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Palm Garden Of Winter Haven

1120 Cypress Gardens Blvd, Winter Haven, FL 33884 · For profit - Limited Liability company · 120 certified beds · (863) 293-3100 Medicare & Medicaid certified

Call the home — (863) 293-3100 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0607) — most recent Apr 2024Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations$24,395 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0607) — most recent Apr 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $24,395 in federal fines (most recent 2024-04-04)
  • its payroll-based staffing score sits well above its independent inspection score
  • about 22% of its spending goes to commonly-owned related companies
  • its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions

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

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

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — 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
400 Avenue K SE · (863) 299-3210 · Call to confirm hours
Pharmacy
970 CYPRESS GARDENS BLVD. · (863) 294-3138 · Call to confirm hours
Grocery
757 Cypress Gardens Blvd · (863) 229-7325 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
1800 Cypress Gardens Blvd · (863) 324-6347

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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 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 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 increased8.9%8.7%15.4%better
Long-stay residents who lose too much weight3.3%5.5%5.4%better
Long-stay residents with a catheter left in their bladder1.3%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.8%0.7%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms0.3%4.6%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.1%2.5%3.3%better
Long-stay residents whose ability to walk worsened9.4%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.6%14.4%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers4.6%4.5%4.7%typical
Long-stay residents with worsening bladder/bowel control16.5%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 table2.2%8.6%17.1%better
Short-stay residents who newly got an antipsychotic medication2.2%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine96.2%94.7%79.4%better
Short-stay residents rehospitalized after admission25.1%26.1%22.6%worse
Short-stay residents with an outpatient ER visit9.5%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days3.372.131.67worse
Long-stay outpatient ER visits per 1,000 resident days0.451.151.80better

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.

43.8% 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 91 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

43.8%U.S. median 51.5%
Got home and stayed home
12.5%U.S. median 10.7%
Went back to hospital
49.2%U.S. median 56.6%
Met the expected recovery
0.40U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 49.2% 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 65 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 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 SNF43.8%CMS range 35.4–58.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.5%CMS range 9.0–16.910.7%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 discharge49.2%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 discharge50.8%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 discharge40.0%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 identified57.5%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 worsened2.1%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 hospitalization10.2%CMS range 6.4–15.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.051.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.70
RN hours/ resident / day
0.84
LPN hours/ resident / day
2.22
Aide hours/ resident / day
3.76
Total nurse hours/ resident / day
0.43
RN hoursweekends
30.6%
Total nursing turnover
15.8%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 113.6 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.76 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 3.37 hrs/resident/day on weekends vs 3.92 on weekdays — 14% thinner on weekends. RN hours go from 0.81 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

8
deficiencies at the latest standard inspection (2024-06-20)
3
at the previous standard inspection (2022-03-10)

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

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

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.

