Palm Garden Of Largo
10500 Starkey Rd, Largo, FL 33777 · For profit - Limited Liability company · 140 certified beds · (727) 397-8166 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0565)
- it has 3 actual-harm citations
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $66,613 in federal fines (most recent 2025-06-21)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- about 21% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 fell from 2 to 1 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.7% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.0% | 5.5% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.3% | 0.9% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.3% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 0.0% | 4.6% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.3% | 2.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 11.5% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 33.3% | 14.4% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 4.5% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.1% | 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 table | 7.6% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.6% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.3% | 94.7% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.3% | 26.1% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 7.9% | 9.1% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.38 | 2.13 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.60 | 1.15 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
62.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 522 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 41.5% 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 207 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.54 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 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.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 62.6%CMS range 58.6–66.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.0%CMS range 10.0–14.4 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 41.5% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 45.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 31.9% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 99.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.7%CMS range 4.8–9.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 140 beds and averages 135.8 residents a day — about 97% occupied, or roughly 4 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 3.64 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.19 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.32 hrs/resident/day on weekends vs 3.77 on weekdays — 12% thinner on weekends. RN hours go from 0.61 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · Gcited before2026-05-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observations, interviews, and record review, the facility failed to ensure the safety of one resident (#2) out of three residents sampled. This failure resulted in a fall with major injury for Resident #2 when the individual care plan for transfer was not followed during a shower. Findings included: On 05/18/2026 at 12:15 p.m. Resident #2 was observed lying down in bed. She stated she was still in pain from the fall she had a week ago during a shower. She stated a Certified Nursing Assistant (CNA) transferred her with the Hoyer Lift without assistance in the shower chair. She stated during her shower she kept telling the CNA she felt like she was going to fall out of the chair. She stated the chair felt like it was falling apart and she knew she was going to fall. She stated the CNA left her in the bathroom alone and that is when she fell out of the shower chair. Resident #2 stated she has never broken anything on her body before and she was in a lot of pain.Review of an admission record, dated 05/20/…
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.
- Actual harm · Gcited before2025-06-21 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 protect the resident's right to be free from neglect related to: 1) providing timely care and services to prevent physical/emotional discomfort for toileting assistance for one resident (#4) out of five residents sampled, and 2) protecting residents from unsympathetic/negative attitudes from staff for three residents (#6, #7, and #5) out of three residents sampled. These failures resulted in emotional/psychological distress and a fear of retaliation among residents. Findings included: 1. During a facility tour on 6/21/25 at 9:32 a.m., an observation was made of a call light signal on in Resident #4's room. There were no staff observed in the hallway responding the call light. On 6/21/25 at 9:40 a.m., an observation was made of a staff member at the nurse's station while the call light was displaying on above the nurse's station. The staff member, Staff H, Certified Nursing Assistant (CNA), said she was looking for something and could…
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.
- Actual harm · Gcited before2024-02-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 observation, interviews, and record review, the facility failed to ensure three (#320, #62, #321) of four residents reviewed for falls out of a total sample of 53 residents received accurate evaluations of fall risks to ensure adequate supervision, assistance devices, and individualized interventions were implemented to prevent accidents with injuries. Findings included: 1. Review of the admission Record revealed Resident #321 was originally admitted to the facility on [DATE] with diagnoses to include: history of falling, difficulty in walking, pain in left hip, muscle weakness, unspecified dementia, cognitive communication deficit, essential hypertension, and history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. The resident had a recent hospital stay from 2/16/2024 to 2/24/20224 when she was readmitted back to the facility. The admission Record showed an additional diagnosis of traumatic subdural hemorrhage without loss of consciousness, subsequent encounter…
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.
- Potential for harm · Ecited before2026-05-20 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
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 ensure proper infection control practices were utilized related to contact precautions on two resident units (100 and 200) out of three resident units in the facility.Findings included:An observation was conducted on 5/18/26 at 9:42 a.m. of a staff member entering room [ROOM NUMBER], which had a contact precaution sign on the door. The staff did not use personal protective equipment (PPE) while in the room.An observation as conducted on 5/18/26 at 9:53 a.m. of a staff member in room [ROOM NUMBER], which had a contact precaution sign on the door. The staff member did not have any PPE on while in the room. The staff member exited the room, spoke to the nurse in the hall, reentered the room, then exited again. No hand hygiene was observed. At 9:58 a.m. Staff C, LPN entered room [ROOM NUMBER] without donning PPE.An interview was conducted on 5/18/26 at 10:03 a.m. with Staff C, Licensed Practical Nurse (LPN). Staff C confirmed a resident in…
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.
