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Palm Garden Of Jacksonville

5725 Spring Park Road, Jacksonville, FL 32216 · For profit - Corporation · 120 certified beds · (904) 733-6954 Medicare & Medicaid certified

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2 immediate-jeopardy citations
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • about 17% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Urgent care / clinic
5600 Spring Park Rd Ste 100 · (904) 396-5777 · Call to confirm hours
Pharmacy
5972 University Blvd W · (904) 419-5670 · Call to confirm hours
Grocery
5829 Pepsi Pl · (904) 737-3774 · Call to confirm hours
Park
5465 E 46 1/2 Rd · (231) 775-3700 · Typically dawn to dusk
Place of worship

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

Overall quality measures 3 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.0%8.7%15.4%better
Long-stay residents who lose too much weight1.9%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection2.4%0.7%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.3%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.3%2.5%3.3%better
Long-stay residents whose ability to walk worsened11.0%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication2.6%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine88.9%99.2%95.3%typical
Long-stay residents with pressure ulcers5.4%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control17.0%10.5%21.2%worse than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table0.7%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication1.0%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine76.5%94.7%79.4%typical
Short-stay residents rehospitalized after admission43.7%26.1%22.6%worse
Short-stay residents with an outpatient ER visit8.7%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.012.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.201.151.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

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.

34.9% 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 29 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

34.9%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
36.7%U.S. median 56.6%
Met the expected recovery
0.16U.S. median 0.31
Therapy hours / resident / day
0.09hours / resident / day
Physical therapy
<0.01hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 36.7% 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 30 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 0.16 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF34.9%CMS range 22.8–52.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 6.3–15.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge36.7%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge33.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge26.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified94.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting86.7%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.051.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.40
RN hours/ resident / day
0.89
LPN hours/ resident / day
2.13
Aide hours/ resident / day
3.43
Total nurse hours/ resident / day
0.28
RN hoursweekends
47.0%
Total nursing turnover
46.2%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 111.3 residents a day — about 93% occupied, or roughly 9 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 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 3.26 hrs/resident/day on weekends vs 3.50 on weekdays — 7% thinner on weekends. RN hours go from 0.45 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 47% is about the same as 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

6
deficiencies at the latest standard inspection (2025-08-28)
9
at the previous standard inspection (2023-09-14)

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.

ABCDEFGHIJKL

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.

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2021-11-19 · 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 interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive, person-centered care plan, by failing to 1) Ensure an Agency nurse appropriately assessed a resident's change in condition, including agitation, restlessness, and numerous attempts to jump out of bed for one (Resident #191) resident with a history of falls, behaviors, and suicidal ideation, out of four residents reviewed. The facility failed to ensure the Agency nurse recognized and addressed an emergent situation for a fall-risk resident, which contributed to her death. The facility also failed to 2) Ensure a resident's right to receive treatment for one (Resident #11) residents who required a mammogram, and 3) Ensure one (Resident #23) of one resident sampled, received physician-ordered medication for insomnia (Sleeplessness) for two months, resulting in the resident's increased sleeplessness. There was a total of 37 residents in the sample. 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
  • Immediate jeopardy · J2021-11-19 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 interviews and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to ensure resident safety, by failing to ensure the nursing staff recognized and managed a resident's change in condition, including agitation, restlessness, and numerous attempts to jump out of bed for one (Resident #191) resident with a history of falls, behaviors and suicidal ideation, out of four residents reviewed, from a total of 37 residents in the sample. The facility's failure to ensure nursing staff maintained appropriate skills sets and competencies contributed to Resident #191's death. The facility's employees and service providers failed to provide services to Resident #191 that were necessary to avoid physical harm. During the 3:00 p.m. to 11:00 p.m. shift on [DATE], Certified Nursing Assistant (CNA) B told Licensed Practical Nurse (LPN) C (Agency Nurse) 14 to 18 times throughout the shift, that Resident #191 was observed with agitation, restlessness, 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-08-28 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and a review of policies and procedures, the facility failed to provide food at a safe and appetizing temperature for residents on one of four items on the holding line in the main kitchen and for four of four items on a test tray provided after the last resident received their tray.The findings include:During an observation of the lunch service on 08/28/2025 at 1:10 PM, the temperature of the baked chicken read 104 degrees Fahrenheit (F).During an interview on 08/28/2025 at 1:15 PM, the Certified Dietary Manager (CDM) stated It shouldn't be that temperature.During an observation of a test tray on the hallway cart on 08/28/2025 at 1:35 PM, the temperature of hamburger read 128 degrees F, the temperature of the mechanical soft hamburger read 120 degrees F, the temperature of the green beans read 115.5 degrees F, and the temperature of the mashed potatoes and gravy read 120.5 degrees F.During an interview on 08/28/2025 at 1:40 PM, the CDM stated, I don't know what to say. It should be hotter than that.A Review of the facility's policy and procedure…