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

  • Actual harm · G2024-04-04 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to protect one (#1) resident from witnessed physical abuse by a staff member and failed to protect two residents (#2, #3) following allegations of abuse out of a total sample of four residents. Findings included: 1. During an interview on 04/02/2024 at 12:50 p.m. Staff B, Licensed Practical Nurse (LPN) stated she worked a double on 3/26/24 with Staff A, LPN. Staff A, LPN was with Resident #1, and I heard him state, If you don't stop swearing, I am going to slap the shit out of you. The first time I heard him I was at my med cart down the 40s hall. It was loud enough I could hear it. Staff A, LPN was standing next to the resident's wheelchair; I was probably about 25 feet away. I went back to my desk at the nursing station after med pass. I sat at the nursing station. Resident #1's chair was between the enclave and the nursing station. Staff A, LPN had just finished the dining cart. After cursing at Resident #1, Staff A, LPN moved about to…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-04-04 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to implement the facility's Abuse, Neglect, Exploitation and Misappropriation policy and procedure for witnessed physical abuse of one resident (#1) and allegations of physical and verbal abuse of two residents (#2 and #3) of four sampled residents. Findings included: A review of facility's Abuse, Neglect, Exploitation and Misappropriation Policy and Procedures, last revised September 2023, documented the policy: The center recognizes each resident's right to be free form abuse, neglect, and exploitation (ANE), misappropriation of resident property . This center reports suspicions of crimes committed against a resident of this center in accordance with section 1150B of the Social Security Act to at least one law enforcement agency and the State Agency. Definitions for F600 Staff: Statute 483.12 define staff as employees of the center, the medical director, consultants, contractors, and volunteers. This definition will also include caregivers…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-20 · tag F0645 — pattern
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were updated to include current diagnoses, for six residents (#74, #10, #69, #43, #65, and #5) out of 45 sampled residents. Findings included: 1. During an observation on 06/17/2024 at 12:30 p.m., Resident #74 was in the dining room eating lunch. Resident #74 reached into his pocket and pulled out a 100 dollar bill and put it on the table and said this is for the staff for doing such a great job. He then picked up the money and stuck it back in his pocket. Review of Resident #74's admission Record showed Resident #74 was admitted to the facility on [DATE] with diagnoses of unspecified mood [affective] disorder, seizures, major depressive disorder, and adjustment disorder with anxiety. Review of the Level I PASRR, dated 03/06/2023, showed in Section I-Part A was marked for Depressive Disorder. Section II: Other Indications for PASRR Screen Decision-Making questions 1…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to implement an effective infection control program related to ensuring staff were educated on transmission-based precautions (TBP) and the personal protective equipment (PPE) to be worn when entering isolation precaution rooms, and failed to ensure signage was posted related to the type of TBP for two residents (#44 and #83) out of two residents sampled for isolation precautions. Findings included: On 6/17/24 at 9:54 a.m., an observation was made of the area outside of Resident #44's room. A caddy holding gloves, blue gowns, and red biohazard bags hung on the hallway side of the door. The area outside of the room did not show the type of PPE staff were to wear or when to wear PPE during the care of Resident #44. An interview was conducted on 6/17/24 at 10:15 a.m., with Staff E, Certified Nursing Assistant (CNA) as the staff member was leaving Resident #44's room. The staff member stated the resident was on contact precautions. An…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-20 · 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 ensure a dignified dining experience for one resident (# 66) out of eight residents sampled. Findings included: On 6/17/2024 at 11:00 a.m., Resident # 66 was observed in his room watching television. He was presented well groomed, with no signs of distress. He said the staff always delivers his meal and leaves his urinal with urine in it on his bedside table while he eats his meal. He said he has asked them multiple times to remove it, but they all tell him they will do it after they finish passing their trays. On 6/20/2024 at 8:30 a.m., and 9:00 a.m., Resident # 66 was observed sitting up in his bed eating his breakfast. His urinal was observed with urine in it next to his meal tray. Resident # 66 stated he asked staff this morning to empty his urinal, but they just delivered his breakfast tray, without cleaning his table and removing his urinal. He stated his urinal had been on his table for a while. A review of the admission record,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-20 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to report an allegation of abuse within the required timeframe for one resident (#81) out of three residents sampled. Findings Include: An interview was conducted on 06/20/2024 at 1:00 p.m., with Staff L, Risk Manager (RM), and the Nursing Home Administrator (NHA). Staff L, reported Staff M, Registered Nurse (RN) Unit Manager, notified her on 6/12/ 2023 at 11:30 p.m. that Resident #81's family member had called around 10:30 p.m., and reported Resident #81 informed her (the family member) the assigned Certified Nursing Assistant, (CNA) was yelling and throwing things around in his room. The family member reported the CNA jumped on Resident #81's back and stomped on him. Staff L stated she was not able to hear everything Staff M, RN was saying to her over the phone due to poor phone reception. She said she told Staff M to file a grievance and she would follow-up on it in the morning. The RM stated, the next day when she returned to work, she called…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-06-20 · 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 observations, interviews, and record review, the facility failed to accurately assess and document the skin condition for one resident (#69) out of three residents sampled for skin conditions. Findings included: On 6/18/24 at 10:46 a.m., an observation was conducted of Resident #69 during the administration of medications. The observation revealed the resident's bilateral feet were extremely dry with dry, tan-colored ridged scale-like overgrowth of skin visible on the bottom of one foot and toenails on both feet were thick, yellowed and long. The resident had scratches on bilateral arms. Review of Resident #69's Order Summary Report, active as of 6/19/24 at 3:20 p.m., revealed the following orders: - Halobetasol propionate external cream 0.05% - Apply to entire body topically every day and evening shift for atopic dermatitis for 4 weeks. Ordered on 6/12/24. Review of Resident #69's Weekly Skin check, effective 6/13/24, showed the resident's skin was intact. Review of a nursing note, dated 6/19/24 at 1:35 a.m., revealed Resident #69 voiced no discomfort and skin was warm,…

