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Palm Garden Of Tampa

3612 E 138th Ave, Tampa, FL 33613 · For profit - Corporation · 120 certified beds · (813) 972-8775 Medicare & Medicaid certified

Call the home — (813) 972-8775 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • about 19% 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
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3450 E Fletcher Ave · (813) 739-7495 · Call to confirm hours
Pharmacy
3450 E Fletcher Ave Ste 140 · (727) 359-0040 · Call to confirm hours
Grocery
J50.5 mi
14442 Hellenic Dr · (813) 520-8843 · Call to confirm hours
Park
3000 Medical Park Dr · 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 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased6.6%8.7%15.4%better
Long-stay residents who lose too much weight1.3%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 infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.0%4.6%6.5%check this — see note marked star below the table
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 injury1.7%2.5%3.3%better
Long-stay residents whose ability to walk worsened6.2%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication9.0%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine97.9%99.2%95.3%typical
Long-stay residents with pressure ulcers1.6%4.5%4.7%better
Long-stay residents with worsening bladder/bowel control6.7%10.5%21.2%better than state — see note marked double-dagger below the table
Long-stay residents who got an antipsychotic medication — see the note below the table2.7%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication0.2%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine93.2%94.7%79.4%better
Short-stay residents rehospitalized after admission28.6%26.1%22.6%worse
Short-stay residents with an outpatient ER visit7.0%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days3.032.131.67worse
Long-stay outpatient ER visits per 1,000 resident days0.941.151.80better

* 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.

59.1% 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 328 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.1%U.S. median 51.5%
Got home and stayed home
11.8%U.S. median 10.7%
Went back to hospital
50.0%U.S. median 56.6%
Met the expected recovery
0.33U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 50.0% 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 122 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 29% 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 SNF59.1%CMS range 52.1–64.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.8%CMS range 9.2–15.110.7%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 discharge50.0%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 discharge49.2%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 discharge36.9%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified94.2%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 setting98.0%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 discharge100.0%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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%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 hospitalization7.4%CMS range 5.0–11.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.40
RN hours/ resident / day
1.08
LPN hours/ resident / day
2.17
Aide hours/ resident / day
3.66
Total nurse hours/ resident / day
0.36
RN hoursweekends
47.5%
Total nursing turnover
41.2%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 114.7 residents a day — about 96% occupied, or roughly 5 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 3.66 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.17 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 3.33 hrs/resident/day on weekends vs 3.79 on weekdays — 12% thinner on weekends. RN hours go from 0.42 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 48% 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