    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 · Ecited before2025-08-28 · 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 observations, interviews, and a review of the facility's policies and procedures, the facility failed to ensure food was safely stored, labeled, or discarded for two (open, unlabeled beef base paste and spoiled green peppers) of six items in the walk-in cooler and for two (uncovered cake and open, unlabeled jelly) of four items in the main kitchen. Unsafe food handling practices represent a potential source of pathogen exposure.The findings include:On 8/25/2025 at 9:45 AM during a tour of the kitchen with the Dietary Supervisor, an open container of Beef Base Paste was found undated in the walk-in cooler. (Photographic evidence obtained) Two green bell peppers located in a carboard carton in the walk-in cooler, dated 8/12/2025, were noted to have shriveled, brownish black sections with a thick greenish substance oozing from them. (Photographic evidence obtained)During an interview on 8/25/2025 at 9:45 AM, the Dietary Supervisor stated, The paste should have been dated when opened and I'm not sure why someone hasn't thrown these peppers out.On 8/25/2025 at 9:55 AM during 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 · D2025-08-28 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review, the facility failed to properly document a discharge plan for two (Residents #11 and #118) of six residents reviewed for transfer/discharge. When the facility transfers or discharges a resident, the facility must ensure that the transfer or discharge is documented in the resident's medical record. The findings include:1.A review of Resident #11's medical record revealed that she was care planned to remain in long-term care at the center on 2/19/2025. Further review of the resident's record revealed a nursing note dated 8/7/2025 at 1:09 PM that read, Social Worker approached Writer and reported that the Resident would be discharge going home on 8/8/25 and for the Resident to go home with all her medication and pick up would be at 11:30. Will report to the upcoming nurse of the same.Further review of Resident #11's record revealed a physician's order dated 8/7/2025 that read, Discharge to Terrace of Jacksonville as per family request on 8/8/2025 with all medication. Transportation will be at 11:30.Further review of Resident #11's record revealed…

    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 · D2025-08-28 · 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 interviews, record review, and a review of the facility's policies and procedures, the facility failed to provide necessary treatment and services, consistent with professional standards of practice to promote healing and prevent infection for one (Resident #101) of two residents reviewed for wound care from a total survey sample of 46 residents. The findings include: A review of the medical record revealed that Resident #101 was admitted to the facility on [DATE] with a re-entry on 1/30/25. His diagnoses included cerebrovascular disease, 9/27/23, hemiplegia/hemiparesis following cerebral infarction affecting the left non-dominant side, 10/5/23, type II diabetes mellitus with diabetic neuropathy, 11/7/23, a history of falling, 11/7/23, low back pain, 4/24/24, peripheral vascular disease, 5/21/24, pain in left shoulder, 9/23/24, acquired absence of other right toe(s), 5/21/24, acquired absence of other left toe(s), 10/2/24, and idiopathic aseptic necrosis of left toe(s). A review of the quarterly minimum…

