Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Ocala during CMS and state inspections, most recent first.
A resident with chronic pain and multiple diagnoses was given Tramadol for pain levels below the physician-ordered threshold. The MAR showed the medication was administered for pain scores of 4 and 5, despite orders specifying use only for pain levels 6 to 10. Interviews with the DON, Medical Director, and an LPN confirmed that medication was given outside of prescribed parameters, and relevant policies were not provided during the survey.
The facility did not consistently develop or implement comprehensive care plans for residents with specific needs, including one resident at risk for falls who did not have required bilateral fall mats in place, two residents with diabetes who frequently refused blood glucose monitoring without care plan focuses for refusals, and a resident receiving oxygen therapy without a care plan focus for oxygen use. Staff interviews confirmed these omissions, which were not in accordance with facility policy.
Four residents were observed receiving oxygen therapy at flow rates higher than those ordered by their physicians, with staff interviews confirming the discrepancies and lack of consistent monitoring. Residents did not adjust their own oxygen, and staff acknowledged responsibility for ensuring correct flow rates, which was not consistently performed.
Two residents with physician orders for oxygen therapy were not accurately coded as receiving oxygen in their MDS assessments. Both had significant cardiopulmonary diagnoses and orders for oxygen as needed, but their quarterly MDS assessments did not reflect this treatment. Facility staff confirmed the inaccuracy and acknowledged the lack of a policy guiding this process.
A resident with dysphagia and a physician order for nectar thickened liquids was given regular thin liquids by a physical therapist who failed to verify the current diet order in the electronic medical record, resulting in the resident coughing after consuming the water. Staff interviews confirmed that the resident was not to receive thin liquids except under speech therapy supervision, and that standard protocol requires staff to check diet orders before providing food or fluids.
A resident with a history of multiple medical conditions received Vancomycin for C. diff prophylaxis after developing loose stool. Despite a negative C. diff test, the antibiotic was continued and administered for several days. The Infection Preventionist confirmed that the medication should have been discontinued after the negative result, which was not done in accordance with facility policy on antibiotic stewardship.
Surveyors found that food items in the main kitchen and a nourishment room were not stored or labeled according to facility policy. An unwrapped, undated pizza and a container of sour cream with unclear dating were found in the kitchen, while a bowl of fruit in a nourishment room refrigerator lacked both a date and resident identification. The Dietary Supervisor acknowledged these lapses and confirmed that facility policy requires proper labeling and dating of all food items.
A resident with a high fall risk and a history of fractures, Huntington's Disease, and ataxia was left unsupervised during toileting, contrary to their care plan. This resulted in a fall causing head injuries and a transfer to a higher level of care. The CNA involved did not follow the updated care plan, which required supervision in the bathroom.
Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including fibromyalgia, chronic pain, dementia, and other conditions, was administered Tramadol HCL 50 mg outside of the physician-ordered parameters. The physician's order specified that the medication should only be given for moderate to severe pain levels of 6 to 10. However, review of the Medication Administration Record (MAR) showed that the medication was administered on several occasions for pain levels documented as 4 or 5, which did not meet the criteria set by the physician's order. Interviews with facility staff, including the DON and the Medical Director, confirmed that staff are expected to follow medication orders and parameters as written. An LPN acknowledged administering the medication outside the prescribed parameters. Additionally, when requested, the facility was unable to provide policies and procedures related to medication administration and following physician orders by the time of survey exit.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents with specific medical needs. For one resident at risk for falls, observations revealed that only one fall mat was placed at the bedside while the care plan required bilateral floor mats whenever the resident was in bed. Staff interviews confirmed that both sides should have had mats in place, but this was not consistently implemented as observed on multiple occasions. Two residents with diabetes who frequently refused blood glucose monitoring (accu-checks) did not have care plan focuses addressing their refusals, despite repeated documentation of refusals and staff education attempts in the electronic medical record. Staff interviews acknowledged that these refusals should have been care planned, but the care plan coordinator was not always informed or did not review all relevant documentation to identify the need for care plan updates. Additionally, a resident receiving oxygen therapy via nasal cannula at 3 liters per minute did not have a care plan focus for oxygen therapy, even though there was a physician order for oxygen use. Staff interviews confirmed that the care plan should have included this intervention from admission, but it was omitted. The facility's policy requires comprehensive care plans to address all nursing, medical, and psychosocial needs, but these requirements were not met for the residents identified.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician orders for four residents who were receiving oxygen therapy. Observations revealed that each resident was receiving oxygen at a higher flow rate than prescribed. For example, one resident was observed receiving oxygen at 4 liters per minute (LPM) when the physician order specified 2 LPM as needed for shortness of breath, and another was receiving 5 LPM when the order was for 3 LPM. In each case, the oxygen concentrator was placed outside the resident's reach, and residents reported that only staff handled the oxygen equipment. Interviews with nursing staff confirmed that the oxygen flow rates being administered did not match the physician orders, and staff acknowledged the discrepancies during the survey. Staff also indicated that they were responsible for checking and adjusting the oxygen flow rates, but these checks were not consistently performed as required. The Director of Nursing confirmed that staff should ensure oxygen is administered at the ordered rate, but this was not done for the residents in question.
