Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Pinellas during CMS and state inspections, most recent first.
A resident with heart failure, DM2, HTN, and HLD developed chest pain radiating to her back, diaphoresis, clamminess, and repeated requests to go to the ER. Staff obtained orders for STAT EKG, CXR, and labs, but the diagnostics were not completed, no change of condition was documented, and the resident remained in the facility for hours before becoming unresponsive in her wheelchair and dying shortly after EMS arrival.
A resident developed worsening symptoms including chest pain radiating to the back, sweating, clamminess, pallor, vomiting, and repeated requests to go to the hospital. Staff repeatedly raised concerns to the APRN and DON, but the physician and family were not notified of the significant change in condition, and no change-of-condition process was completed.
A resident with cognitive impairment and a history of exit-seeking behavior managed to leave the facility unnoticed through an ambulance entrance with an electromagnetic lock. The resident walked 0.8 miles along busy roads before being spotted by a staff member. The facility did not notice the resident's absence for approximately 30 minutes. Contributing factors included unauthorized use of entry/exit codes, failure to recognize elopement signs, and sharing of codes with non-staff individuals. The root cause analysis identified deficiencies in door security, staff awareness, and response to elopement risks.
A resident with cognitive deficits and confusion exited the facility through an ambulance entrance door by using a security code. The resident walked outside, traversing busy roads before being noticed by a staff member. Despite a care plan in place for elopement risk, the resident's actions were not adequately monitored. Unauthorized sharing of door codes and staff unfamiliarity with safety protocols contributed to the incident. The investigation highlighted a lack of awareness and prompt response from staff, as well as inadequate supervision and safety measures.
Failure to Transfer Resident With Chest Pain and Change in Condition
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards and failed to send a resident to a higher level of care when requested. Resident #2 was admitted with diagnoses including heart failure, type 2 diabetes mellitus with diabetic neuropathy, hypertension, and hyperlipidemia, and had intact cognition. On the day of the event, staff documented that the resident complained of chest pain radiating to her back, appeared clammy and sweaty, and repeatedly stated that she wanted to go to the hospital. Staff also documented earlier complaints of pain, anxiety, and vomiting, but no change of condition documentation was completed in the electronic record. The record showed that an APRN ordered STAT EKG, chest x-ray, and labs for chest pain, but the facility did not complete the diagnostics. Staff contacted the outside EKG/lab provider and were told a STAT EKG could not be done and could only be ordered routine. Despite repeated reports that the resident wanted to go to the ER and staff concerns that she needed emergent care, the resident remained in the facility for hours. Nitroglycerin was not ordered until later in the afternoon, and documentation reflected that the resident briefly improved, but she then became unresponsive in her wheelchair with agonal breathing and cyanosis. The resident was a DNR, EMS was called, and she was pronounced dead shortly thereafter. Interviews confirmed that staff believed the resident should have been sent out earlier, that the facility had educated staff they could only call the nurse practitioner and not send residents out, and that the Medical Director was not notified. The Interim DON, NHA, Medical Director, and other staff acknowledged that a change of condition should have been completed and that the resident should have been transferred to the hospital when she first reported chest pain and requested to go. The facility policy required prompt notification of the physician and family for significant changes in condition or transfer needs, and the Medical Director agreement included oversight of emergency resident care and clinical issues.
Failure to Notify Physician and Family of Significant Change in Condition
Penalty
Summary
The facility failed to ensure that Resident #2’s family and physician were notified of a significant change in condition. The resident’s record showed the primary physician was the Medical Director. Progress notes documented complaints of middle back pain, anxiety, vomiting, chest pain radiating to the back, sweating, clamminess, pallor, and repeated statements that she wanted to go to the hospital because she did not feel good. Staff interviews confirmed that Resident #2’s condition worsened over the course of 4/7/26 and 4/8/26, and that staff repeatedly expressed concern that she needed emergent care. Staff B, RN, stated the resident appeared “as a ghost,” was sweating and clammy, and kept saying she wanted to go out. Staff B reported concerns were brought to the Former DON and APRN multiple times, but the response was to schedule an in-house cardiology consult. Staff B also stated she was never told she could send the resident directly to the emergency department. The APRN stated she should have collaborated with the primary physician but did not. The Interim DON, Former DON, NHA, Director of Quality Assurance and Risk Management, and Medical Director all confirmed that a change of condition should have been completed and that the physician and family should have been notified. The Medical Director stated she was not notified of the resident’s chest pain and would have sent the resident to the hospital right away based on the reported symptoms.