    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 · D2024-06-20 · 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 record review and interview, the facility failed to ensure one resident (#7) out of the one sampled resident was appropriately assessed related to Post Traumatic Stress Disorder (PTSD). Findings included: A review of the admission Record for Resident #7 showed he was initially admitted to the facility on [DATE] with a diagnosis to include PTSD. A review of Section C- Cognitive Patterns of the Minimum Data Set (MDS), dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitively intact. Section I- Active Diagnoses of the MDS showed the resident had a diagnosis of PTSD. A review of the Clinical admission record, dated 06/07/24, showed the Trauma Informed Care Screening was not completed. Further review of the medical record showed the Trauma Informed Care Screening was present in the medical record. On 6/19/24 at 10:49 a.m. an interview was conducted with the Director of Nursing (DON). The DON stated a Trauma Informed Care Assessment should…

    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 before2024-06-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less that 5.00%. Twenty-six medication administration opportunities were observed and three errors were identified for two residents (#69 and #98) out of six residents observed. These errors constituted a 11.54% medication error rate. Findings included: On 6/18/24 at 10:46 a.m., an observation was made of Staff I, Registered Nurse (RN). Staff I dispensed the following medications for Resident #69: -Breo Ellipta 200 microgram/25 microgram (mcg/mcg) inhaler -Buspirone 5 milligram tablet -Calcium carbonate oral chewable antacid over the counter (OTC) tablet -Cetirizine 10 milligram (mg) OTC tablet -Vitamin D 25 mcg (1000 international unit) OTC tablet -Combivent Respimat 20 mcg/100 mcg inhaler -Escitalopram 10 mg tablet The staff member confirmed dispensing 2 inhalers, one chewable tablet, and 4 oral tablets. Upon entering the resident room, Resident #69 was non-verbal. The staff member administered one…

    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 · D2024-06-20 · 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, interviews, and record review the facility failed to ensure food was labeled and expired items were discarded in one nourishment room (100-hall) of two nourishment rooms. Findings included: During an observation on 06/18/2024 at 3:50 p.m. of the 100-hall nourishment room, two cartons of milk were identified to be expired as of 6/14/2024. An additional observation revealed two frozen dinners were in the freezer without a resident's name or room number to identify who they belonged to. During an interview on 06/18/ 2024 at 3:50 p.m. the Unit Manager (UM), confirmed the milk should be discarded and stated the kitchen staff are typically the ones who go through the items in the nourishment rooms. During an interview on 06/18/2024 at 4:00 p.m. with the Certified Dietary Manager (CDM), she stated the food in the freezer should have been dated and labeled with the resident's name. Review of the Food Labeling and Dating Refrigeration policy that was not dated, revealed: Purpose: The center adheres to labeling and dating system to ensure the safety of ready-to-eat,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-04 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to thoroughly investigate an allegation of physical abuse for one resident (#3) of four sampled residents. Findings included: A review of facility's Abuse, Neglect, Exploitation and Misappropriation Policy and Procedures, last revised September 2023, documented the policy as: The center recognizes each resident's right to be free form abuse, neglect, and exploitation (ANE), misappropriation of resident property . This center reports suspicions of crimes committed against a resident of this center in accordance with section 1150B of the Social Security Act to at least one law enforcement agency and the State Agency. Definitions for F600 Staff: Statute 483.12 define staff as employees of the center, the medical director, consultants, contractors, and volunteers. This definition will also include caregivers that provide care and services to the resident on behalf of the center. Willful: Statute 483.5 in the definition of abuse this means the individual must have acted deliberately, NOT that the individual must have intended to…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-04 · 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