- Potential for harm · Ecited before2025-02-10 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 interview and record review, the facility failed to follow the comprehensive person-centered care plan for three (#2, #4, #5) of three sampled residents related to bed mobility and transfers. Findings included: 1. Resident #2 was admitted on [DATE] and readmitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to traumatic subarachnoid hemorrhage without loss of consciousness on 08/18/2021; orthostatic hypotension, intervertebral disc displacement, lumbar region; other specified disorders of the brain; diabetes; anemia; adult failure to thrive; unspecified dementia severe; Cognitive Communication Deficit; stage 3 chronic kidney disease; Chronic Obstructive Pulmonary Disease, tremor, low back pain, hypertensive chronic kidney disease and spondylosis. Review of the Care Plans showed: ADL (Activities of Daily Living) Self-Care and/or mobility deficit. Resident #2 was at risk of developing complications associated with decreased ADL self-performance related to: weakness,…
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.
- Potential for harm · F2024-02-29 · tag F0645 — widespreadPASARR screening for Mental disorders or Intellectual Disabilities
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 record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnosis for four of four residents sampled for PASARRs (Residents #16, #20, #74 and #71). Findings included: 1. Review of the electronic medical record (EMR) revealed Resident #16 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder date 4/26/23, major depressive disorder date 7/14/23, schizoaffective disorder bipolar type date 6/20/23 and anxiety disorder date 4/26/23. Review of a level I PASARR for Resident #16 dated 04/25/23 showed the qualifying diagnoses were not checked or indicated. Further review showed a level II PASARR not submitted following qualifying diagnoses of schizoaffective disorder. 2. Review of the EMR for Resident #20 revealed the resident was admitted to the facility on [DATE] with diagnoses to include major…
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.
- Potential for harm · E2024-02-29 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
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 review, the facility failed to ensure grievances were addressed in a timely manner for resident council members with potential to affect a census of 135. Findings included: On 02/26/24 at 2:05 p.m., an interview was conducted with Resident #17, who was the Resident Council President. She stated the primary complaints that were on-going were related to food, care, and call bells not answered. She stated the residents complain the issues have not changed and are still ongoing. She stated the Director of Activities (DOA) reports to the DON after each meeting. She stated she would let her know what was discussed at the meeting. Resident #17 said, The problem is they don't have consistency, because they use lots of agency aides. The agency aides makes care more difficult because they don't know the residents or their needs. Some of them don't care. Yes, we have presented grievances through resident council. On 2/27/24 at 1:20 p.m., a Resident Council meeting was held with 11 residents…
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.
- Potential for harm · Ecited before2024-02-29 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 observations, interviews and medical record review, the facility failed to implement care plan interventions for four of fifty-three sampled residents (#106, #39, #109, #94), as evidenced by:1.) Staff not providing Resident #106 with a call light within his reach, while in bed and during two days observed (2/26/2024, 2/27/2024); 2.) Staff not performing and/or documenting monitoring of psychotropic medication use for Resident #106; 3.) Staff not coordinating dental services as needed for Resident #39; and 4). Failure to provide rehabilitation and restorative services for residents #109, and #94. Findings included: 1. On 2/26/2024 at 1:34 p.m. and at 2:20 p.m., Resident #106 was observed in his room and lying flat in a low to the floor bed, and with covers pulled over him. He was noted resting comfortably with his eyes closed. The call light button and cord were observed lying on the floor on one side of the dresser and close to the roommate's side of the room. The call light was not within Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-29 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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, interviews, and record review, the facility failed to revise and individualize a care plan to reflect a resident's condition for three residents (#320, 321, and 62) out of four sampled residents. Finding included: Review of the admission Record revealed Resident #320 was admitted to the facility on [DATE], with diagnoses to include: Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, Difficulty Walking, Anxiety Disorder, Diabetes Type 2, Anemia, Monoplegia of upper limb following Cerebral Infarction, other co-morbidities. Review of Resident #320's Medical Certification for Medicaid Long-Term Care Services and Patient Treatment Transfer Form, AHCA Form 5000-3008 dated 1/5/2024, showed resident to be at risk for falls. Review of Resident #320's Physician Order Summary Report active as of 1/14/2024 revealed resident was receiving: Alprazolam (psychotropic), Diphenhydramine HCl (antihistamine), Bupropion HCl (psychotropic), Dicyclomine HCl (cathartic), Dulcolax (cathartic), GlycoLax…
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.
