No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Palm Garden Of Ocala

2700 SW 34th St, Ocala, FL 34474 · For profit - Limited Liability company · 180 certified beds · (352) 854-6262 Medicare & Medicaid certified

Call the home — (352) 854-6262 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation$8,512 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a middle-of-the-pack inspection score (3/5)
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,512 in federal fines (most recent 2024-12-19)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • about 21% 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.

4/5
CMS overall
4 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 5 of 5

Worth a closer look. This home's quality-measure rating runs 2 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 — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Urgent care / clinic
3306 SW 26th Ave · (352) 622-2020 · Call to confirm hours
Pharmacy
2575 SW 42nd St, Ste 100 · (352) 237-3648 · Call to confirm hours
Grocery
3128 SW 27th Ave · (352) 237-5313 · Call to confirm hours
Park
3750 SW 27th Ave · (352) 629-2489 · Typically dawn to dusk

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 improved from 3 to 4 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 rating4★
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 increased6.5%8.7%15.4%better
Long-stay residents who lose too much weight1.8%5.5%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.1%0.7%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms2.4%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 injury3.2%2.5%3.3%typical
Long-stay residents whose ability to walk worsened4.5%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication31.8%14.4%18.9%worse
Long-stay residents given the seasonal flu vaccine99.4%99.2%95.3%typical
Long-stay residents with pressure ulcers2.6%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control11.9%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 table4.3%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine99.6%94.7%79.4%better
Short-stay residents rehospitalized after admission21.8%26.1%22.6%typical
Short-stay residents with an outpatient ER visit4.3%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.702.131.67worse
Long-stay outpatient ER visits per 1,000 resident days1.021.151.80better

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.

51.8% 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 234 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.8%U.S. median 51.5%
Got home and stayed home
10.9%U.S. median 10.7%
Went back to hospital
46.7%U.S. median 56.6%
Met the expected recovery
0.32U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 46.7% 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 184 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% 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 SNF51.8%CMS range 45.6–57.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 8.3–14.010.7%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 discharge46.7%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 discharge51.6%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 discharge40.2%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 identified89.8%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 setting100.0%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 discharge91.7%98.7%Oct 2024–Sep 2025CMS 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 stay1.2%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 worsened2.0%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 hospitalization7.8%CMS range 4.9–11.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.061.02Oct 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

0.32
RN hours/ resident / day
0.99
LPN hours/ resident / day
2.13
Aide hours/ resident / day
3.45
Total nurse hours/ resident / day
0.13
RN hoursweekends
51.9%
Total nursing turnover
18.2%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 176.3 residents a day — about 98% 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 3.45 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 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 3.13 hrs/resident/day on weekends vs 3.57 on weekdays — 12% thinner on weekends. RN hours go from 0.40 to 0.13 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 52% 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 (2025-06-12)
6
at the previous standard inspection (2024-03-07)

Deficiencies are unchanged from the previous inspection. 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.

19 citations, most serious first. The 11 most serious are shown; the remaining 8 are one tap away and print in full.

  • Actual harm · Gcited before2024-12-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure adequate supervision during toileting to prevent an accident resulting in head injury and transferred to a higher level of care for 1 of 3 residents reviewed for accident prevention (Resident #1). Findings include: Review of Resident #1's admission record documented diagnosis to include wedge compression fracture of first and fifth lumbar vertebra, Huntington's Disease, and ataxia (poor muscle control that affects balance and coordination). Review of the fall risk assessment for Resident #1 dated 12/14/2024, revealed a score of 13. A Score 10 or higher indicated the resident is at high risk of falls. Review of Resident #1's progress note dated 12/18/2024 documented, Late entry. Staff A, CNA [Certified Nursing Assistant] reports toileting resident and allowed her privacy and upon return to bathroom resident on left side appearing to bleeding {sic} from head. Resident states 'I fell.' Review of Resident #1's progress note dated 12/19/2024…