7
deficiencies at the latest standard inspection (2026-05-07)
9
at the previous standard inspection (2023-11-16)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · Ecited before2026-05-07 · tag F0761 — failed to label and store drugs safely — pattern
    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 observations, interviews, and record review the facility did not ensure medications were stored in accordance with current professional standards for 4 of 6 medication carts and 1 of 2 medication storage rooms.Findings included:1. An observation on 5/5/2026 at 2:31 P.M. of the C Wing Medication Room revealed:1 box of bisacodyl suppositories in the cabinet above the sink that expired 2/20261 syringe of Aplisol Tuberculin in the refrigerator that expired 5/2/20262. An observation on 5/5/2026 at 2:37 P.M. of the C Wing Team 2 Medication Cart revealed: 1 medication card for hydrochlorothiazide that expired 4/30/20261 medication card for hydrochlorothiazide that expired 3/31/20261 medication card for ondansetron that expired 2/28/20263. An observation on 5/5/2026 at 3:00 P.M. of the A Wing Team 3 Medication Cart revealed: 8 expired insulin pens6 boxes of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution opened and did not have an expiration date.2 boxes of bisacodyl suppositories that expired on 4/2025 and 2/20261 Trelegy inhaler opened on 3/21/2026 and did not 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 · Dcited before2026-05-07 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility did not ensure specialized call light was within reach for one (Resident #3) of four residents sampled for call lights.Findings included:An observation on 5/4/2026 at 10:58 A.M. of Resident #3 revealed she was lying in bed; a red call light with a press pad was on the right side of the residents bed; not resting on Resident #3's pillow next to her head. Upon request Resident #3 could not reach her call light and press the pad.An observation on 5/6/2026 at 10:36 A.M. of Resident #3 revealed the call light was on the right side of the residents bed; not resting on Resident #3's pillow next to her head. Upon request Resident #3 could not reach her call light and press the pad.An observation and interview on 5/6/2026 at 3:58 P.M. of Resident #3 revealed the call light lying on the right side of the mattress and out of reach. Resident #3 said she was uncomfortable and wanted the fan placed on her.A record review of Resident #3's admission record 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to develop care plans with goals and interventions for two residents (#52 and #105) of 2 residents reviewed for care plans, related to: 1. Not developing care plan to reflect Resident #105 who had a diagnosis of Post Traumatic Stress Disorder (PTSD); 2. Facility and Resident #52 having a video camera facing from the hallway into the room and the need for two or more staff members to enter the resident's room for any reason to include care and services.Findings included:1.On 5/4/2026 during a record review for Resident #105, it was found she was admitted with a diagnosis of Post Traumatic Stress Disorder (PTSD) with an onset date of 7/25/2024, Alzheimer's, and seizures.Review of Resident #105's medical record revealed she was admitted to the facility on [DATE] and with a readmission from the hospital on [DATE]. Review of the advance directives revealed Resident #105 had a responsible party for making her medical decisions. Review of the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such 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 The facility did not ensure one (Resident #11) was provided with adequate pain management out of three residents sampled for pain management.On 5/04/26 at 2:09 p.m., an interview was conducted with Resident #11. Resident #11 stated she had a Leave of Absence (LOA) from the facility the morning of 4/24/26 and returned to the facility on the morning of 4/26/26. On 4/24/26, Resident #11 stated she was provided one Oxycodone tablet when she left on LOA. She stated her nurse told her there was only one tablet remaining in her prescription. She stated she experienced pain while on LOA, and one tablet was not enough to address the pain. Resident #11 stated a family member provided her with Tylenol, but it was not enough for her pain. Resident #11 stated she was not offered an option to delay her LOA until her prescription was refilled.Review of Resident #11's admission record revealed the resident was admitted on [DATE]. The record includes diagnoses not limited to unspecified abnormalities of gait and mobility,…