    Based on record review and interviews, the facility failed to develop a person-centered care plan to include a communication plan for a non-verbal resident for one resident (#3) of four sampled residents. Findings included: A review of Resident #3's Transfer/Discharge Report documented an admission date of 01/03/2023. The record documented the resident had a spouse. Resident #3 had medical diagnoses to include aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; unspecified dementia and chronic obstructive pulmonary disease. A review of Resident #3's care plan revealed no focus, goal or interventions related to Resident #3 being non-verbal and with the ability to answer yes and no questions. A review of Resident #3's Minimum Data Set Assessments (MDS) Section C - Cognitive Patterns documented the Brief Interview for Mental Status, dated 01/16/2024, and 02/15/2024, as the resident was rarely/never understood. During an interview conducted on 04/03/2024 at 9:40 a.m. the Social Services Assistant (SSA) stated she…

    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
Show the remaining 12 citations
  • Potential for harm · D2024-02-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to provide housekeeping and maintenance services to maintain a sanitary and homelike environment related to not ensuring a mattress was in good repair for one resident (#9) of a sample of nine residents for two days (2/10/24 and 2/11/24) of a two day survey. Findings included: An observation on 2/10/24 at 10:01 a.m. revealed the bare mattress for Resident #9 had a large worn area in the shape of a circle in the middle to upper area of the mattress. The first layer of the dark blue material was worn through and exposed the next layer of a lighter blue material. Towards the top of the worn circle was a yellow stained area. (Photographic Evidence Obtained) An interview on 2/10/24 at approximately 11:50 a.m. with Staff A, Certified Nursing Assistant (CNA) revealed Resident #9 was at dialysis. She confirmed if something was wrong with a mattress a work order would be completed. An interview on 2/10/24 at 12:00 p.m. with Staff B, Registered Nurse/Unit Manager (RN/UM) was conducted. Staff B stated if a repair was an…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-03-10 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    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 a medication administration error rate of less than 5%. A total of 36 administration opportunities were observed with 10 medication errors for three residents (#57, #443, and #49) of five residents observed for medication administration, resulting in a medication administration error rate of 38.46%. Findings included: 1. A review of Resident #57's admission Record revealed Resident #57 was admitted to the facility on [DATE] with a diagnosis of constipation. A review of Resident #57's physician's orders revealed an order dated 09/29/2021 for Senokot tablet, give one tablet by mouth one time a day for constipation. An observation of medication administration for Resident #57 was conducted on 03/09/2022 at 8:20 a.m. with Staff E, Registered Nurse (RN). Staff E prepared thirteen medications for administration to Resident #57, including Senokot 8.6 milligrams (mg) by mouth. After preparing the medications, Staff E, RN entered…