    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 before2025-12-17 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 physician ordered medication parameters were followed for adequate indications for use, resulting in the administration of unnecessary medications for 1 of 3 residents, Resident #1 reviewed for unnecessary pain medications.Findings include:Review of Resident #1's admission record documented diagnosis of fibromyalgia (a disorder of pain processing causing chronic widespread pain), low back pain, unspecified, unspecified dementia, unspecified severity without behavioral disturbance, psychotic, mood disturbance and anxiety, insomnia unspecified, essential (primary) hypertension (high blood pressure), hyperlipidemia unspecified (high cholesterol), migraine, long term use of opiate analgesic, fracture of one rib, left side, gastroesophageal reflux disease without esophagitis, anxiety disorder, major depressive disorder, recurrent, mild, unspecified glaucoma and presence of right artificial shoulder joint. Review of Resident #1's physician order dated 12/9/2025 read, Tramadol HCL tablet 50 mg (milligram) give 1 tablet 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-12 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 1 of 2 residents reviewed for accidents (Resident #70), 2 of 5 residents reviewed for insulin administration (Residents #82 and #167), and 1 of 8 residents reviewed for oxygen therapy (Resident #166). Findings include: 1) During an observation on 6/10/2025 at 8:07 AM, Resident #70 was lying in bed. The bed was in a low position. There was one fall mat on the right side of the bed. There was a fall mat stored behind a chair in the resident room (Photographic evidence obtained). During an observation on 6/11/2025 at 7:54 AM, Resident #70 was lying in bed. The bed was in a low position. There was one fall mat on the right side of the bed. There was a fall mat stored behind a chair in the resident room. Review of Resident #70's care plan initiated on 4/21/2025 read, Focus: At risk for falls related to general weakness, impaired mobility, advanced age, poor safety awareness, right sided hemi [hemiplegia], dm [diabetes mellitus], gout, g-tube [gastrostomy tube],…

    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 · Ecited before2025-06-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care as ordered by physician for 4 of 8 residents reviewed for respiratory services (Residents #19, #66, #166 and #51). Findings include: 1) During an observation on 6/9/2025 at 9:27 AM, Resident #19 was in bed, receiving oxygen at 4 liters per minute via nasal cannula. The oxygen concentrator was on the left side of the bed outside of the resident's reach. During an interview on 6/9/2025 at 9:27 AM, Resident #19 stated, I don't touch the oxygen. The nurses do that. They take it off and put it on for me. Review of Resident #19's physician order dated 2/20/2025 read, Oxygen at 2 LPM [liters per minute] via N/C [nasal cannula] PRN [as needed] as needed for Shortness of Breath. No Humidity. During an interview on 6/10/2025 at 7:47 AM, Staff E, Licensed Practical Nurse (LPN), stated, The oxygen is not running at the right amount. 2) During an observation on 6/9/2025 at 12:19 PM, Resident #66 was receiving oxygen at 5 liters per minute via nasal cannula from an oxygen…

    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 before2025-06-12 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 interview, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status for 2 of 8 residents reviewed for oxygen therapy (Resident #19 and #99). Findings include: 1) Review of Resident #19's admission record showed an admission date of 6/27/2024 with the diagnoses including chronic systolic (congestive) heart failure, acute pulmonary edema, dyspnea, dependence on supplemental oxygen, and anxiety disorder. Review of Resident #19's physician order dated 2/20/2025 read, Oxygen at 2 LPM [Liters Per Minute] via N/C [Nasal Cannula] PRN [as needed] as needed for Shortness of Breath, No Humidity. Review of Resident #19's quarterly MDS assessment dated [DATE] showed no entries documented for receiving oxygen therapy under Section O- Special Treatments, Procedures and Programs. 2) Review of Resident #99's admission record showed an admission date of 8/30/2024 with the diagnoses including chronic obstructive pulmonary disease with (acute)…

    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 · Dcited before2025-06-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents were free of accident hazards for 1 of 5 residents reviewed for dining (Resident #70). Findings include: During an observation on 6/10/2025 at 11:05 AM, Resident #70 was sitting in a wheelchair in the hallway with a gait belt and walker. Staff A, Physical Therapist (PT), was in front of Resident #70 with a clear plastic cup containing water. Staff A gave the cup to Resident #70. Resident #70 started drinking water from the cup. Staff B, Licensed Practical Nurse (LPN), asked Staff A if Resident #70 was supposed to be given regular thin liquids because she believed Resident #70 was on a thickened liquid diet. Staff A, PT, stated, She [Resident #70] is doing well with it. Staff B, LPN, stated she would need clarification after checking the order in the computer and reading out loud Resident #70 had a thickened liquid diet order. Staff B stated she would go get clarification from the speech therapist and walked away from the medication cart. Staff A tried to remove the cup from Resident #70's…

    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 before2025-06-12 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary 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 record review and interview, the facility failed to ensure residents' medication regimens were free from unnecessary antibiotic use for 1 of 3 residents reviewed for active infections (Resident #165). Findings include: Review of Resident #165's admission record showed the resident was admitted on [DATE] with diagnoses including essential (primary) hypertension, fracture of right femur, history of falling, peripheral vascular disease, and non-infective gastroenteritis and colitis. Review of Resident #165's physician orders showed an order dated 6/7/2025 for stool test for Clostridium difficile (C. diff) one time only for loose stool for 1 day. Review of Resident #165's physician orders showed an order dated 6/7/2025 for administration of Vancomycin HCl (Hydrochloride) oral capsule 125 MG (milligram) 1 capsule by mouth four times a day for prophylaxis. Review of Resident #165's lab results dated 6/8/2025 for C. diff. showed a negative result. Review of Resident #165's physician orders showed an order…