    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 · D2026-05-07 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    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 ensure one of two residents (#105) who were diagnosed with Post Traumatic Stress Disorder (PTSD), were assessed and monitored for specific trauma related behaviors and failed to ensure care staff were aware of resident #105 having PTSD, and having knowledge of what specific trauma based behaviors to look out for. Findings included: On 5/6/2026 at 9:15 a.m. and multiple other observations Resident 105's room was approached and entered after knocking. During all times observed, Resident #105 was observed in her room lying flat under the covers and presenting with her eyes closed. The call light was placed within her reach. Resident was noted sleeping most to all of the days observed and did not appear to be up out from her bed. Interviews with passing staff members had confirmed Resident #105 likes to stay in her room but did not know the reasons of why she did not spend time out from her room much. Resident #105 did resident in a 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · 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 interviews and record review, the facility did not ensure medication recommendations were reviewed for one (Resident #4) of five residents sampled for unnecessary medications.Findings included:A review of Resident #4's pharmacy recommendations revealed:3/12/2026-3/13/2026 - Not signed by attending physician or medical directorHydrocodone-Acetaminophen tablet 10-325mg - Give 1 tablet by mouth every 6 hours as needed for pain. Recommendation: Please reduce PRN (as needed) analgesic therapy until the lowest effective dose is achieved.A review of Resident #4's active physician orders as of 5/6/2026 revealed:Hydrocodone-Acetaminophen Tablet 10-325 MG Give 1 tablet by mouth every 6 hours as needed for PainA review of Resident #4's pharmacy recommendations revealed:2/13/2026-2/14/2026 - Not signed by attending physician or medical directorInsulin Glargine Solostar SQ (subcutaneously) - Inject 10-unit SQ in the morning. Recommendations: Please adjust the diabetes regimen by initiating Metformin 250mg BID (twice a day) with food and increasing insulin glargine to 15 units SQ in 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-07 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility did not provide therapy services needed for one (Resident #38) of one resident sampled for specialized rehabilitative services .Findings included:An observation on 5/4/2026 at 9:15 A.M., Resident #38 was sleeping; her breakfast tray was on the bedside table and was not eatenAn observation on 5/4/2026 at 1:00 P.M., Resident #38 was sleeping: her lunch tray was on the bedside table and was not eaten.A record review of Resident #38's evaluations revealed a referral to therapy was made on 4/30/2026 related to a decline in self-feeding.A review of Resident #38's quarterly minimum data set (MDS) dated [DATE] and 1/27/2026 revealed Resident #38 required supervision or touching assistance with eating.A review of Resident #38's annual MDS dated [DATE] revealed Resident #38 required supervision or touching assistance with eating.A review of Resident #38's culinary profile valuation dated 4/30/2026 revealed Resident #38's average meal intake was 25% and her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-02 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record review the facility failed to allow one (Resident #2) to return after hospitalization of three residents reviewed for readmission. Findings included: On 3/2/26 at 5:02 PM an interview was conducted with Resident #2's family member. The family member said Resident #2 was in the hospital from Tuesday, 2/24/26 to Saturday, 2/28/26. Resident #2 was supposed to be discharged on Friday 2/27/26 back to the [facility]. Resident #2 had to stay an additional day in the hospital as [facility] refused to take Resident #2 back at the last moment. Resident #2 was discharged to another nursing facility on Saturday, 2/28/26. Resident #2's family member stated the discharge delay was stressful for Resident #2. The family member stated they had to scramble the morning of 2/28/26 to find another facility for Resident #2. Resident #2 was anxious and now didn't know where she was going to go. The family member said [facility] was unhappy with them as we were vocal and advocating for Resident #2. The facility provided a letter to Resident #2 dated 2/24/26 from the Nursing…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-11-16 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    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 maintain an effective pest control program as evidenced by small gnat like flies observed in the kitchen at the hand washing station, inside the dry storage area, inside the freezer, the dish cleaning area, around a cart outside of the freezer, and flies were observed over the tray/cook line for two days (11/13/23 and 11/15/23) out of four days of survey. Findings included: On 11/13/2023 at 7:20 a.m. during the initial kitchen tour the trash can at the hand washing station was observed to be overflowing with trash and the entire area had gnat like flies flying around. In addition, inside the dry storage area dead gnat like flies were observed on several plates. An observation of the inside of the freezer revealed dead gnat like flies in the corner on the floor behind milk crates. Outside of the freezer gnat like flies were observed flying around a cart that had several containers with tops that appeared dirty and smeared with a brown pasty substance. Also observed during this time was the dish cleaning area…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-16 · tag F0585 — failed to handle grievances — pattern
    Honor 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 observations, interviews, and record reviews the facility failed to resolve grievances related to dietary concerns in a timely manner for two residents (#4 and #85) out of the two sampled residents for grievances. Findings included: 1. On 11/14/23 at 10:12 a.m., Resident #4 reported he was the Resident Council President. He stated the number one concern in the facility was food. The food was cold, did not taste good, and was always late. He reported these concerns have been voiced over and over during the Resident Council Meetings and nothing changes. The response from staff related to the food concerns was always something about the budget. If they are served hotdogs, then they probably won't get mustard and ketchup. Administration took away cokes and they are only served ginger ale and diet ginger ale. They were told this was for nutritional reasons. The administration took away vending machines for residents. They have one in the staff break room but if they want something they have to ask a staff…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · E2023-11-16 · tag F0700 — pattern
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 reassess the need for an appropriate use of bed rails for one resident (#80) of three residents sampled for bed rails. Findings included: On 11/15/23 at 4:09 p.m. Resident #80 stated the facility just came in and took the rails off the bed. The resident reported using the rail/enabler to assist with getting into bed and moving up in the bed. The resident stated he knew what a trapeze was and had not been assessed for one. The observation revealed Resident #80 had a left upper arm contracture which was held in front of the chest. An observation of the resident bed revealed no assistance devices were attached to the bed. The Quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #80 had a Brief Interview of Mental Status score of 13, indicative of an intact cognition. Section GG of the MDS identified the resident had Range of Motion limitations on one side of the upper and lower extremities. The MDS revealed the 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-16 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to ensure medications were stored in a safe manner in regards to 1) leaving one of two treatment carts unlocked while unattended (C-wing), 2) unopened eye drops requiring refrigeration stored in one (100-hall team #2) out of six medication carts, 3) one (C-wing team #3) out of six medication carts held medication tablets in a medication cup and a loose tablet, 4) three (C-wing, A-wing team #2, C-wing team #1) out of six medications carts left unlocked while unattended, 5) medications left on top of two unattended medication carts (100 team #2 and A-wing) out of 6 carts, 6) allowing a visitor unattended access to an unlocked medication cart (A-wing team #2 and C-wing team #1) out of six carts, and 7) allowed one resident (#85) to have a prescribed Albuterol inhaler at bedside. Findings included: 1. On 11/13/23 at 7:27 a.m., an observation was made of an unlocked treatment cart parked inside the C-wing nursing station. The observation…