- Potential for harm · E2024-02-29 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed, and five errors were identified for four (#17) out of five residents observed. These errors constituted a 16.67% medication error rate. Findings included: 1. On 2/28/24 at 7:29 a.m., an observation of medication administration with Staff H, Licensed Practical Nurse (LPN), was conducted with Resident #17. The staff member dispensed the following medications: - Vitamin D3 125 microgram (mcg) tablet over-the-counter (otc) (5000 international unit (iu)) - Ferrous sulfate 325 (milligram) mg otc tablet - Gabapentin 300 mg capsule - Tizanidine 2 mg capsule - Tamsulosin 0.4mg capsule - Metformin 1000 mg tablet The staff member had dispensed 2 tablets of Vitamin B12 then moved them both to another cup and set it aside, reporting the Vitamin B12 was to be administered by injection not orally. Staff H confirmed dispensing 6 oral tablets, and these were all the medications to be given at this time. 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.
- Potential for harm · Ecited before2024-02-29 · tag F0761 — failed to label and store drugs safely — patternEnsure 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 reviews, and interviews, the facility failed to ensure medications were stored appropriately in six resident rooms (202, 207, 223, 304, 317 and 325), medications were stored in locked cart while unattended in one (A-wing #2) out of six carts, one insulin vial for one (#37) out of two residents sampled for insulin administration was not expired, medications with a shortened life once open were labeled with an open date on two (A-Wing#1 and Rehab #2) of three sampled medication carts, one (A-wing) of three medication refrigerators were locked and inaccessible to unauthorized personnel, and one (Rehab) out of three refrigerated controlled substance boxes were locked. Findings included: 1. On 2/26/24 at 10:08 a.m., a tube of Preparation H, hemorrhoidal ointment, was observed sitting in a cardboard box on top of a dresser in room [ROOM NUMBER]-W. The observation also revealed one container of disinfecting wipes in the bottom drawer of a dresser belonging to Resident #52 and one on top of…
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.
- Potential for harm · Ecited before2024-02-29 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
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 reviews, and interviews, the facility failed to initiate an effective Infection Control program related to the posting of precautions required for one (room [ROOM NUMBER]) of one rooms observed with a Personal Protective Equipment (PPE) caddy hanging from doorway, ensure direct care staff (Staff B, J, BB and DD) kept fingernails at an appropriate length and within policy parameters, ensure facility staff were knowledgeable on the types of PPE required to enter two resident rooms (#104 and #327) with posted precaution signage, and PPE caddies were stocked with required PPE for one (#104) of three residents on precautions. Findings included: 1. On 2/26/24 at 9:41 a.m. an observation was made of a PPE caddy containing gowns, gloves, and face masks hanging from the shut door of room [ROOM NUMBER]. The caddy and surrounding area of the doorway did not have a sign posted indicating the type of precautions staff and visitors were to take prior to entering the resident room. (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.
- Potential for harm · D2024-02-29 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 interviews and medical record review, the facility failed to ensure one of fifty-three sampled residents (#76) was provided and maintained with privacy/dignity during two of four days observed (2/26/2024, and 2/27/2024). Findings included: On 2/26/2024 at 10:20 a.m. while touring the C wing halls, and prior to getting to Resident #76's room, the resident could be overheard calling out and moaning loudly. Upon reaching the resident's room, the door was open, and Resident #76 was noted lying flat in bed and with the covers off her body. She was observed not wearing any clothing and the bottom half of her body was exposed with only wearing an adult brief. Resident #76 was not interviewable. Three staff members were observed walking by the room and did not intervene to cover the resident up or assist the resident. On 2/27/2024 at 7:15 a.m. Resident #76's room was approached, and the door was open. From the hallway, the resident was observed lying in bed and with the covers off her lower…
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.
