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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palm Garden Of Sun City during CMS and state inspections, most recent first.
Failure to Investigate Resident Grievance: A resident with a BIMS of 13 and significant ADL needs had grievances raised by her POA about an LPN’s unprofessional and undignified comments, along with delayed follow-up on lab orders. The DON and NHA acknowledged the concerns but did not document a formal grievance investigation, did not follow up with the resident, and did not track the complaint in the grievance log.
A resident with bilateral above-knee amputations, impaired gait, and coordination deficits, who was care planned as total assist x2 for bed mobility and incontinent care, fell from bed during incontinent care when only one CNA provided assistance. The resident became agitated, pulled on the privacy curtain, and rolled out of bed, sustaining a small forehead abrasion. The CNA reported she was unaware that two-person assistance was required and believed, based on prior information from nurses, that the resident was a one-person assist, despite the Kardex specifying total assist x2.
A resident who was dependent on staff for transfers due to significant mobility impairments was injured when two CNAs failed to properly secure the sling straps during a mechanical lift transfer from wheelchair to bed. As a result, the resident fell from the lift, sustained a head laceration, and required hospital treatment. The incident occurred despite clear care plan instructions and facility procedures requiring two-person assistance and proper sling attachment.
A resident with multiple medical conditions, including contractures and significant pain, was neglected in a facility. The resident was not provided with necessary pain management, supportive devices, or adequate ADL care. Despite family concerns and staff awareness, the resident's pain and therapy needs were not addressed, and she remained confined to bed without a wheelchair or special chair. The facility's policies on neglect and nail care were not followed, leading to the resident's physical harm and pain.
A resident with significant medical conditions, including contractures, experienced inadequate pain management and care. Despite expressing pain and needing assistance, the resident only received Tylenol, which was insufficient. Communication failures led to the resident not receiving prescribed Tramadol, and therapy evaluations were not completed due to pain. The resident's hygiene and positioning needs were also neglected, contributing to her discomfort.
The facility failed to ensure proper food safety and storage practices, including staff not wearing hairnets, unlabeled and improperly stored food items, and incomplete temperature logs. These deficiencies were observed in the kitchen, dining room, nourishment room, and activity room, with photographic evidence supporting the findings.
The facility failed to accurately complete PASRR forms for several residents, leading to deficiencies in documenting mental disorders or intellectual disabilities. A resident with Major Depressive Disorder and Dementia had incorrect PASRR documentation, while another with multiple mental health diagnoses was not marked for dementia. Additionally, a resident's PASRR form did not reflect their anxiety and major depressive disorder, and another's form incorrectly marked the absence of dementia. The Care Plan Specialist confirmed these inaccuracies, and the facility lacked a PASRR policy.
The facility failed to properly store and label medications, with pills found on bedside tables and loose in medication carts. Expired medications and non-medication items were stored improperly, contrary to facility policy. Staff interviews revealed lapses in cleaning and monitoring responsibilities, and the DON was unaware of these issues.
The facility failed to maintain proper infection control practices, including incorrect precaution signage, inadequate hand hygiene, and improper PPE usage. Respiratory masks were left uncovered, and staff entered rooms with contact precautions without PPE. Confusion among staff regarding PPE protocols and inconsistent adherence to facility policies contributed to these deficiencies.
A resident was left to sleep on an unmade bed after a CNA failed to return to remake it following a urinal spill. The resident, who required assistance with personal care, was found on a bare mattress by another CNA. The facility lacked a specific policy on dignity, as confirmed by the DON.
The facility failed to develop care plans for two residents, one requiring splint management and another with impaired vision. A resident with a physician's order for a palm protector was often found without it, and staff did not assist in its application. Another resident with vision impairment struggled to find her glasses and could not read facility materials, yet had no care plan addressing her vision needs. The deficiencies were acknowledged by staff but not rectified at the time of the survey.
A resident with a right-hand contracture did not receive physician-ordered splint management, as the palm guard was not consistently applied. Despite the order for the palm guard to be worn at all times except for hygiene, staff were confused about the resident's orthotic device, and there was no documentation in the care plan or administration records. The DON acknowledged the need for an updated care plan, highlighting a gap in adherence to the facility's restorative nursing policy.
A resident on a vegetarian diet, who prefers fish, was not provided with balanced meals, lacking protein options. Observations revealed that selected meal items were altered by staff, and the resident expressed dissatisfaction with limited vegetarian options, often feeling hungry after meals. The care plan indicated a nutritional risk, but menu selections lacked protein, leading to inadequate meal offerings.
The facility was found to have falsified documentation related to refrigerator temperature logs and inaccurately documented services for a resident with significant medical conditions. The temperature logs were retroactively completed, and the resident's records inaccurately reflected frequent transfers and locomotion activities, despite the resident remaining in bed without a wheelchair. These actions violated the facility's Code of Conduct, which requires accurate and complete records.
Failure to Investigate Resident Grievance
Penalty
Summary
The facility failed to investigate and resolve a grievance related to alleged poor staff treatment for one resident. The resident was admitted with diagnoses including orthopedic aftercare, closed fracture of the left femur, dorsalis, muscle weakness, abnormalities of gait, and a history of falls. Her 5-day MDS showed a BIMS score of 13, indicating she was able to communicate about her medical care and services, and she required substantial assistance with most ADLs, including toileting. The resident’s POA reported that during the resident’s stay, staff did not follow up on laboratory orders in a timely manner and spoke to both the POA and the resident in an undignified and unprofessional manner. The POA stated an LPN made an inappropriate comment while assisting with care and later returned to the room and made another unprofessional remark directed toward the POA and resident. The POA reported the first incident to the DON and asked that the LPN no longer provide care to the resident. The DON and NHA acknowledged they were aware of the concerns but did not document a formal complaint or grievance investigation. They stated they believed the matter was handled by having the LPN apologize, and they did not follow up with the resident regarding the allegations. The grievance log reviewed by surveyors did not show the resident or POA as having any investigated complaints or grievances, and the DON and NHA confirmed they did not follow the facility’s grievance process for documenting, investigating, and tracking the concerns raised during the resident’s admission.