    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 · D2023-11-16 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide access to activities for one resident (#74) out of one resident sampled for activities. Findings included: On 11/13/2023 at 8:25 AM, Resident #74 was observed sleeping in bed. Floor mats were observed on each side of the bed. On 11/13/2023 at 11:45 AM, Resident #74 was observed in bed. The roommates television (TV) was on. On 11/13/2023 at 2:30 PM, Resident #74 was observed in bed. The resident was observed with the head of the bed slightly raised, utilizing the left hand, and tapping on the overbed table. Resident #74's TV was not on, but the roommate's TV could be heard. On 11/14/2023 at 9:05 AM, Resident #74 was observed in bed, with the head of the bed at a 90-degree angle, being assisted with breakfast. Resident #74 stated breakfast was good. Resident was utilizing left hand to tap on the over bed table. On 11/15/2023 at 3:30 PM, Resident #74 was observed in bed with the head of the bed raised. Resident #74's TV was on, 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 reviews, the facility failed to allow two residents (#64 and #62) out of 40 sampled residents to exercise their autonomy related to the individual preference of having a personal refrigerator in their room. Findings included: 1) The review of Resident #64's admission Record identified the resident was originally admitted on [DATE] and re-admitted on [DATE]. The record included diagnoses not limited to cervical spina bifida with hydrocephalus, moderate protein-calorie malnutrition, and unspecified paraplegia. On 11/14/23 at 9:24 a.m., Resident #64 reported having a personal refrigerator and the facility had removed it about 3-4 weeks before his birthday in June. The resident stated the facility informed him the removal was due to health and safety. The resident reported being able to maintain the refrigerator and it had contained cans of soda. Resident #64 reported it was a new refrigerator bought by a family member. During the interview, a refrigerator was not…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to inform the resident/resident representative of a change in status and change in medication for two residents (#99 and #314) of two residents sampled for change of status. Findings included: 1) Review of the admission Record revealed Resident #99 was admitted to the facility on [DATE], with diagnoses to include surgical aftercare following surgery on the digestive system, difficulty in walking, malignant neoplasm of the pancreas, and other co-morbidities. An admission Minimum Data Set (MDS), dated [DATE], for Resident #99 showed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. During an interview on 11/13/2023 at 8:18 AM, Resident #99 stated, My discharge medication list from the hospital and my surgeon showed Lovenox to be given to prevent thrombosis, which I have had in the past. I received two injections from here, then the nurses stopped administering. I wasn't receiving the medication. I kept…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide treatment and care according to physician orders for non-pressure related skin conditions for two residents (#314 and #316) of two residents sampled for skin conditions. Findings included: 1) On 11/13/23 at 08:13 AM, Resident #314 was observed laying in the bed, sheet up to waist with arms on top of the sheet. Resident had a soiled dressing, with dried blood visible to his left forearm dated 11/12/2023. Directly above the left forearm was a soiled folded gauze with medical tape wrapped around the arm, undated. A soiled dressing to left elbow, the dressing was peeling off and undated. The dressing to the right elbow was soiled with red and brown bloody drainage and starting to peel off the skin dated 11/12/2023. (Photographic Evidence Obtained). During an interview on 11/13/23 at 12:00 PM, the family member of Resident #314 stated the resident had several skin areas that needed bandages, the ones you can see on his arms and on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-16 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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, interviews, and record review the facility failed to ensure the medication error rate was less than 5.00%. Thirty-seven medication administration opportunities were observed and nine errors were identified for two residents (#211 and #25) of four residents observed. These errors constituted a 24.32% medication error rate. Findings included: 1) On 11/15/23 at 7:46 a.m., an observation of medication administration with Staff D, Registered Nurse (RN), was conducted with Resident #211. The staff member dispensed the following medications: - Levofloxacin 500 milligram (mg) tablet - Lisinopril 10 mg tablet - Mucinex DM 600 mg Guaifenesin/30 mg Dextromethopran over-the-counter (otc) tablet - Aspirin 81 mg chewable otc tablet - Nifedipine Extended Release (ER) XL 60 mg tablet - Polyethylene glycol 3350 - 17 grams (gm), mixed with 4 ounce (oz) of water - Vitamin D 25 microgram (mcg) - 2 otc tablets Staff D confirmed 7 tablets and one liquid medication. The staff member administered oral medications and identified the resident was to receive short and long-acting…

