Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palm Garden Of Clearwater during CMS and state inspections, most recent first.
A deficiency was cited when a resident's care plan did not include all necessary components, such as measurable timetables and specific actions, resulting in incomplete planning and documentation of care needs.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment was not maintained to minimize risks, and supervision was insufficient to prevent incidents.
The facility failed to ensure accurate PASRR assessments for twelve residents, leading to deficiencies in the screening process. The PASRR Level I assessments contained inaccuracies, such as unchecked diagnoses of mental illnesses like anxiety disorder, depressive disorder, and psychotic disorder, despite these conditions being present in the residents' medical records. Additionally, the facility lacked a policy and procedures for PASRR, contributing to the inaccuracies observed in the screenings.
The facility failed to provide sufficient staffing to ensure timely meal service, resulting in residents receiving cold meals. Multiple residents reported concerns about food temperature, and observations showed delays in meal service on two units. Staff interviews revealed high resident-to-staff ratios, with staffing decisions based on census numbers rather than resident needs. The facility lacked a clear staffing policy, contributing to the deficiency.
The facility failed to maintain professional standards for food service safety, with staff not wearing proper hair restraints, inadequate labeling of food items, and poor cleanliness in the kitchen and nourishment rooms. Staff did not perform hand hygiene or sanitize thermometer probes between food items, and food temperatures were not maintained at safe levels. The facility's policies on personal hygiene, food labeling, and temperature recording were not followed, leading to deficiencies in food service safety.
The facility failed to maintain resident dignity by requiring residents to wear informational wristbands without consent and failed to ensure the privacy of a resident's catheter bag, which was visible from the hallway. Residents expressed discomfort with the wristbands, and staff did not promptly address the visibility of the catheter bag, violating residents' rights to dignity and privacy.
The facility failed to follow physician orders for wound care for three residents, leading to deficiencies in care. A resident with a terminal prognosis had a wound dressing that was not changed as ordered. Another resident with diabetes and dementia had an undated bandage on her shin, with staff unsure of who was responsible for care. A third resident with a surgical wound lacked an active order for wound care, leading to confusion among staff. These issues highlight a failure to adhere to wound care protocols.
The facility failed to provide bedtime snacks to several residents, resulting in a gap of at least 15 hours between dinner and breakfast. Despite the Dietary Manager's claim that snacks are sent to units, residents reported not receiving them or being offered inadequate options. The Registered Dietitian confirmed the extended time between meals, which violates the facility's policy requiring snacks to be offered at bedtime.
Two residents expressed concerns about meals, care, and food temperatures, but the facility failed to document and resolve these grievances promptly. Despite communicating their issues to various staff members, including the Dietary Manager and Unit Manager, the grievances were not recorded in the logs, and no changes were made. The facility's grievance policy outlines the process for handling grievances, but inconsistencies in documentation and follow-up were evident.
A resident at risk for pressure ulcers was not provided with the prescribed offloading boot, as staff were unaware of the order and the resident's care needs. Despite documentation indicating the boot was offered, observations and interviews revealed it was not, leading to a failure in preventing pressure ulcers.
A facility failed to follow a contracture maintenance program for a resident with right-sided weakness, resulting in the resident not wearing a prescribed hand splint over several days. The care plan required the splint to be worn as tolerated, but staff were unaware of this requirement, and there was no documentation in the MAR or TAR to support the splint's use. Interviews with staff confirmed a lack of awareness and documentation regarding the splint, despite the resident's cognitive intactness and ability to make decisions.
The facility failed to ensure accurate documentation in the medical records for three residents, leading to discrepancies in dietary restrictions and physician orders. One resident was incorrectly documented as taking nutrition orally despite being on an NPO diet with a gastrostomy tube. Two other residents on NPO diets were documented as having been provided snacks.
A resident with severe medical conditions was given ice cream by an activity aide despite having an NPO order, leading to severe respiratory distress and hospital transfer. The facility failed to report the incident within the required timeframe.
The facility failed to develop an accurate care plan for a resident who was NPO and exhibited non-compliant behaviors. Despite the resident's dependence on a gastric tube for nutrition, the care plan did not reflect his NPO status and lacked specific interventions for his behaviors. Interviews revealed that the facility was aware of the issues but did not adequately address them in the care plan.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on observations and review of the care planning process, which did not meet regulatory standards for comprehensive and measurable care planning.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding specific residents, their medical history, or the exact nature of the hazards or accidents were provided in the report.