    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 · D2025-08-28 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 observations, record review, interviews, and a review of facility policies and procedures, the facility failed to 1) Ensure medications were properly labeled for one resident (#110) to facilitate safe medication administration, and 2) Ensure medications were properly stored for one resident (#97) to prevent unauthorized access to medications, out of five residents reviewed for medication storage/labeling, from a total survey sample of 46 residents.The findings include:1.On 8/25/25 at 10:25 AM, Resident #97 was observed lying in bed awake. Anti-diarrheal medication was observed in a clear plastic bag at the bedside. (Photographic evidence obtained) The resident was asked if someone in the facility had given her the medication. She stated, I brought it with me when I came here. I was having the worse diarrhea, going several times a day. The resident mentioned that she received visits from a relative. She stated, My cousin comes weekly to visit. She was asked if her cousin brought the anti-diarrheal…

    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 observations, interviews, and record review, the facility failed to obtain emergency dental care to meet the needs of one (Resident #101) of 46 residents in the total survey sample who was experiencing dental pain. The findings include:During a facility tour on 08/25/2025 at 1:01 PM, Resident #101 was observed guarding the left side of his face. He stated as he talked the air was getting to his tooth, and it was very painful. He rated his pain at a 6 on a scale of zero to 10 with zero indicating no pain and 10 indicating the worst possible pain. He stated the pain was intermittent when something cold came into contact with the tooth.A review of the medical record revealed that Resident #101 was admitted to the facility on [DATE] with a re-entry on 01/30/2025. His diagnoses included cerebrovascular disease, 09/27/2023, hemiplegia/hemiparesis following cerebral infarction affecting the left non-dominant side, 10/05/2023, type 2 diabetes mellitus with diabetic neuropathy, 11/07/2023, a history of falling,…

    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 before2024-09-04 · 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

    Based on record review and interviews, the facility failed to identify and provide needed care and services in accordance with professional standards of practice, by failing to monitor blood glucose levels for one (Resident #3) of two residents reviewed for blood glucose monitoring. The findings include: A record review for Resident #3's medical record revealed an admission date of 5/10/24. Her diagnoses included type 2 Diabetic Mellitus with diabetic chronic kidney disease, type 2 Diabetic Mellitus with diabetic polyneuropathy, and hypertension. Review of the resident's current physician orders included: - Humulin N Subcutaneous Suspension (Insulin NPH (Human Isophane) Inject 5 units subcutaneously in the evening for Diabetes with order date 5/10/24. Insulin Aspart Solution 100 unit/ml, inject 5 units subcutaneously as needed for Diabetes Mellitus - may administer 5 units when Humulin N (Insulin NPH) is out of stock per primary provider with order date of 6/11/24. (Photographic evidence obtained) Review of Resident #3's medication administration record (MAR) for the month of July,…

    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 · D2024-09-04 · tag F0711 — isolated
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews, interviews, and observations, the facility failed to 1) Ensure that the physician/physician representative reviewed the resident's total program of care, including medications and treatments, and 2) Sign and date all orders for one (Resident #3) of two residents reviewed for blood glucose monitoring. The findings include: A record review for Resident #3's medical record revealed an admission date of 5/10/24. Her diagnoses included type 2 Diabetic Mellitus with diabetic chronic kidney disease, type 2 Diabetic Mellitus with diabetic polyneuropathy, and hypertension. Review of the resident's current physician orders included: - Humulin N Subcutaneous Suspension (Insulin NPH (Human Isophane) Inject 5 units subcutaneously in the evening for Diabetes with order date 5/10/24. Insulin Aspart Solution 100 unit/ml, inject 5 units subcutaneously as needed for Diabetes Mellitus - may administer 5 units when Humulin N (Insulin NPH) is out of stock per primary provider with order date of 6/11/24. (Photographic evidence obtained) Review of Resident #3's medication…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-09-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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, staff interview, and facility policy and procedure review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, by failing to 1) Ensure sanitary storage of bulk food items, 2) Ensure baking pans were air dried, and 3) Ensure that the ice and water dispensing machine used for residents' drinks in the nourishment room, was clean and sanitary. The findings include: During the initial tour of the kitchen on 09/11/23 at 11:30 AM, wet nesting of large baking pans was observed on the storage rack. The bulk flour bin had a plastic bowl lying in the product. The bulk sugar bin had a Styrofoam drinking cup lying in the product. The bulk rice bin had a plastic plate lying in the product. (Photographic evidence obtained) During a subsequent tour of the kitchen on 09/13/23 at 12:50 PM, wet nesting of large baking pans was observed on the storage rack. During an interview with the Dietary Manager on 09/13/2023 at 12:55 PM, she agreed that the pans were wet nesting and that the facility did not…