Show the remaining 17 citations
- Potential for harm · Dcited before2024-02-29 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 facility policy review, the facility failed to protect a resident's right to be free from abuse and neglect, failed to ensure a resident who required one-person assistance with ADLs (activities of daily living), was provided timely care and assistance with toileting, and neglected to ensure a comfortable environment for one out of two residents reviewed (Resident #94.) Findings included: Resident #94, an [AGE] year-old female was admitted to the facility on [DATE] with diagnoses to include senile degeneration of brain, not elsewhere classified, abnormal weight loss, adult failure to thrive, age-related osteoporosis without current pathological fracture, anxiety disorder, unspecified, calculus of gallbladder without cholecystitis without obstruction, constipation, unspecified, gastro-esophageal reflux disease without esophagitis, iron deficiency anemia, unspecified, other idiopathic scoliosis, lumbar region, retention of urine, unspecified, rheumatoid…
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.
- Potential for harm · D2024-02-29 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, record review and facility policy review, the facility failed to ensure allegations of abuse and neglect were investigated for one (#94) of two residents reviewed. Findings included: On 02/27/24 at 10:54 a.m., an interview was conducted with Resident #94. She stated on the night of 02/14/24, a certified nurse's assistant (CNA) was not nice. She said, I believe she was an agency staff. I do not know her. She was rough during care. I turned on the call light at about 4:30 a.m. She entered the room in a hurry, she woke me up. She turned off my call light and left. When she came back, she was not in a good mood. She treated me badly. I said, get another job. She turned off my light again and left. Five times I put on my call light and each time she came in and turned it off. The whole time she did not change me. Finally, she changed me. She then put my blanket and sheet on the chair and left me exposed. I was cold. I turned on the light again. She came in and I said, I am cold. I need my blanket. She said you should say I'm sorry first. I refused to apologize.…
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.
- Potential for harm · Dcited before2024-02-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 observations, record reviews, and interviews, the facility failed to ensure skin conditions were identified and treated for three (#57, #274, and #21) out of nine residents reviewed for skin conditions and failed to identify and respond to one (#325) out of one residents sampled for change in condition in a timely manner that resulted in a hospitalization. Findings included: On 2/29/24 at 4:13 p.m., Resident #57 was observed lying in bed, wearing bilateral offloading boots. The observation was conducted with Staff S, Registered Nurse (RN). The staff member explained the observation to the resident, who assisted with raising right foot from the boot. The observation revealed a topical patch had been applied to the front ankle area of the resident, which the staff member reported as a Lidocaine patch, a gangrenous area was noted to the resident's right great toe and a slightly reddened approximate quarter-sized area was observed on the resident's right heel. The area was confirmed by the staff member.…
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.
- Potential for harm · D2024-02-29 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 reviews and interviews, the facility failed to respond to the consultant pharmacist's recommendations in a timely and accurate manner and for one (#3) out of 5 residents sampled for the administration of unnecessary medications. Findings included: On 2/26/24 at 11:41a.m., Resident #3 was observed and interviewed in the resident's room. The resident was alert and oriented and able to respond appropriately to initial interview questions. Review of Resident #3's admission Record showed the resident was admitted on [DATE] with diagnoses not limited to unspecified site unspecified osteoarthritis, age-related osteoporosis without current pathological fracture, and generalized muscle weakness. Review of the admission Medication Regimen Review Report, issued on 1/2/24, revealed the consultant Pharmacist asked for the facility to add pain intensity for use on as needed (prn) Norco (Hydrocodone/Acetaminophen (ApAp) order. The recommendation revealed Moderate pain handwritten across 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.
- Potential for harm · D2024-02-29 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 medical record review, the facility failed to ensure one of six sampled residents (#106) for use of psychotropic medication use, was monitored and documented for signs/symptoms/side effects. Findings included: A record review for Resident #106, revealed diagnoses to include but not limited to: Nontraumatic subarachnoid hemorrhage, Aphasia, Dysarthria, Epilepsy, Mood disorder, Abnormalities in gait, Lack of coordination Dementia, Major depression disorder, Anxiety, and Insomnia. Review of the current [NAME] Data Set (MDS) 12/15/2023 Quarterly assessment revealed; Cognition/Brire Interview Mental Status score 3 of 15, which indicated Resident #106 would not have been able to speak related to his medical and care services; Mood - None noted. However, indicated under social isolation - Sometimes; Behaviors - Rejection of care 1-3 days. Review of the current month (02/2024) physician's order sheet revealed psychotropic medication use to include; a. Ativan 0.5 mg (milligram) 1 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.