Inaccurate MDS Coding for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents who had physician orders for oxygen therapy. One resident, admitted with diagnoses including chronic systolic heart failure, acute pulmonary edema, dyspnea, and dependence on supplemental oxygen, had a physician order for oxygen as needed for shortness of breath, but the quarterly MDS assessment did not document oxygen therapy under Section O. Similarly, another resident with diagnoses such as chronic obstructive pulmonary disease, pneumonia, heart failure, and emphysema also had a physician order for oxygen as needed, yet their quarterly MDS assessment lacked documentation of oxygen therapy. Interviews with the Director of Nursing and the MDS Coordinator confirmed that both residents had oxygen orders and that the MDS assessments were not accurate, with the MDS Coordinator noting the absence of a relevant policy.
Resident Given Incorrect Liquid Consistency Due to Failure to Verify Diet Order
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, recent TIA, and prior NPO status with PEG tube was given regular thin liquids by a physical therapist during a hallway therapy session. The resident had a current physician order for a mechanical soft diet with nectar thickened fluids, as confirmed by recent swallow studies and speech therapy notes. Despite this, the physical therapist provided the resident with a cup of water, believing the resident had been upgraded to thin liquids based on a misunderstanding from a previous staff meeting. The therapist did not verify the resident's current diet order in the electronic medical record before providing the water. A licensed practical nurse observed the therapist giving the resident water and questioned whether the resident was supposed to receive thin liquids, as she believed the resident was still on a thickened liquid diet. The therapist insisted the resident was doing well and had been upgraded, but the nurse checked the electronic record and confirmed the resident was still on nectar thickened liquids. Before the cup could be removed, the resident drank a large amount of water and subsequently coughed. The incident was witnessed by staff, and the water was removed from the resident. Interviews with the speech therapist, director of nursing, registered dietician, and director of rehabilitation confirmed that the resident was not to receive thin liquids except under the supervision of speech therapy. All staff interviewed stated that the standard protocol is to verify diet orders in the electronic medical record before providing food or fluids, and that non-nursing staff should consult nursing staff before giving anything to eat or drink. The physical therapist admitted to not checking the current order and relying on memory, which led to the resident being given the wrong liquid consistency.
Failure to Discontinue Unnecessary Antibiotic Therapy After Negative C. diff Result
Penalty
Summary
A resident with a medical history including hypertension, right femur fracture, history of falls, peripheral vascular disease, and non-infective gastroenteritis and colitis was admitted to the facility. The resident developed loose stool for one day, prompting a physician order for a stool test for Clostridium difficile (C. diff) and a prophylactic order for oral Vancomycin. The C. diff test result returned negative the following day, but the Vancomycin order for prophylaxis continued, and the resident received the antibiotic multiple times daily for several days after the negative result. Despite the negative C. diff result, physician orders and the Medication Administration Record showed that Vancomycin was administered through at least 6/12, with a continued order for administration until 6/15. The Infection Preventionist confirmed that the antibiotic should have been discontinued after the negative test result. Facility policy requires systematic efforts to optimize antibiotic use, including discontinuation when antibiotics are no longer needed, but this was not followed in this case.
Failure to Store and Label Food Items According to Policy
Penalty
Summary
Surveyors observed that the facility failed to store food in a safe and sanitary manner in both the main kitchen and one of the nourishment rooms. In the main kitchen's walk-in cooler, an unwrapped pepperoni pizza was found sitting on top of a cardboard box without any opened or expiration date, and a 5-pound container of sour cream was present with a date written in marker that could not be clarified as either the opened or expiration date. The Dietary Supervisor acknowledged these issues, stating that the pizza should have been wrapped and dated, and that the sour cream should have been discarded if the date indicated it was opened. Additionally, in a nourishment room on Hallway 400, a grocery bag containing a clear plastic bowl of fruit (strawberries and grapes) was found in the refrigerator without an expiration date or a label identifying the owner. The Dietary Supervisor confirmed that all food brought in should be labeled with the resident's name and the date it was brought in. Review of facility policies confirmed requirements for proper labeling, dating, and storage of food items, which were not followed in these instances.
Inadequate Supervision During Toileting Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision during toileting for a resident, resulting in an accident that led to a head injury and subsequent transfer to a higher level of care. The resident, who had a history of wedge compression fractures, Huntington's Disease, and ataxia, was identified as being at high risk for falls with a score of 13 on the fall risk assessment. Despite the care plan specifying that the resident should not be left alone in the bathroom, a CNA allowed the resident privacy during toileting, which led to the resident falling and sustaining injuries. The incident was reported by the CNA, who found the resident bleeding on the bathroom floor. The Director of Nursing confirmed that the CNA had not followed the care plan, which had been updated to include the requirement for supervision in the bathroom following a previous fall. The Director of Quality Assurance noted that the CNA was informed that the resident required assistance but was not explicitly told not to leave the resident alone. The resident's hospital records indicated superficial lacerations to the scalp and a closed head injury, with the resident being alert and oriented to person and place but not time or situation.
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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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Nursing homes near Ocala
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Ocala | 0.4 mi | ★★★★★ | 8 | 0 |
| Hawthorne Center For Rehabilitation And Healing Of | 0.6 mi | ★★★★★ | 16 | 0 |
| Avante At Ocala, Inc | 2.2 mi | ★★★★★ | 27 | 0 |
| The Lodge Healthcare And Rehabilitation Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Ocala Health And Rehabilitation Center | 2.9 mi | ★★★★★ | 10 | 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.