    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 · F2023-09-14 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, facility document review, staff interview, manufacturer's specifications review, and facility policy and procedure review, the facility failed to ensure essential mechanical equipment in the kitchen was maintained in a safe operating condition, as evidenced by the dish machine not functioning according to manufacturer's specifications to ensure dishware was sanitized properly. Failure to properly wash and sanitize glassware and dishes used by residents presents the potential for pathogen exposure and negative health outcomes. The findings include: During the initial tour of the facility kitchen on 09/11/23 at 11:30 AM, Dietary Staff Member G was operating the dish machine. The temperature gauge was observed. The wash cycle temperature went to 112 degrees Farenheit (F). The rinse cycle temperature was observed to go to 112 degrees F. The gauge did not move during the cycles. On the front side of the dish machine a metal plaque was observed to read: Wash cycle minimum temperature: 120 degrees F, Rinse cycle minimum temperature: 120 degrees F, Sanitizer 50 ppm…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · E2023-09-14 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, medical record review, and facility policy review, the facility failed to maintain a clean and sanitary homelike environment for four (Residents #50, #1, #3, and #87) of seven residents receiving enteral nutrition. Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. It is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs. The findings include: 1. On 09/11/23 at 11:30 a.m., Resident #50 was observed lying in bed connected to a running tube feeding pump. Her tube feeding pump and the pole it was attached to were observed to be covered in beige debris along the entire pole (Photographic evidence obtained); and the tube feeding pump was observed with beige debris on the pump device. (Photographic evidence obtained) On 09/12/23 at 6:06 a.m., Resident #50 was observed lying in bed connected to a running tube feeding pump. Her tube feeding pump and the pole it was attached to were…

    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 · E2023-09-14 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to provide services which met professional standards of quality, specifically leaving medications unattended at the resident's bedside, for four (Residents #12, #33, #105, and #50) of six residents observed during medication administration, from a total of 32 residents sampled. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. The findings include: On 9/11/23 at 1:35 pm, Resident #12 was observed lying in her bed. A medication cup was observed on the tray table in front of the resident. Two pills were observed in the cup. (Photographic evidence obtained) There were no staff observed in the room. She stated the medication was hers. She stated the pills were Gabapentin and Darvocet. When asked when the medications were brought to her or when they were scheduled to be taken, she stated, No one is on a schedule around here. On 9/12/23 at 7:30 am, Resident #12 was observed lying in her…

    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 · D2023-09-14 · 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 observations, resident and staff interviews, record review, and a review of facility training for all employees to include agency, the facility failed to honor the residents' right to be treated with dignity and respect, and failed to protect and value residents' private space by not knocking and asking for permission before entering the room for one (Resident #93) of two residents reviewed for dignity, from a total sample of 32 residents. The findings include: An interview was conducted with Resident #93 on 09/11/2023 at 11:58 AM. He was observed to be dressed and sitting upright in bed with the bed in its lowest position. He stated he was waiting for his lunch tray. During the interview, Agency Certified Nursing Assistant (CNA) A entered the room without knocking first or asking for permission to enter before entering. When CNA A was informed that an interview was being conducted, he continued into the room and stated Okay. CNA S was informed again that there was an interview in progress to which he…

    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 · D2023-09-14 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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 observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to provide reasonable accommodation of resident needs for one (Resident #8) in a sample of 32 residents. The facility failed to ensure that the resident had their call light within reach and was able to use it if desired. The findings include: On 09/11/23 at 11:10 a.m., Resident #8's call light was observed on the floor behind the right side of the head of his bed, out of reach. Resident #8 was non-verbal. He accurately answered yes/no questions by shaking or nodding his head. When asked if he could reach his call light, he shook his head no. (Photographic evidence obtained) On 09/11/23 at 1:23 p.m., the same call light was again observed on the floor behind the right side of the head of the bed, out of the resident's reach. On 09/12/23 at 8:01 a.m., Resident #8 was observed lying in bed. His call light was observed on the floor on the right side and underneath his bed. (Photographic…