    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 · D2021-09-23 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 interviews the facility failed to ensure one resident (#30) was assessed for self-administration of a medication and that the medication was not stored at bedside out of five residents sampled for unnecessary medications. Findings included: An observation was made at 3:18 p.m. on 9/22/21 of a box labeled, Fluticasone Propionate Nasal Spray on the over-bed-table of Resident #30. (Photographic Evidence Obtained) The resident stated that she had brought the nasal spray from home and used it every couple of days. She reported that staff were aware she had it and that she did not try to hide it. A review of Resident #30's September 2021 physician orders indicated that the resident did not have an order for the Fluticasone and the facility had not assessed the resident for self-administration of the medication. On 9/22/21 at 4:01 p.m., the Director of Nursing (DON) stated Resident #30 was not allowed to self-administer medications. An observation was conducted with the DON, who…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-09-23 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview with the resident, interview with facility staff, and review of facility documents, the facility failed to provide one resident with impaired vision, (Resident #56) with assistance at meals, leisure activities to meet his needs of a total sample of 21 residents reviewed for accommodation of needs. Findings included: A review of the admission Record for Resident #56 showed the resident was admitted to the facility on [DATE] with diagnoses that included gastrointestinal hemorrhage, a wedge compression fracture of the spine, macular degeneration and glaucoma. On 09/20/21 beginning at 11:52 a.m. Resident #56 was observed sitting in his wheelchair next to his bed with the over bed table in front of him. His television was on. When the surveyor knocked on his door and called out to him, the resident looked at the door, toward the sound, but it didn't appear that he was looking at the surveyor. The resident was observed to be holding his call bell and to the cord to the receiver of the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-09-23 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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, resident and facility staff interviews, and review of facility documents, the facility failed to revise a care plan to meet the needs related to accommodating needs, specifically for impaired vision for one resident (#56) of 21 residents reviewed. Findings included: Review of the admission Record for Resident #56 showed the resident was admitted to the facility on [DATE] with diagnoses that included gastrointestinal hemorrhage, a wedge compression fracture of the spine, macular degeneration and glaucoma. On 09/20/21 beginning at 11:52 a.m. Resident #56 was observed sitting in his wheelchair next to his bed with the over bed table in front of him. His television was on. When the surveyor knocked on his door and called out to him, the resident looked at the door, toward the sound, but it didn't appear that he was looking at the surveyor. The resident was observed to be holding his call bell and to the cord to the receiver of the phone tightly. When asked why, he reported that he had to hold…