    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 · D2022-03-10 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and medical record review, the facility failed to provide Activities of Daily Living (ADL) care for one dependent resident (#42) related to eating assistance out of a total sample of thirty-two residents. Findings included: On 3/7/2022 at 12:15 p.m. Resident #42 was observed in his room reclined back in his bed with his lunch meal tray positioned in front of him, on the over the bed table. Resident #42 was observed self-feeding while using a fork to bring food to his mouth. Further observations revealed he was dropping bits of food from his fork to his upper shirt area. Also, his shirt appeared liquid soaked, from when he took sips from his hydration cup. Resident #42 dropped food from his fork to his shirt three times during this observed timeframe. No staff were observed in the room to assist him or supervise him during the meal. On 3/8/2022 at 7:55 a.m. Resident #42 was observed in his room and reclined back in his bed with his breakfast meal tray placed on the over the bed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-03-10 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 policy review, the facility did not ensure one resident's (#392) food preferences were honored out of five sampled residents. Findings included: An observation and interview was conducted on 03/07/2022 at 9:27 a.m. with Resident #392 and the resident's family member. The resident expressed she was a diabetic, she received insulin on a sliding scale, and stated she received a lot of regular sugared style foods since arriving to the facility. The family member also expressed her concern as she stated after [Resident #392] arrived at the facility they met with the CDM (Certified Dietary Manager) and asked that [Resident #392] only receive sugar free [gelatin dessert], sugar free pudding and other sugar free desserts. She also noted that she does not receive her NAS (No Sugar Added) house shakes. Almost a month later she has yet to receive her requested food items; even after several conversations with dietary staff. Resident #392 stated she dislikes oatmeal and orange juice 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2020-12-18 · tag F0759 — failed to keep medication error rate low — pattern
    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%. Twenty-nine medication administration opportunities were observed and fifteen errors were identified for one resident (#52) of five residents observed. These errors constituted a 51.72% medication error rate. Findings included: On 12/15/20 at 11:08 a.m., an observation of medication administration with Staff C, Licensed Practical Nurse (LPN), was conducted with Resident #52. Staff C was observed administering the following medications: - Amlodipine 10 milligram (mg) tab orally - Bupropion Hydrobromide (HBr) Extended Release (XL) 300 mg tab orally - Ferrous Sulfate 325 mg tab orally - Metformin 500 mg tab orally - Gabapentin 300 mg capsule orally - Metoprolol Tartrate 25 mg tab orally - Myrbetriq Extended Release (ER) 50 mg tab orally - Furosemide 40 mg tab orally - Clearlax 30 milliliter (mL) orally - Levemir 100units(u)/mL - 40 units subcutaneous injection On 12/15/20, prior to the observation, Staff C was observed administering medications. 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 · D2020-12-18 · 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 observations, record review, and interviews the facility failed to ensure one resident (#51) of 28 sampled residents was accurately assessed for the use of adaptive/bed rails as evidence by the presence of bilateral raised adaptive rails and the inaccurate screening for the rails during quarterly reviews for their use. Findings included: Resident #51 was initially admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses of Parkinson's Disease, generalized weakness, unspecified lack of coordination, right knee contracture, and left knee contracture. An observation on 12/15/20 at 10:36 a.m., revealed Resident #51 was lying in a low bed with floor mats on each side of the bed and 1/4 bed/adaptive rails raised bilaterally. The Adaptive Rail Screen, with an effective date of 2/7/20, indicated the use of adaptive rails were considered due to a medical symptom and the resident's physical need for the rails was due to weakness, the cognitive reason was checked as none, and had a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-12-18 · 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, record review, and interviews the facility failed to review and revise a comprehensive, person-centered care plan by not including an intervention of adaptive/bed rails for one resident (#51) of 28 sampled residents. Findings included: Resident #51 was initially admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses of Parkinson's Disease, generalized weakness, unspecified lack of coordination, right knee contracture, and left knee contracture. An observation on 12/15/20 at 10:36 a.m., revealed Resident #51 was lying in a low bed with floor mats on each side of the bed and 1/4 bed/adaptive rails raised bilaterally. The Adaptive Rail Screen, with an effective date of 2/7/20, indicated the use of adaptive rails were considered due to a medical symptom and the resident's physical need for the rails was due to weakness, the cognitive reason was checked as none, and had a history of rolling out of bed. The screen indicated the resident requested the adaptive rails…

    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 · D2020-12-18 · 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 interviews, the facility failed to ensure that a physician order was written accurately for one resident (#23) out of five sampled residents for unnecessary medications. Findings included: A review of the admission Record for Resident #23 revealed that the resident was initially admitted into the facility on [DATE] with a diagnosis of essential hypertension. A review of the Order Summary Report for 11/01/20 revealed the following: Verapamil HCL ER Tablet Extended Release 120 MG (milligram) - Give 3 tablet by mouth in the evening for htn (hypertension) SBP (systolic blood pressure) less than 100 or DBP (diastolic blood pressure) less than 50, Notify MD (medical doctor). A review of the Order Summary Report for 12/18/20 revealed the following: Verapamil HCL ER Tablet Extended Release 120 MG- Give 3 tablet by mouth in the evening for htn (hypertension) SBP (systolic blood pressure) less than 100 or DBP (diastolic blood pressure) less than 50, Notify MD. The physician orders did not…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-12-18 · 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 review, and interview the facility failed to accurately monitor the use of psychotropic medications for one resident (#79) out of five residents sampled for unnecessary medications. Findings included: Resident #79 was admitted on [DATE]. The admission Record included diagnoses of dementia in other diseases classified elsewhere without behavioral disturbance, moderate recurrent major depressive disorder, and unspecified psychosis not due to a substance or known physiological condition. The physician Order Summary Report, active as of 12/18/20, identified that Resident #79 has been administered the psychotropic medications Seroquel daily for psychosis, Sertraline daily for depression, and Melatonin at bedtime for insomnia. The December 2020 Medication Administration Record (MAR) instructed licensed personnel to monitor for types of behaviors with corresponding numerical indicators, as well as non-pharmaceutical interventions attempted, the outcome of interventions, and the side…