Inaccurate PASRR Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Review (PASRR) assessments for twelve residents, leading to deficiencies in the screening process. The PASRR Level I assessments for these residents contained inaccuracies, such as unchecked diagnoses of mental illnesses like anxiety disorder, depressive disorder, and psychotic disorder, despite these conditions being present in the residents' medical records. For instance, Resident #1's PASRR indicated no diagnosis or suspicion of serious mental illness, despite having major depressive disorder and anxiety disorder. The report highlights several instances where the PASRR Level I screenings did not reflect the residents' actual diagnoses. For example, Resident #126's PASRR failed to check anxiety disorder, even though it was part of the resident's medical history. Similarly, Resident #44's PASRR marked no suspicion of serious mental illness, despite the presence of anxiety disorder, depressive disorder, and psychotic disorder. These discrepancies indicate a lack of thoroughness in the PASRR screening process, which is crucial for determining the need for a Level II evaluation. Additionally, the facility lacked a policy and procedures for PASRR, as confirmed by the Nursing Home Administrator. This absence of a structured approach to PASRR assessments likely contributed to the inaccuracies observed in the screenings. The failure to accurately complete PASRR assessments could lead to inappropriate admissions and inadequate care planning for residents with serious mental illnesses or intellectual disabilities.
Inadequate Staffing Leads to Cold Meals for Residents
Penalty
Summary
The facility failed to ensure sufficient staffing to provide timely meal service to residents on two units, B and D, out of four units in the facility. Multiple residents expressed concerns about the temperature of their meals, consistently reporting that the food was cold. Observations revealed delays in meal service, with meal carts arriving and being served over extended periods, contributing to the cold food issue. The staff available for meal service varied, with some instances having only two CNAs and one nurse to serve meals, which may have contributed to the delays. Interviews with staff indicated that CNAs were responsible for a high number of residents, often exceeding ten, which they reported made it difficult to provide quality care. The facility's staffing decisions were based on census numbers, with no adjustments made for weekends. The Nursing Home Administrator and Director of Nursing stated that staffing was based on resident acuity and needs, but there was no clear policy or procedure for staffing, and the facility did not provide one when requested. This lack of a formal staffing policy may have contributed to the inadequate staffing levels observed.
Deficiencies in Food Service Safety and Hygiene
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. In the kitchen, staff were found not wearing proper hair restraints, with hair exposed beyond the acceptable limit. Additionally, food items in the walk-in fridge were not labeled correctly, and some were in poor condition, such as wrinkled peppers with dark spots. The walk-in freezer had scattered food particles and debris on the floor, indicating a lack of cleanliness. Furthermore, the kitchen hood was observed to have a brown rusted color and areas of oxidation, suggesting inadequate cleaning. In the nourishment rooms, the microwave was found with dried food particles, and staff were observed using cell phones while handling clean kitchen items, which is against the facility's policy. During meal service, staff failed to perform hand hygiene before taking food temperatures and did not sanitize the thermometer probe between different food items. The temperature of the ribs was recorded below the required safe level, and cold food items were not maintained at the appropriate temperature, indicating a failure in monitoring and maintaining food safety standards. The facility's policies on personal hygiene, food labeling, and temperature recording were not followed, as evidenced by the lack of handwashing, improper use of hair restraints, and failure to label and date food items correctly. The Certified Dietary Manager (CDM) acknowledged these deficiencies and stated that staff should not be using cell phones in the kitchen and that the dietary team is responsible for maintaining cleanliness. However, the observations during the survey revealed significant lapses in adhering to these policies, contributing to the overall deficiency in food service safety.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain resident dignity by requiring residents to wear plastic informational wristbands without their consent or understanding. Observations over several days revealed that multiple residents were wearing these wristbands, which contained personal information such as photos, numbers, and barcodes. Interviews with residents indicated that many did not understand the purpose of the wristbands and expressed discomfort and a desire not to wear them. The facility's Director of Nursing (DON) and Registered Nurse/Unit Manager (RN UM) confirmed the use of wristbands for resident identification but were unable to provide consent forms for the residents involved. Additionally, the facility failed to ensure the privacy of a resident using an indwelling catheter. On multiple occasions, the catheter bag was observed hanging in a manner that made it visible from the hallway and nurses' station, without being placed in a privacy bag. This was contrary to the facility's catheter care policy, which requires the use of a privacy bag to maintain resident dignity and privacy. Staff members, including a Certified Nursing Assistant (CNA) and the RN UM, were observed not addressing the visibility of the catheter bag promptly. The facility's failure to obtain consent for wristbands and to maintain the privacy of catheter bags violated residents' rights to dignity and privacy. The Nursing Home Administrator (NHA) acknowledged the lack of specific policies and procedures related to privacy and dignity, relying instead on general guidelines in the resident rights section of the admission packet. The absence of consent forms and the improper handling of catheter bags highlight deficiencies in the facility's adherence to resident rights and care standards.