    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 · D2021-09-23 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    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, interview and record review the facility failed to ensure treatment and care was provided related to the appropriate application of a splint for one resident (#81) of 48 sampled residents. Findings included: Review of Resident #81's admission Record revealed this resident was admitted to the facility on [DATE] with a diagnosis primary diagnosis of Infection and inflammatory reaction due to internal right hip prosthesis. A review of the Minimum Data Set Assessment, dated 6/28/21, indicated Resident #81 had a Brief Interview of Mental Status score of 15 indicating the resident was cognitively intact. Review of the physician orders for September 2021 revealed, Patient to wear right ankle brace in bed as tolerated every day and night shift, with a start date of 7/15/21. Review of the electronic Therapy Page revealed Precautions: (PT) [patient] Fall risk, R [right] THA [total hip arthroplasty] revision (6/15/21), RLE (right lower extremity) WBAT [weight bearing as tolerated], brace for RLE…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-09-23 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such 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 interviews, observation of the resident (#140) at meals, and review of the resident's medical record and facility documents, the facility failed to ensure one (#140) of one resident reviewed for dialysis services received care and services to meet her needs. Findings included: On 09/20/2021 at 1:55 p.m., an interview was conducted with Resident #140. She was sitting in a recliner in her room with the television on. She confirmed that she went to her dialysis sessions three times a week, leaving the facility about 10:30 a.m. and returning by 4:30 p.m. She confirmed she had a catheter in her upper left chest which the facility nurses did not touch at all, she was knowledgeable about her diet and fluid intake, she knew her weight had remained pretty stable and she reported that the dialysis facility drew her labs. She confirmed that she was given a lunch to take with her but since she slept the whole day, she hadn't been eating the packed lunch. She said that since she ate breakfast before she left the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-09-23 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. On 09/21/2021 beginning at 2:45 p.m., an observation began of the 100 wing for sufficient staff. Initially only two aides were observed, both in and near to the day room. One aide was providing one on one care to a male resident and the second was talking with that aide. No other aides were observed on the unit. At 2:49 p.m. while walking the halls to observe for the aides, at the end of the high numbered rooms, a resident called out for help. When the surveyors approached the resident she asked for help, that she was wet and needed to be changed. The surveyors asked her to put her call bell on and someone would come to assist. The surveyors walked up the hall, continuing to look for aides and finally when they reached the nursing station without observing any aides, they asked they nurses where their staff were. One of the three nurses at the station reported that they were down the halls. The nurse walked down the low numbered hall and found no aide. She walked down the middle hall and found one aide in 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-09-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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, record reviews, and interviews the facility failed to ensure target behaviors, side effects, and outcomes were monitored and documented for two (#6 and #30) out of five residents sampled for unnecessary medications. Findings included: 1. On 9/20/21 at 1:05 p.m., Resident #6 was observed lying in bed, quiet and eyes closed. The resident was very thin with muscle-wasting, wearing a nasal cannula delivering 3 liters of oxygen per minute. On 9/21/21 at 8:51 a.m., the resident was observed lying in bed, wearing a nasal cannula delivering oxygen, mouth open, eyes closed, and with neck hyperextension on pillows. Resident #6 was admitted , per the admission Record, on 1/11/21 and readmitted on [DATE]. The medical record included diagnoses not limited to dementia in other diseases classified elsewhere without behavioral disturbance, unspecified mood disorder due to known physiological condition, and unspecified schizoaffective disorder. A review of the physician orders for September 2021 for…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-09-23 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-six medication administration opportunities were observed, and twenty-three