    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 · D2020-12-18 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 resident (#52) out of five residents observed during the mandatory task of Medication Administration received medication within the parameters ordered by the physician. Findings included: Resident #52 was admitted on [DATE]. The admission Record included diagnoses not limited to other specified diabetes mellitus with diabetic neuropathy and unspecified Type 2 diabetes mellitus with diabetic neuropathy. An observation at 11:08 a.m. on 12/15/20, during the mandatory task of Medication Administration revealed Resident #52 lying in bed and Staff C, Licensed Practical Nurse (LPN) asking Resident #52 if she wanted her scheduled laxative. Staff C was witnessed, at 11:08 a.m., administering by subcutaneous injection, Resident #52's 8:00 a.m. dose of 40 units of Levemir (Insulin Detemir), three hours past the scheduled time and two hours past the accepted nursing standard allowing for medication administration one hour before and one…

    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 · D2020-12-18 · 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 record review and interviews, the facility failed to ensure documentation was accurate on the November and December 2020 Medication Administration Records (MAR) for two residents (Resident #23 and #4) out of 28 sampled residents. Findings included: 1. A review of the admission Record for Resident #23 revealed that the resident was initially admitted into the facility on [DATE] with a primary diagnosis of metabolic encephalopathy. The active physician orders as of 11/01/2020 revealed the following order: Evaluate for respiratory symptoms. Notify MD/charge nurse if identified every 4 hours new or worsening malaise- Y (yes) or N (no), dizziness- Y or N, diarrhea- Y or N, sore throat- Y or N, Cough- Y or N, loss of taste/smell- Y or N. A review of the Medication Administration Record (MAR) for 11/01/20-11/30/20 revealed the following documentation for the order: NA (not applicable) was documented instead of Y or N according to the order on the following days in November: 1st, 2nd, and 5th through the 30th.…

    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 · D2020-12-18 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and review of the policy and procedure, it was determined that the faciltiy did not ensure an effective Quality Assurance and Performance Improvement (QAPI) plan was implemented to monitor corrective action to ensure that adaptive rail assessments were accurate for three residents (#3, #5, #6) of four residents reviewed. Findings included; Review of the facilty policy titled, QAPI - Nursing, Social Services, Risk Management, with an effective date of February 20, 2018 and a revision date of May 2018, revealed : Policy: Each center must develop, implement, and maintain an effective comprehensive date driven Quality Assurance and Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. QAPI identifies opportunities for improvement, addresses gaps in systems and involves performance improvement plans with monitoring of interventions. Procedure: 5. The center must take action aimed at performance improvement and, after…

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

    Administration Deficiencies · Deficient, Provider has date of correction

“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

$24,395 in federal fines across 1 penalty.

  • $24,395 — penalty dated 2024-04-04

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 5 of 53.4+1.6 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 13 homes this chain runs (chain average 3.1★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
PALM GARDEN HEALTHCARE HOLDINGS, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 11/01/2013
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
REGIONS BANKOrganization5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTERESTsince 11/01/2013
PGWIN RE, 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
DAVID, WASEEMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2024
WASHINGTON, TUNYAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/14/2025
PALM HEALTHCARE MANAGEMENT, LLCOrganizationADP OF THE SNFsince 03/14/2025

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.

$13.5M
Net patient revenuemost recent cost report
-6.1%
Operating marginrevenue minus expenses
$3.1M
Related-party expense22% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 11%Other / private 30%

This home reported $3.1M paid to related parties — landlords or management companies under common ownership — equal to about 22% 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

$347per resident / day
operating cost
$10,541per month
≈ monthly operating cost
$327per 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 105566. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-20, 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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