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders and provide appropriate wound care for three residents, leading to deficiencies in care. Resident #5, who was admitted with a terminal prognosis and at risk for skin integrity issues, had a wound dressing on her forehead that was not changed as per the physician's orders. The dressing was supposed to be changed every other day, but it was observed to be dated two days prior, and staff admitted to documenting the change without actually performing it. Resident #138, who has multiple diagnoses including diabetes and dementia, was observed with an undated bandage on her left shin. The facility's records showed that the wound care orders were not consistently followed, and there was confusion among staff about who was responsible for changing and documenting the dressing. The wound care nurse and floor nurses had conflicting accounts of the care provided, and the bandage was found to be undated, which is against the facility's policy. Resident #266, admitted with a surgical wound on the left knee, did not have an active order for wound care until several days after admission. The hospital discharge summary specified that the dressing should remain until a certain postoperative day unless saturated, but this order was not transcribed into the facility's records. Staff interviews revealed a lack of clarity on the need for physician orders for dressing changes, and the Director of Nursing confirmed the absence of an active order for the resident's wound care.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to offer a nourishing snack at bedtime for five out of six residents sampled for dining. Interviews with residents revealed that they were not offered evening snacks, and when they requested snacks, the staff either did not have any available or provided inadequate options. One resident mentioned that the kitchen was closed when they attempted to request a snack, while another resident was given a moon pie after expressing their desire for a snack. The residents expressed their dissatisfaction with the lack of snacks, indicating a preference for having something to eat before bedtime. The Dietary Manager stated that snacks are sent to the units each evening for residents who have requested them, along with a variety of other snacks for those who might request them. However, the Registered Dietitian noted that there was at least a 15-hour gap between dinner and breakfast, which exceeds the facility's policy of no more than 14 hours between meals unless a nourishing snack is provided. The facility's policy requires that snacks be offered at bedtime and that there be no more than 14 hours between the evening meal and breakfast unless a nourishing snack is served, which was not adhered to in this case.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for two residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Resident #109 expressed repeated concerns about meals and care, stating that the facility did not listen to her. Despite these concerns being communicated to various staff members, including the Dietary Manager and the Unit Manager, there was no documentation of these grievances in the facility's grievance logs from November 2024 to February 2025. The Dietary Manager acknowledged receiving concerns from residents but admitted to not documenting them consistently. Resident #268 also reported concerns about care and food temperatures since admission, stating that these issues were communicated to multiple staff members, including CNAs, nurses, and the Unit Manager, but no changes were made. The grievance logs from January 2025 to February 2025 did not reflect any grievances for Resident #268. Staff members, including a CNA and an RN, confirmed that grievances could be filed by anyone, but there was a lack of documentation and follow-up on these concerns. The facility's grievance policy, revised in March 2024, outlines the process for handling grievances, including the roles of the Grievance Official and Social Services personnel. However, interviews with staff revealed inconsistencies in the documentation and resolution of grievances. The Social Services Director, responsible for overseeing the grievance process, confirmed that grievances are discussed in daily meetings and tracked for trends, but there was no follow-up with residents unless the issues were related to Social Services. The Nursing Home Administrator stated that grievances are logged and discussed in manager meetings, but the process failed to ensure timely resolution and documentation of the residents' concerns.
Failure to Provide Pressure Ulcer Prevention Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident with a known risk for pressure ulcers. The resident, who was admitted with diagnoses including palliative care, weakness, and reduced mobility, had orders to wear a right offloading boot when in bed to prevent pressure ulcers. However, observations over several days revealed that the resident was not wearing the prescribed boot, and staff were unaware of the resident's need for the boot or the associated doctor's orders. Interviews with multiple CNAs assigned to the resident indicated a lack of awareness regarding the resident's need for the offloading boot. The CNAs, who regularly cared for the resident, were not informed about the resident's upper or lower extremity weaknesses or the requirement for the boot. The resident herself could not recall being offered the boot recently and mentioned that it hurt her foot, but there was no documentation of refusal or any behavior issues related to the boot in her care plan. The facility's records, including the February 2025 MAR, inaccurately documented that the resident was offered and assisted with the boot, despite observations and interviews indicating otherwise. The Rehabilitation Department was not involved in the resident's care concerning the boot, as it was ordered by the physician for pressure ulcer prevention. The lack of proper communication and documentation led to the resident not receiving the necessary care to prevent pressure ulcers, as per professional standards of practice.
Failure to Implement Contracture Maintenance Program
Penalty
Summary
The facility failed to adhere to the contracture maintenance program for a resident, resulting in the resident not being assisted with the donning and doffing of their splint device over a four-day observation period. The resident, who has a history of right-sided weakness due to a cerebrovascular accident, was observed without the prescribed right hand splint on multiple occasions. Interviews with the assigned CNAs revealed they were unaware of the resident's need for a splint, indicating a lack of communication and training regarding the resident's care plan. The resident's care plan and physician's orders specified the use of a right resting hand splint to be worn as tolerated, with specific instructions for application and removal during evening and morning care. However, there was no documentation in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) to support that the splint was offered, worn, or refused, suggesting a failure in record-keeping and adherence to the care plan. Interviews with nursing staff, including an LPN and RN Unit Manager, confirmed the absence of documentation regarding the splint's use and any refusals by the resident. The Rehabilitation Director was unaware that the splint was not being applied as per the care plan and acknowledged that the responsibility for applying the splint lay with the night shift aides. Despite the resident's cognitive intactness and ability to make decisions, there was no evidence of documented refusals of the splint, further highlighting the facility's failure to implement and monitor the prescribed contracture maintenance program effectively.