    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 · Dcited before2025-06-12 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure foods were stored in a safe and sanitary manner in the main kitchen and in 1 of 3 nourishment rooms of the facility. Findings include: During an observation while conducting a tour of the main kitchen on 6/9/2025 at 9:08 AM with the Dietary Supervisor, there were one unwrapped peperoni pizza sitting on top of a cardboard box located on the third shelf with no opened date or expiration date, and one 5-pound plastic container of sour cream sitting on the second shelf with a date of 5/10/25 written in black marker in the walk-in cooler. During an interview on 6/9/2025 at 9:12 AM, the Dietary Supervisor acknowledged the unwrapped, undated pizza and stated, That should be wrapped up with a use by date on it. The Dietary Supervisor could not clarify if 5/10/25 was the opened date or the expiration date of the sour cream. The Dietary Supervisor stated, I think that is the opened date. It [the container of sour cream] should have been…

    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 · E2024-03-07 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    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 prevent the possible spread of infection for residents on contact isolation, during hydration pass, and medication administration. Findings include: 1) Review of the admission record for Resident #52 documented diagnosis to include acute kidney failure, type 2 diabetes mellitus, chronic kidney disease stage 3, personal history of transient ischemic attack (TIA) and cerebral infarction (a stroke) and essential (primary) hypertension. Review of the document titled, Lab results report for Resident #52 dated 3/3/2024 read, C. [Clostridium] Difficile Molecular [a highly sensitive and specific test for the presence of a toxin-producing C. difficile organism] result positive. 1st call attempt-3/4/2024 7:25 PM- unable to reach nurse. Critical result called to [Staff name] on 3/5/2024 9:35 AM by [laboratory staff name]. Review of Resident #52's physician orders dated 3/5/2024 read, Contact precautions every shift for C. Diff [Clostridium Difficile] for 14 days. During an observation of Resident #52's room on 3/5/2024…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-07 · tag F0658 — failed to meet professional standards of care — isolated
    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 observation, interview, and record review the facility failed to ensure medications were administered according to professional standards of practice and quality for 4 of 5 observations for medication administration, Residents #603, #138, #36, and #17. Findings include: During an observation of medication administration on 3/6/2024 at 8:39 AM with Staff C, Licensed Practical Nurse (LPN) for Resident #603, Staff C, LPN did not vigorously cleanse the right single lumen peripherally inserted catheter (PICC) needleless connector, did not allow the needleless connector to fully dry, attached 0.9% normal saline and flushed the PICC line without verifying placement by checking for blood return. Review of the admission record for Resident #603 documented admission diagnosis of pneumonia, aspergillosis (an infection caused by aspergillus, a common mold), acute upper respiratory infection, unspecified atrial fibrillation (an irregular heartbeat), type 2 diabetes mellitus, atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain), heart failure, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-07 · 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 observation, interview, and record review, the facility failed to ensure residents who are unable to carry out activities of grooming and personal hygiene receive these necessary services for 1 of 4 residents, Resident #12. Findings include: Review of Resident #12's medical record documented the resident was admitted on [DATE] with a diagnosis of: cardiomegaly, mild protein-calorie malnutrition; nontraumatic hematoma of soft tissue; carpal tunnel syndrome, unspecified upper limb; lesion of ulnar nerve, right upper limb; history of falling; unspecified dementia; unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; other idiopathic peripheral autonomic neuropathy; contracture, right hand. During an observation on 3/4/24 at 12:30 PM Resident #12 was sitting up in bed eating lunch. The fingernails of both resident's hands were long and dirty. The resident's hair was unkempt and matted. During an interview on 3/4/24 at 12:30 PM, Resident #12's son stated,…