- Potential for harm · D2024-02-29 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one (#39) of two residents sampled for dental care received dental services to meet her needs as requested. Findings included: Observation and interview on 2/27/2024 at 9:30 a.m. with Resident #39 revealed several missing teeth. Of the remaining teeth, several were noted to be broken/chipped and dark in color. Resident #39 stated she brushed her teeth on her own every day and denied assistance with oral care by staff. Resident #39 stated, I don't have any pain right now, but I have had pain and one of my teeth on my right side of my mouth cuts into my mouth at times. Resident #39 could not recall how long she has had this problem and if she had reported this to staff. Resident #39 did remember dental services seeing her in the facility. Review of Resident #39's admission record revealed an original admission date in 2015 with the most recent readmission date in November of 2023. Review of the annual Minimum Data Set (MDS)…
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.
- Potential for harm · D2024-02-29 · tag F0849 — isolatedArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
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, and interviews, the facility failed to collaborate care with an external provider for one (#74) out of one resident sampled for Hospice services, as evidenced by not ensuring staff collaborated care with the provider, the medical record contained provider assessments, and staff had knowledge of the services provided by the Hospice staff. Findings included: An observation was made on 2/26/24 at 11:17 a.m. of Resident #74. The resident was observed lying in bed, dressed and clean, the television was playing without sound, and the resident was talking to self. The resident was confused and speaking repetitively. An observation was made on 2/27/24 at 8:30 a.m. of Resident #74 sitting in a wheelchair, feet dangling with a meal tray on the over-bed table to the side of the resident. The resident was talking to self, regarding a church. Review of Resident #74's clinical record showed the resident was admitted on [DATE] and included diagnoses not limited to unspecified chronic…
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.
- Potential for harm · D2024-02-29 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
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 one of fifty-three sampled residents (#106) was provided a call light button and placed within his reach, while in bed and during two of four days observed (2/26/2024, and 2/27/2024). Findings included: On 2/26/2024 at 1:34 p.m. and at 2:20 p.m., Resident #106 was observed in his room and lying flat in a low to the floor bed, and with covers pulled over him. He was noted resting comfortably with his eyes closed. The call light button and cord were observed lying on the floor on one side of the dresser and close to the roommate's side of the room. The call light was not within Resident #106's reach, should he need to use it to get staff assistance. On 2/27/2024 at 8:20 a.m. Resident #106 was observed in his room and lying flat in a low bed. The call light cord and button (soft bulb) was observed on the floor behind the left side of the bed and at the wall floor, unreachable by the resident. During both observed dates (2/26/2024 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.
- Potential for harm · D2023-08-15 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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, record review, and interview, the facility failed to make prompt efforts to resolve grievances for one (Resident #2) of three sampled residents. Findings included: A review of the admission Record showed Resident #2 was initially admitted into the facility on [DATE] with a primary diagnosis of unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the Minimum Data Set (MDS), Section C, Cognitive Patterns dated 07/09/23, showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. Section G, Functional Status, showed Resident #2 needed extensive assistance with one-person physical assist for bed mobility, dressing, toilet use, and personal hygiene. He needed limited assistance with one-person physical assist for transfer and locomotion on and off the unit. Resident #2 was independent with walking in the room and eating. Section P, Restraints and Alarms. showed…
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.
- Potential for harm · D2023-08-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 review the facility failed to report timely misappropriation of resident property related to a pack of narcotic pills for one (Resident #6) out of 2 reportable events reviewed. Findings include: Resident #6 was readmitted to the facility on [DATE] and initially admitted to the facility on [DATE]. Her medical diagnoses included but were limited to chronic pain syndrome, specific disorders of bone density and structure, intraductal carcinoma in situ of left breast, polyneuropathy, and cognitive communication deficit. An interview was conducted with Resident #6 on 8/15/23 at 1:50 p.m. She was observed in her wheelchair writing on a piece of paper at a desk in her room. She stated she had her Percocets [pain medication] go missing one time, but the facility did well with that. They got me more medications and I got my dose that night. They gave me Ibuprofen instead and that was fine. The resident appeared to be comfortable during the interview without any complaints or grimacing of…
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.