Documentation Errors in Medical Records
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records for three residents. Resident #1, who had multiple diagnoses including pneumonia and severe protein-calorie malnutrition, was documented as taking nutrition and medication orally despite having a gastrostomy tube and being on an NPO diet. The LPN responsible for the documentation admitted to the error, stating it was careless charting and that the resident was actually receiving everything via the g-tube. The Director of Nursing acknowledged the documentation errors and expressed concern over the accuracy of the records. Resident #2, who was on an NPO diet due to pneumonitis from inhalation of food and vomit, was documented by certified nursing assistants as having been provided snacks on multiple occasions. This was contrary to the physician's orders and the resident's dietary restrictions. An observation of Resident #2 showed that he was alert but non-verbal, and he acknowledged questions by nodding. Resident #3, who had diagnoses including pleural effusion and dysphagia, was also on an NPO diet. However, the certified nursing assistants documented that he had been provided a snack on one occasion. An observation of Resident #3 showed that he was in bed and did not respond when spoken to. These documentation errors indicate a failure to adhere to the residents' dietary restrictions and physician orders, compromising the accuracy of the medical records and potentially the residents' care.
Failure to Timely Report Incident Leading to Hospital Transfer
Penalty
Summary
The facility failed to report an event that led to the transfer of a resident to a higher level of care within the specified timeframe. The resident, who had a history of severe medical conditions including pneumonia, urinary tract infection, severe protein-calorie malnutrition, and others, was admitted to the facility and later discharged to the hospital. The resident was cognitively intact and required partial assistance for daily activities. On the day of the incident, the resident attended an ice cream social and was given ice cream by an activity aide, despite having a medical order for nothing by mouth (NPO) and being on enteral feeding via a peg tube. The resident began experiencing severe respiratory distress during the social event, with oxygen saturation levels dropping significantly. The resident was placed on portable oxygen and a rebreather mask but showed minimal improvement. The decision was made to transfer the resident to the emergency room, and 911 was called. The incident was initially reported to the Director of Quality Assurance/Risk Manager (DOQA/RM) by the weekend supervisor, who stated that the resident had grabbed the ice cream. However, further investigation revealed that the ice cream was handed to the resident by the activity aide, who had access to the dietary list indicating the resident's NPO status. The DOQA/RM initiated an investigation on the following day and discovered the full details of the incident. The activity aide was removed from the schedule and later terminated. The facility reported the incident to the appropriate authorities, including the State Survey Agency, Adult Protective Services, and local law enforcement, but not within the required timeframe. The delay in reporting and the failure to follow the resident's medical orders led to the deficiency noted in the report.
Inadequate Care Plan for NPO Resident with Non-Compliant Behaviors
Penalty
Summary
The facility failed to ensure the Comprehensive Patient-Centered Care Plan was developed and accurate for a resident who was NPO (nothing by mouth) and exhibited non-compliant behaviors. The resident, who had multiple diagnoses including pneumonia, severe protein-calorie malnutrition, and dysphagia, was dependent on a gastric tube for nutrition and hydration. Despite this, the care plan did not accurately reflect the resident's NPO status and failed to address his non-compliant behaviors, such as drinking tap water and eating unauthorized food items. The MDS coordinator confirmed that the behavior care plan did not indicate the resident was NPO and acknowledged that the interventions could have been personalized but were not. Interviews with the Director of Quality Assurance/Risk Manager (DOQA/RM) and the Director of Nursing (DON) revealed that the facility was aware of the resident's non-compliant behaviors but did not adequately address them in the care plan. The DOQA/RM discovered an unopened package of snacks in the resident's room, and the DON confirmed that the care plan interventions were basic and needed to be more focused on the resident's specific behaviors. The facility's policy required a baseline care plan to be developed within 48 hours of admission, but the care plan for this resident did not meet the required standards for addressing dietary orders and specific health and safety concerns.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clearwater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westchester Gardens Health & Rehabilitation | 0.5 mi | ★★★★★ | 1 | 0 |
| Aviata At Countryside | 0.7 mi | ★★★★★ | 0 | 0 |
| Oakpark Health And Rehabilitation Center | 1.9 mi | ★★★★★ | 13 | 0 |
| Aviata At Oldsmar | 2.3 mi | ★★★★★ | 0 | 0 |
| St Mark Village | 2.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.