#1, #4).Findings: 1. Resident #1 was initially admitted to the facility on [DATE] from an acute care hospital with diagnoses that included metabolic encephalopathy (abnormal brain function), dysphagia (trouble swallowing), diabetes, sepsis, congestive heart failure, acute kidney failure, and adult failure to thrive. On [DATE] at 10:30 AM, Licensed Practical Nurse (LPN) C confirmed she was the Night Supervisor on [DATE]. She recalled when she arrived for her shift that night, she was told by 3-11 PM staff that resident #1 had been found unresponsive by an unidentified Certified Nursing Assistant (CNA) who had gone to the room to check on her. LPN C remembered the CNA…

  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 · E2024-10-17 · tag F0813 — pattern
  Have a policy regarding use and storage of foods brought to residents by family and other visitors.
  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 a policy or training to staff regarding reheating of food for residents. This lack of instruction caused the resident to receive second degree burns when her food was heated in the microwave, for 1 of 1 resident reviewed for burns, of a total sample of 39 residents, (#27). Findings: Resident #27 was admitted to the facility on [DATE] with diagnoses to include left sided hemiplegia and hemiparesis (one sided paralysis and weakness), type 2 diabetes mellitus with diabetic neuropathy (diabetic nerve damage), and contracture of the left hand. Review of a Nurse's Progress Note dated 10/02/24 at 7:33 PM, by Licensed Practical Nurse (LPN) J revealed, the Certified Nursing Assistant (CNA) notified him that resident #27 burned herself with a noodle soup that she was eating. He documented that, Upon assessment resident have a skin tear on left hand. No complaint of pain /discomfort. Physician notified as well her daughter. Per interview with the…

  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 · D2024-10-17 · tag F0550 — failed to protect resident dignity and rights — isolated
  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 treat residents with dignity and care to promote quality of life by standing while feeding them and referring to residents as feeders for 2 of 6 residents reviewed for assisted dining, of a total sample of 37, (#15 and #29). Findings: 1. On 10/16/24 at 9:45 AM, resident #15's assigned Certified Nursing Assistant (CNA) D was observed in the residents room standing over the resident while feeding her. CNA D stated she was aware she was supposed to sit while feeding residents, but explained she was busy running from resident to resident and didn't get a chair. She stated she knew it was important to sit while assisting residents with their meals to be at eye level with them. On 10/16/24 at 12:41 PM, CNA C was observed as she delivered and set up the lunch tray in front of resident #15, then left the room. Two minutes later at 12:43 PM, resident #15 was observed eating the food from her lunch tray with her hands. At 12:44 PM, CNA D passed by…

  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 · D2024-10-17 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I evaluation was completed, (#33), and failed to request a Level I and/or Level II PASARR evaluation after a new major mental disorder diagnosis, (#65), for 2 of 2 residents reviewed for PASARR, of a total sample of 37. Findings: 1. Resident #33 was re-admitted to the facility from the hospital on 3/29/24 but was initially admitted on [DATE]. On admission she had diagnoses that included cerebral infarction stroke), aphasia (difficulty speaking), vascular dementia with other behavioral disturbances, major depressive disorder, and mood disorder. Review of Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that resident #33 was severely cognitively impaired, had impairments to both upper and lower extremities limiting range of motion, was bedbound, and dependent for all activities of daily living (ADLs). Review of the medical record for resident #33 revealed a…

  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 · D2024-10-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  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, record review, and facility's policy review, the facility failed to ensure care and services consistent with professional standards of practice to prevent pressure ulcers was provided, by failing to follow physician's order for weekly skin sweeps for 1 of 4 residents reviewed for pressure ulcer, of a total sample of 37 residents, (#42). Findings: Resident #42, a [AGE] year-old male was admitted to the facility on [DATE], and readmitted on [DATE]. His diagnoses included heart failure, cognitive communication deficit, diabetes type II, peripheral vascular disease, and malignant neoplasm (cancer) of the prostate. The resident's significant change Minimum Data Set assessment, with Assessment Reference Date of 9/08/24, revealed the resident's cognition was moderately impaired, with a Brief Interview of Mental Status score of 10 out of 15. The assessment noted the resident had functional limitation in range of motion to one side of his lower extremity, was dependent on staff assistance 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-10-17 · 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 ensure respiratory therapy was provided as per physician orders for 1 out of 1 resident reviewed for respiratory care, of a total sample of 37 residents, (#93). Findings: Resident #93 was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), heart disease, hyperlipidemia, hypotension, history of falling, cognitive communication deficit, ischemic cardiomyopathy, and essential hypertension. Review of the Significant Change Minimum Data Set assessment with reference date 5/29/24, revealed resident #93 had mild cognitive impairment, had no behaviors, nor refused care, and required the use of oxygen. Resident #93 was dependent for transfers and used a wheelchair for mobility. Review of resident #93's Physician Orders for continuous oxygen was 1 liter per minute (LPM) every shift for Shortness of breath. Resident #93 had a baseline Care Plan for required use of oxygen as ordered because of the…

  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

“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

$18,106 in federal fines across 2 penalties.

• $9,053 — penalty dated 2024-10-17
• $9,053 — penalty dated 2024-10-17

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to HARBORVIEW HEALTH SYSTEMS — 22 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 14 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner 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 $680K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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