errors were identified for three (#66, #90, and #58) of five observed residents. These errors constituted a 63.8% medication error rate. Findings included: 1. On 9/21/21 at 8:23 a.m., an observation of medication administration with Staff Member C, Licensed Practical Nurse (LPN), was conducted with Resident #66. Staff C was observed administering the following medications: - Levetiracetam 1000 milligram (mg) tablet orally. - Metoprolol Tartrate 25 mg tablet orally. - Potassium Chloride (Cl) Extended Release (ER) 10 milliequivalent (meq) caplet orally. - Sodium Chloride (Cl) 1 gram (gm) tablet orally. The observation indicated that the pharmacy label of the blister-packaged Metoprolol indicated the medication was to be administered if vital signs were within parameters. The staff member stated that the Metoprolol doesn't have any parameters, nothing pops up (on 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-09-23 · 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 observations, record reviews, and interviews the facility failed to ensure medications stored in three (A-Wing 3, C-Wing 1, and C-Wing 2) out of the six facility medication carts were stored appropriately as evidenced by narcotic medications not accounted for when administered and medications were not dated when opened when medications had a shortened shelf life. Findings included: Staff F, Licensed Practical Nurse (LPN) was observed, at 5:52 p.m. on 9/22/21, at the A-Wing nursing station. After reviewing the A-Wing Medication Cart 3 with Staff F. A full review of the controlled medications was made with Staff F and it was found that multiple narcotics had not been signed out when he had administered them. Four Controlled Medication Utilization Records for different residents were identified as not having the medications reconciled against the number of tablets/capsules available on the blister packages. (Photographic Evidence Obtained) Staff F stated he knew that the record should be signed off when the medication was administered but did not have time because 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-09-23 · 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 of dietary staff, interview with dietary staff, and review of dietary documents, the facility failed to ensure the kitchen equipment was maintained in a clean manner, items stored in the walk in refrigerator were dated and discarded when indicated by the date, the temperature and sanitation logs for the dish machine were accurately completed, and a floor drain was kept clean. Findings included: On 09/20/2021 at 10:00 a.m. a tour of the facility's main kitchen began. Staff J, Dietary Aide was standing at the dirty side of the dish machine and was observed to push a rack of dirty items into the dish machine. She was not able to answer questions about the dish machine so the Dietary Manager stepped in to answer. The temperatures of the dish machine met the standard per the manufacturer's guidelines, but the sanitizer strip did not change color to indicate the correct amount of sanitizer. The Dietary Manager checked the bucket of sanitizer and realized that the tubing was not in the sanitizer which did not allow the sanitizer to flow into the machine. The monitoring…

    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

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to PALM GARDEN HEALTH AND REHABILITATION — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 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 11/01/2013
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
PGTPA RE, LLCOrganization5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 07/29/2024
REGIONS BANKOrganization5% OR GREATER SECURITY INTERESTsince 11/01/2013
BOMBERGER, JEFFREYIndividualCORPORATE OFFICERsince 10/01/2014
CHALMERS, JAMESIndividualCORPORATE OFFICERsince 01/01/2015
GREENE, ROBERTIndividualCORPORATE OFFICERsince 10/01/2014
FAROOQUI, ZUBAIRIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2018
RAMDAYAL, HOPEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/07/2023
PALM HEALTHCARE MANAGEMENT, LLCOrganizationADP OF THE SNFsince 04/03/2025

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

7 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$13.7M
Net patient revenuemost recent cost report
-3.9%
Operating marginrevenue minus expenses
$2.7M
Related-party expense19% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 14%Other / private 27%

This home reported $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 19% 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

$359per resident / day
operating cost
$10,914per month
≈ monthly operating cost
$345per 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 105591. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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