    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
Show the remaining 8 citations
  • Potential for harm · D2024-03-07 · 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 interview the facility failed to ensure medications were managed in accordance with professional standards for 1 of 5 residents, Resident #111, reviewed for medications. Findings include: Review of Resident #111's admission Record, date of initial admission 5/17/2023, documented the resident was admitted with diagnoses that included type 2 diabetes mellitus with unspecified complications. Review of Resident #111's physician order dated 1/6/2024 read, Lantus Subcutaneous Solution 100 Unit/ML [milliliter] (Insulin Glargine) Inject 30 unit subcutaneously two times a day for DM [diabetes mellitus]. Review of Resident #111's medication administration record (MAR) for the period of 2/1/2024-2/29/2024 documented the resident refused the Lantus medication 18 times, was not administered the medication 15 times coded as 9 Other/See Nurse Notes and was not administered the medication 12 times coded as 5 Hold/See Nurse Notes. Review of the MAR for the period of 3/1/2024-3/6/2024 documented Resident #111 refused the Lantus medication 4 times, was not administered 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 · D2024-03-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 provide appropriate treatment and services to prevent possible urinary tract infections for 1 of 3 residents, Resident #67 reviewed for indwelling urinary catheters. Findings include: Review of the admission record documented Resident #67 was admitted to the facility with the following diagnoses: type 2 diabetes mellitus without complications, occlusion and stenosis of the left carotid artery, essential (primary) hypertension, atherosclerotic heart disease of the native coronary artery without angina pectoris (chest pain), seizures, pressure ulcer sacral region, hypothyroidism, heart failure unspecified, unspecified dementia without behavioral disturbances, and major depressive disorder. Review of Resident #67's physician orders dated 1/31/2024 read, Indwelling catheter #16 FR [French] per 10 ml [milliliter] DX [diagnosis] unstageable sacral wound. During an observation on 3/4/2024 at 12:33 PM Resident #67 was in bed, the urinary catheter drainage bag was resting on the floor attached to the bed with the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-07 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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 and interview, the facility failed to ensure the kitchen environment was kept clean and sanitary in accordance with professional standards. (Photographic evidence obtained). Findings include: During the kitchen tour on 3/4/2024 at 9:15 AM with the Certified Dietary Manager (CDM), there was brownish water overflowing from a floor drain next to the food prep area in the main kitchen. During an interview on 3/4/2024 at 9:15 AM, the CDM stated, It has been like that for a few days, and I will have to have maintenance look at it. During a follow up visit of the kitchen on 3/5/2024 at 6:45 AM, brownish water was overflowing from the floor drain next to the food prep area in the main kitchen. During a follow-up visit to the kitchen on 3/6/2024 at 10:00 AM, there was brownish water overflowing from the floor drain next to the food prep area in the main kitchen. During an interview on 3/6/2024 at 10:00 AM, the CDM stated, The problem is that we could not get the top off the drain to clean it out, and maintenance has called the plumber. During an interview on 3/6/2024 at…

    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 before2022-10-28 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 interview, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 3 residents sampled for discharge review, Resident #147. Findings include: Review of Resident #147 progress note dated 8/5/2022 reads pt. [patient] in bed no apparent distress skin warm to touch, VS (vital signs) taken and recorded all WNL (within normal limits), pt. is able to voice his needs, denied pain and discomfort when asked, wife and son at bed side waiting for discharged info [information] pt went home with family about 12 noon. Review of Resident #147 Minimum Data Set (MDS) dated [DATE] read Section A0310, Type of Assessment: Discharge assessment-return not anticipated. Section A2000 discharge date [DATE], Discharge Status: Acute Hospital. Review of Resident #145 IDT (interdisciplinary team) Discharge summary dated [DATE] read B. Final Summary- Social Services: 10. Guest Family request discharge to home today 8/5/22. Baycare hh [Home Health] ordered per request. No…

    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 · Dcited before2022-10-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care received such care consistent with professional standards of practice for 1 sampled resident, Resident #130, out of 28 residents who needed respiratory care. Findings include: During an observation on 10/24/2022 at 3:28 PM, Resident #130 did not have any nasal cannula or mask to receive oxygen. During an interview on 10/24/2022 at 3:28 PM, Resident #130 stated, I am supposed to be on oxygen 24 hours. During an observation on 10/26/2022 at 8:25 AM, Resident #130 was receiving oxygen at 3.5 L/min (liters per minute) via N/C (nasal cannula). During an interview on 10/26/2022 at 8:25 AM, when asked about the dose of oxygen, Resident #130 stated, They gave me two. Review of Resident #130's medical records revealed the resident was admitted on [DATE] and readmitted on [DATE] with the diagnoses including osteomyelitis, gastrointestinal hemorrhage, anemia, chronic obstructive pulmonary disease,…

    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 · D2022-10-28 · 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

    Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. Findings include: An observation on October 25, 2022 at 9:10 AM of the 500 hall medication cart with Staff A, Licensed Practical Nurse (LPN) and Director of Nursing (DON) revealed 3 insulin pens were opened and undated in the cart. An envelope for Resident #141 in 503 W contained 1 Humulin 70/30 KwikPen with order date of 10/23/22 without an open date. Another envelope for Resident #141 contained an insulin pen, Humulin 70/30 KwikPen with order date of 10/13/22 without an open date. An envelope for Resident #149 in 505 D contained an insulin pen, Insulin Asparte Protamine 70/30 with an order date of 10/13/22 without an open date. The LPN was observed to uncap each pen and observe that each pen did have medication missing (photographic evidence obtained). During an interview on October 25, 2022 at 9:10 AM Staff A, LPN stated Insulin pens should be labeled with an open date, I should have…

    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 · D2022-10-28 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medical records were accurately documented in accordance with accepted professional standards and practices for 1 of 3 residents reviewed, Resident #76. Findings include: During an observation on 10/24/2022 at 10:00 AM, Resident #76 was in her bed. The resident had scratches on her both arms from elbow to the tip of fingers. She had a band aid on the back of her left hand. During an interview on 10/24/2022 at 10:23 AM, Resident #76 stated, The scratches is from me. I am bad about that. They remind me not to scratch. I scratch them while asleep. During an observation on 10/25/2022 at 9:30 AM, Resident #76 was in her bed with no Geri sleeves. During an observation on 10/26/2022 at 1:25 PM, Resident #76 was in her bed with no Geri sleeves. During an observation on 10/27/2022 at 10:20 AM, Resident #76 was in her bed with no Geri sleeves. Review of Resident #76's medical records revealed the resident was admitted on [DATE] with the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-10-28 · tag F0636 — widespread
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 minimum data set assessments were completed and transmitted in a timely manner for 38 residents (Resident #2, 3, 4, 5, 6, 9, 8, 10, 11, 12,13, 14, 15, 23, 24, 25, 26, 27, 28, 29, 32, 33, 35, 36, 37, 39, 40, 41, 42, 43, 48, 49, 50, 51, 59, 109, 111) of 38 residents reviewed for resident assessment. Findings include: Resident records were reviewed to determine the completion and transmission status of sampled residents' minimum data set assessments. The review revealed the following: Resident #2 Assessment Type: Quarterly Assessment Reference Date: 8/31/22 Status: 41 days overdue Assessment Type: Full Assessment Reference Date: 3/9/22 Status: 230 days overdue Resident #3 Assessment Type: Quarterly Assessment Reference Date: 8/31/22 Status: 42 days overdue Resident #4 Assessment Type: Quarterly Assessment Reference Date: 8/30/22 Status: 43 days overdue Resident #5 Assessment Type: Quarterly Assessment Reference Date: 8/31/22 Status: 42 days overdue Resident #6 Assessment Type: Quarterly Assessment Reference Date:…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident 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

$8,512 in federal fines across 1 penalty.

  • $8,512 — penalty dated 2024-12-19

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 →

RatingThis homeChain avg
Overall 4 of 53.1+0.9 vs chain
Health inspection 3 of 52.6+0.4 vs chain
Staffing 3 of 53.4-0.4 vs chain
Quality measures 5 of 54.4+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 / managerTypeRoleShareSince
PALM GARDEN HEALTHCARE HOLDINGS, LLCOrganization5% 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 SNFNO PERCENTAGE PROVIDEDsince 11/01/2021
JAMES O. MCCARVER RESIDUARY TRUST SHARE U/A DATED 06/22/2001Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 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 SNFNO PERCENTAGE PROVIDEDsince 11/01/2013
MCCARVER, PATSYIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 11/01/2013
REGIONS BANKOrganization5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTERESTsince 11/01/2013
PALM GARDEN OF OCALA LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 07/29/2024
BOMBERGER, JEFFREYIndividualCORPORATE OFFICERsince 10/01/2014
CHALMERS, JAMESIndividualCORPORATE OFFICERsince 01/01/2015
GREENE, ROBERTIndividualCORPORATE OFFICERsince 10/01/2014
MARTINEZ IRIZARRY, ALFONSOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/19/2020
WALKER, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/28/2022
PALM HEALTHCARE MANAGEMENT, LLCOrganizationADP OF THE SNFsince 03/31/2025

CMS files one row per role, so the 19 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.

$19.3M
Net patient revenuemost recent cost report
-9.7%
Operating marginrevenue minus expenses
$4.5M
Related-party expense21% of expenses
Who pays — share of resident-days
Medicaid 69%Medicare 13%Other / private 18%

This home reported $4.5M 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. 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

$349per resident / day
operating cost
$10,598per month
≈ monthly operating cost
$318per 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 105562. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-12, 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.

What to do next