- Potential for harm · Ecited before2021-12-10 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 3. Resident observed on 12/8/2021 at 12:18 p.m. with linear and circular markings along the left shoulder and Right lower leg. Resident #64 was observed scratching at her shoulder. Review of weekly skin checks dated 12/9/2021 revealed the resident had impaired skin. Review of the Situation, Background, Appearance, Review and notify (SBAR) form dated 12/9/21 detailed the resident with skin or wound ulcer. Primary care clinician notified on 12/9/21 at 11:40 a.m. and ordered lac hydrin lotion for dry skin. Review of the weekly skin assessment dated [DATE] at 5:13 p.m. revealed the resident with intact skin. Review of the weekly skin assessment dated [DATE] at 5:13 p.m. revealed the resident with intact skin. Review of the weekly skin assessment dated [DATE] at 8:13 p.m. revealed the resident with intact skin. Review of the weekly skin assessment dated [DATE] at 8:13 p.m. revealed the resident with intact skin. Review of the care plan revealed the resident focus area of risk for alteration in skin integrity related…
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.
- Potential for harm · E2021-12-10 · tag F0867 — failed to act on quality-improvement findings — patternSet 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and the facility Plan of Correction review, the facility failed to ensure it had a functioning Quality Assurance Committee. The facility had deficient practices identified during the Recertification and Complaint survey for complaint numbers 2021003271, 2020019788, and 2020011362, conducted on [DATE] to [DATE] and was cited F684. The facility developed a Plan of Correction with a completion date of [DATE]. On [DATE], the facility was recited F684 for failure to ensure Best Practice for Peripherally Inserted Central Catheters (PICC) was utilized for three (#5, #9, #10) out of three sampled residents on intravenous therapy, as evidenced by omitted monitoring, medication, intermediate flushes, and dressing changes. The facility had not comprehensively implemented the plan of correction for the identified deficiency. Findings included: A review of the facility Quality Assurance and Performance Improvement (QAPI) plan, policy, and procedures, undated, documented: Palm…
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.
- Potential for harm · D2021-12-10 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure reasonable accommodation for one (#34) out thirty-six sampled residents as evidenced by not keeping fluids within reach due to visual impairment. Findings included: On 12/07/21 at 1:25 p.m. Resident #34 was observed seated in her wheelchair and comfortable. During the interview the resident was identified with a visual deficit and unable to make eye contact. The resident said she would like some orange juice. The bedside table was observed with two Styrofoam cups and located to her left side approximately three feet away from the resident's seated position and not within the resident's reach. The resident activated the call light button, and after a short period Staff Member C entered the room and identified herself as the unit manager. Staff Member C provided the resident with juice and confirmed the resident's fluids were not within reach. Medical record review of the admission Record form revealed Resident #34 had resided at the facility for three years, and had diagnoses not limited to legal…
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.
- Potential for harm · Dcited before2021-12-10 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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
Based on observations, interviews, and record review, the facility failed to develop comprehensive care plans related to the monitoring and placement of an elopement bracelet alarm on one (Resident # 424) of five residents sampled for accidents. Findings included: An observation on 12/07/21 at 3:15 p.m. revealed Resident #424 sitting in a wheelchair across from the nursing station with an elopement alarm bracelet located on the resident's right ankle. A review of Resident #424's admission record revealed medical diagnoses of weakness, focal traumatic brain injury, atrial fibrillation, vascular dementia, hearing loss, and adjustment disorder with mixed anxiety. Resident #424's care plan revealed focus areas related to being a fall risk with poor safety awareness with unsafe ambulation (date initiated 12/01/21), and impaired cognition with short-term and long-term memory deficits with problems understanding others due to disease process and vascular dementia (date initiated 12/02/21). The care plan did not identify interventions related to monitoring placement and functionality of an…
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.
- Potential for harm · Dcited before2021-12-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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
Based on observation, interview and record review, the facility failed to ensure prescribed biological medications were secured for one Resident #29 on three (12/08/21, 12/09/21 and 12/10/21) of four days observed. Findings Included: During an interview and observation with Resident #29 on 12/8/21 at 12:48 p.m. three tubes of medication were observed in a clear plastic bag in the resident's room. The medications were Clotrimazole-Betamethasone Cream, Ammonium Lactate Cream 12%, and triple antibiotic ointment, and were labelled with the resident's last name. Photographic evidence was obtained. On 12/09/21 at 10:32 a.m. Resident #29 was observed sitting in a recliner talking with the nurse. The bag containing the three biological medications was observed on the resident's bedside table. An observation on 12/10/21 at 8:00 a.m. with the Director of Nursing (DON), confirmed the three medicated creams were in a clear plastic bag labelled with the resident's name and located in the resident's room. The DON stated the medications should be secured in the medication cart by the nurse. 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.