    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 · D2023-09-14 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and staff interview, the facility failed to ensure residents' personal privacy during medical treatment for one (Resident #50) of six residents observed during medication administration. Resident #50 was not provided privacy during medication administration via her gastrostomy tube (feeding tube). Each resident has the right to privacy and confidentiality for all aspects of care and services. A nursing home resident has the right to personal privacy of his or her own physical body. The findings include: On 09/14/23 at 8:50 a.m., Licensed Practical Nurse (LPN) B was observed preparing medications for Resident #50. A review of the resident's medication orders revealed that all of her medications were administered through her gastrostomy tube (feeding tube). LPN B was observed administering three medications to Resident #50 via her gastrostomy tube. During the medication administration, the resident's bedcovers were pulled down and her hospital gown was pulled up, exposing the resident's abdomen and upper thighs. The resident was observed in the bed…

    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 · Dcited before2023-09-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    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 observations, interviews, record review, and review of facility training, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for one (Resident #107) of three residents reviewed for ADLs, from a total sample of 32 residents. The findings include: On 09/11/2023 at 11:19 AM, Resident #107 was observed in her room lying in bed. Her hands were exposed and her fingernails were noted to be long in length, with dark colored debris between the fingertips and fingernails. When greeted, she reported she was legally blind but could see shadows. When asked if she preferred her fingernails at the current length, she stated no, she felt they were too long but didn't want to cause any problems. (Photographic evidence obtained) A review of the medical record revealed that Resident #107 was admitted to the facility on [DATE]. Her diagnoses included surgical aftercare following surgery 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 · D2023-09-14 · 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

    Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure disposition of medications for two (Resident #12 and Resident #105) six residents observed during administration of medications, from a total of 32 residents sampled. Method of disposition (including controlled medications) should prevent diversion and/or accidental exposure and is consistent with applicable state and federal requirements, local ordinances, and standards of practice. The findings include: 1. On 9/12/23 at 7:30 am, Resident #12 was observed lying in her bed. A white round pill was observed on her bed to her right. (Photographic evidence obtained) The pill was observed to have the letters RP on one side and 10/325 on the other side. The resident was asked if she knew there was a pill in her bed. She stated, No, I didn't know that. I don't know what that is. I had a pain pill earlier, but I don't think that's my pain pill. She was asked not to take the pill, but to drop it into a medication cup for the nurse to see. Registered Nurse…

    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 · Fcited before2021-11-19 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by failing to maintain the kitchen in a safe and sanitary manner for the 90 residents in the facility. The findings include: During a visit to the kitchen on 11/15/21 at 10:28 AM, the following observations were made and acknowledged by the Certified Dietary Manager (CDM). 1. The toaster had breadcrumbs inside and outside of the equipment with splatters on it. (Photographic evidence obtained) 2. The microwave had splatter on the tray inside of the machine and had brown splatter on the inside of door. (Photographic evidence obtained) 3. The walk-in freezer had spills on the floor. 4. The thermometer could not be found inside the walk-in freezer. 5. Dry storage closet had food in boxes on the floor. 6. The dry items: flour and sugar were observed in large plastic containers without dates. 7. The ice maker was observed with grayish color on the inside top part of the unit. The outside of unit had white substance build…