Elopement Incident Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to protect a resident (#1) from neglect by not ensuring supervision and services to prevent elopement, despite the resident's known history of exit-seeking behaviors and expressed desire to leave. Resident #1, at risk for elopement, managed to exit the facility unnoticed through an ambulance entrance equipped with an electromagnetic locking device. She walked approximately 0.8 miles along busy roads before being seen by a staff member returning from an appointment. The facility staff did not realize Resident #1 was missing for approximately 30 minutes, highlighting a significant lapse in supervision and safety measures. Review of Resident #1's medical history revealed diagnoses including cognitive communication deficit, anxiety disorder, and muscle weakness. Progress notes indicated mild cognitive impairment and increased wandering behavior, with an elopement evaluation scoring Resident #1 at risk. Despite being identified as an elopement risk, the facility's care plan aimed to prevent unsafe elopement episodes and maintain the resident's safety. Staff interviews revealed Resident #1's consistent exit-seeking behavior, desire to go home, and agitation, indicating a pattern of behavior that should have triggered heightened supervision measures. The facility's investigation identified unauthorized use of entry/exit codes, failure to recognize signs of elopement, and sharing of codes with non-staff individuals as contributing factors to Resident #1's elopement. The root cause analysis highlighted deficiencies in door security, staff awareness, and response to elopement risks. The facility's failure to provide adequate supervision and implement necessary safety measures resulted in an Immediate Jeopardy situation, posing a serious risk of harm to Resident #1 and highlighting systemic failures in protecting residents from neglect and elopement.
Elopement Incident Due to Inadequate Supervision and Unauthorized Door Access
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for Resident #1, who was at risk for elopement due to cognitive deficits and confusion. On 3/25/2024, Resident #1 managed to exit the facility through an ambulance entrance door equipped with an electromagnetic locking device by punching in the security code. She walked outside the facility, traversing busy roads and traveling a significant distance before being noticed by a staff member returning from an appointment. Resident #1 was eventually picked up by facility staff and returned safely, but the incident highlighted a severe lapse in supervision and safety protocols. Multiple staff members acknowledged Resident #1's tendency to wander and exhibit exit-seeking behavior prior to the elopement incident. Despite being identified as at risk for elopement and having a care plan in place, Resident #1's actions were not adequately monitored or prevented. The facility's failure to recognize and address the signs of elopement, as well as the unauthorized sharing of door codes with non-staff individuals, contributed to the breach in safety that allowed Resident #1 to leave the premises unnoticed. The investigation revealed a series of events captured on camera, detailing Resident #1's journey outside the facility and the subsequent efforts to locate and return her safely. Interviews with staff members highlighted a lack of awareness regarding Resident #1's elopement and a failure to respond promptly to the situation. The root cause analysis identified unauthorized door access, inadequate supervision, and staff unfamiliarity with safety protocols as key factors that led to the deficiency in ensuring Resident #1's safety and preventing elopement.
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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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Nursing homes near Largo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sabal Palms Health & Rehabilitation | 1.9 mi | ★★★★★ | 2 | 0 |
| Wrights Healthcare And Rehabilitation Center | 2.1 mi | ★★★★★ | 8 | 0 |
| Belleair Health Care Center | 2.4 mi | ★★★★★ | 27 | 0 |
| Aviata At Bryan Dairy | 2.5 mi | ★★★★★ | 4 | 4 |
| Oak Manor Healthcare & Rehabilitation Center | 2.6 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.