- Potential for harm · Ecited before2020-09-11 · tag F0761 — failed to label and store drugs safely — patternEnsure 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
Based on observations, record review, and interviews the facility: 1. failed to provide a permanently affixed compartment for storage of controlled drugs in three medication storage room refrigerators (A-Wing, C-Wing and Rehab Unit) of 3 refrigerators, and 2. failed to ensure that an opened insulin pen was labeled with the date opened in one medication storage room refrigerator (Rehab Unit) of three medication storage room refrigerators. Findings included: 1. On 09/09/2020 at 8:55 a.m. the Assistant Director of Nursing (ADON) accommodated the observation of the locked storage room on the C-Wing located behind the nurse's station. The refrigerator in the room was locked and contained a locked plastic box that was not permanently affixed and was easily removed from the refrigerator. The plastic box contained a closed small plastic box with plastic tie wraps that contained three vials of Lorazepam 2 mg/ml (milligrams/milliliters), a Schedule IV medication. (Photographic Evidence Obtained) On 09/09/2020 at 9:10 a.m. The ADON then accommodated the observation of the locked storage room…
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.
- Potential for harm · Dcited before2020-09-11 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 implement a care plan intervention related to fall prevention as written and determined by the facility's Interdisciplinary Team for one resident (#59) of four residents that required floor mats. Findings included: Record review of the Incident by Incident Type Log for March 9, 2020 to September 9, 2020 revealed Resident #59 had seven falls since April 2020. Four out of the seven falls were classified as unwitnessed. The unwitnessed falls occurred on 4/29/20, 5/2/20, 6/27/20, and 9/8/20. An observation on 9/9/20 at 2:54 p.m., revealed Resident #59 was lying in bed under the covers. His bed was in the lowest position with the handrails lifted. There were no floor mats observed on the floor beside the Resident's bed. Further observation revealed no floor mat availability within the room. Resident #59's admission Record revealed an admission date of 1/18/20 with medical diagnoses to include heart failure, major depressive disorder, repeated…
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.
“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.
- 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.
Fines & penalties
$66,613 in federal fines across 2 penalties.
- $33,248 — penalty dated 2025-06-21
- $33,365 — penalty dated 2024-02-29
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 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 3.1 | -1.1 vs chain |
| Health inspection | 1 of 5 | 2.6 | -1.6 vs chain |
| Staffing | 3 of 5 | 3.4 | -0.4 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PALM GARDEN HEALTHCARE HOLDINGS, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 11/01/2013 |
| MCCARVER, PATSY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 11/01/2013 |
| JAMES O. MCCARVER QTIP BUSINESS MARITAL TRUST U/A DATED JUNE 22, 2001, | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 38% | since 11/01/2013 |
| JAMES O. MCCARVER RESIDUARY TRUST SHARE U/A DATED 06/22/2001 | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 8% | since 12/23/2014 |
| PATSY E. MCCARVER TRUST U/A DATED JUNE 22, 2001 AS AMENDED, PATSY E | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 48% | since 11/01/2013 |
| PGLAR RE, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 06/20/2024 |
| REGIONS BANK | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST | — | since 11/01/2013 |
| BOMBERGER, JEFFREY | Individual | CORPORATE OFFICER | — | since 10/01/2024 |
| CHALMERS, JAMES | Individual | CORPORATE OFFICER | — | since 01/01/2015 |
| GREENE, ROBERT | Individual | CORPORATE OFFICER | — | since 01/01/2015 |
| FITTS, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/07/2025 |
| KORBAJ, RABEE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/15/2024 |
| PALM HEALTHCARE MANAGEMENT, LLC | Organization | ADP OF THE SNF | — | since 04/08/2025 |
CMS files one row per role, so the 20 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.
This home reported $3.8M paid to related parties — landlords or management companies under common ownership — equal to about 21% 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.
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
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.
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 105574. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-02-29, 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.