    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 · Dcited before2021-11-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for one (Resident #7) of two sampled residents, reviewed for ADLs, out of a total sample of 37 residents. The findings include: On 11/15/2021 at 11:03 AM, Resident #7 was observed in her room with wet/greasy hair. On the front of her scalp, she had several clusters of dry, scaly patches dark beige in color. An attempt was made to interview the resident, but she was unable to answer any questions. A review of the clinical record indicated that Resident #7 was admitted into the facility on 7/23/2021. Her diagnoses included cerebral infarction due to embolism; hemiplegia affecting right dominant side; traumatic hemorrhage of cerebrum; unspecified seizures and anxiety disorder. A review of the quarterly minimum data set (MDS) assessment, dated 10/30/2021, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating 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
  • Potential for harm · D2021-11-19 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    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 that residents with a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain their highest practicable mental and psychosocial well-being, by failing to ensure that seven (7) active Agency nursing staff received education on the identification of a change in condition with proper interventions and documentation per the facility's plan of correction. As a result of the recertification and complaint survey completed on 11/19/2021, the facility was cited at F742 (Treatment/Services for Mental/Psychosocial Concerns) at an Immediate Jeopardy (IJ) level. The IJ was removed at the time of the survey exit on 11/19/2021, however the facility remained out of compliance at a scope and severity of D. The facility's plan of correction was submitted on 12/17/2021 indicating a completion date of 12/21/2021. The findings include: A review of the facility's plan of correction revealed, 3. Re-education to licensed nursing staff to include…

    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 · D2021-11-19 · 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

    Based on interviews, record review and facility policies and procedures, the facility failed to maintain complete and accurate medical records in accordance with professional standards for one (Resident #23, who was receiving controlled medication for insomnia) of six residents sampled for unnecessary medication use were complete and accurate, from a total sample of 38 residents. The findings include: On 11/15/21 at 02:00 PM, an interview was conducted with Resident #23 in her room. She reported that she had not received her sleeping pills for the past three days and it had been very difficult for her to get some restful sleep. She was told by staff that the medication had not been delivered by the pharmacy. A record review for Resident #23 revealed an admission date of 5/8/19, with diagnoses including syncope and collapse, major depressive disorder, and insomnia. A review of Resident #23's quarterly minimum data set (MDS) assessment, dated 8/16/21 revealed a brief interview for mental status (BIMS) score of 14, indicating cognitively intact. Care plan for Resident #23 indicated,…

    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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PALM GARDEN HEALTH AND REHABILITATION — 14 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 →

RatingThis homeChain avg
Overall 3 of 53.1-0.1 vs chain
Health inspection 3 of 52.6+0.4 vs chain
Staffing 3 of 53.4-0.4 vs chain
Quality measures 3 of 54.4-1.4 vs chain
The other 13 homes this chain runs (chain average 3.1★, per CMS)

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

Owner / managerTypeRoleShareSince
PALM GARDEN HEALTHCARE HOLDINGS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 11/01/2013
MCCARVER, PATSYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 11/01/2013
JAMES O. MCCARVER QTIP BUSINESS MARITAL TRUST U/A DATED JUNE 22, 2001,Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF38%since 11/01/2013
JAMES O. MCCARVER RESIDUARY TRUST SHARE U/A DATED 06/22/2001Organization5% OR GREATER INDIRECT OWNERSHIP INTEREST8%since 12/23/2014
PATSY E. MCCARVER TRUST U/A DATED JUNE 22, 2001 AS AMENDED, PATSY EOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF48%since 11/01/2013
PGJAX RE,LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 07/29/2024
REGIONS BANKOrganization5% OR GREATER SECURITY INTERESTsince 11/01/2013
BOMBERGER, JEFFREYIndividualCORPORATE OFFICERsince 10/01/2014
CHALMERS, JAMESIndividualCORPORATE OFFICERsince 01/01/2015
GREENE, ROBERTIndividualCORPORATE OFFICERsince 01/01/2015
DEMPS, KENYONNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/04/2025
ELRAMADY, DALIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/20/2024
PALM HEALTHCARE MANAGEMENT, LLCOrganizationADP OF THE SNFsince 04/04/2025

CMS files one row per role, so the 18 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$11.2M
Net patient revenuemost recent cost report
-10.7%
Operating marginrevenue minus expenses
$2.1M
Related-party expense17% of expenses
Who pays — share of resident-days
Medicaid 72%Medicare 5%Other / private 23%

About 72% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 17% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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

$331per resident / day
operating cost
$10,059per month
≈ monthly operating cost
$299per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.

Typical monthly cost in Florida
$10,342/mo
Nursing home (semi-private)
$12,167/mo
Nursing home (private)
$5,610/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105682. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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