Failure to Provide Required Two-Person Assist During Incontinent Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required two-person assistance for bed mobility and incontinent care was protected from a fall during care. The resident had a history of other abnormalities of gait and mobility, lack of coordination, and bilateral above-knee amputations, and was care planned as total assist x2 for bed mobility, transfers with mechanical lift, and incontinent care. During an episode of incontinent care, a CNA provided care alone. The resident became agitated and combative, and when the CNA turned to clean the resident, the resident pulled on the privacy curtain and rolled out of the bed, resulting in a fall and a small skin tear/abrasion to the forehead. The CNA reported she had routinely cared for this resident and was not aware that two-person assistance was required for bed mobility and incontinent care. She stated she had previously asked nurses whether the resident required two-person assistance and was told the resident was a one-person assist, though she could not recall which nurse provided this information. The CNA later reviewed the chart and saw the resident was documented as an extensive assist, meaning one- or two-person assistance, while the care plan and Kardex specified total assist x2 for bed mobility and incontinent care. The DON stated her expectation was that CNAs review and follow the Kardex prior to providing care and indicated that, in this incident, the Kardex directions for two-person assistance were not followed.
Failure to Ensure Safe Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer of a resident who required a mechanical lift and two-person assistance for transfers. The resident, who was dependent on staff for activities of daily living due to impairments in both upper and lower extremities, was being transferred from a wheelchair to a bed. During the transfer, two CNAs were present; one positioned the sling straps over the front hooks, but the other failed to properly secure the back sling straps to the lift. As the lift was operated and the resident was raised approximately two feet, the unsecured straps led to the resident sliding forward and falling from the sling to the floor. The incident resulted in the resident sustaining a head laceration and crying out in pain, with blood observed on the face and floor. The LPN on duty was notified and, upon assessment, called for emergency medical assistance. The resident was subsequently transferred to a hospital for evaluation and treatment and did not return to the facility. The facility's investigation confirmed that the mechanical lift and sling were not faulty, and the failure was attributed to staff not following the standard operating procedure for mechanical lift transfers. The resident's care plan specified the use of a mechanical lift with two-person assistance for all transfers due to a history of multiple falls and fractures. Facility policy and manufacturer instructions both required that all sling straps be properly secured before lifting a resident. Staff interviews confirmed that the standard practice was to have two staff members present and all four straps hooked appropriately to prevent such incidents. The failure to adhere to these procedures directly led to the resident's fall and injury.
Neglect in Pain and Contracture Management
Penalty
Summary
The facility failed to protect a resident from neglect related to pain management, contracture management, activities of daily living (ADL) care, and seating systems. The resident, who was admitted with multiple medical conditions including nontraumatic intracerebral hemorrhage, moyamoya disease, and contractures, was observed in bed with significant pain and without necessary supportive devices such as palm guards or splints. The resident's care plan did not address contractures of the upper extremities, and the resident was not provided with adequate pain management, as only Tylenol was ordered despite the resident's significant pain during movement. Interviews with staff revealed a lack of communication and follow-up regarding the resident's pain and therapy needs. The resident's primary care nurse practitioner was unaware of the resident's pain issues and therapy status, and a previously ordered pain medication, Tramadol, was not administered due to a system error. The resident's family expressed concerns about the resident's pain, lack of therapy, and inadequate nail care, which were not addressed by the facility. The resident was also not provided with a wheelchair or special chair, resulting in her being confined to bed. The facility's policies on abuse, neglect, and nail care were not followed, as evidenced by the resident's untrimmed and dirty nails and the lack of appropriate interventions for her contractures and pain. The Director of Nursing and other staff members acknowledged the deficiencies in communication and care, but no corrective actions were documented in the report. The facility's failure to provide necessary goods and services resulted in the resident experiencing physical harm and pain.
Inadequate Pain Management and Care for Resident with Contractures
Penalty
Summary
The facility failed to provide adequate pain management for a resident with significant medical conditions, including nontraumatic intracerebral hemorrhage, moyamoya disease, and contractures of the upper and lower extremities. The resident was observed in pain, particularly when moved, and expressed a desire for assistance with her contracted hands. Despite these observations, the resident's care plan did not address the contractures of the upper extremities, and the only pain medication ordered was Tylenol, which was insufficient for her level of pain. Interviews with staff revealed a lack of communication and follow-up regarding the resident's pain management needs. The resident's primary care NP was unaware of the resident's pain issues and believed the resident was receiving physical therapy, which was not the case. The NP had ordered Tramadol for pain management, but this order was not reflected in the facility's system, and the medication was never administered. Additionally, the therapy department did not communicate with nursing about the resident's inability to tolerate therapy due to pain, and no alternative pain management strategies were implemented. The resident's condition was further exacerbated by inadequate hygiene and positioning. Her fingernails were long and dirty, and she was not provided with a wheelchair or appropriate seating system, resulting in her being confined to bed. Staff reported difficulty in cleaning the resident's hands due to her contractures, and her feet were observed to be in poor condition with dry, cracked skin and significant edema. The facility's failure to address these issues contributed to the resident's ongoing pain and discomfort.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety services, as observed in various areas including the kitchen, dining room, nourishment room, and activity room. Dietary staff were not wearing hairnets, as required, and food items were improperly stored. Specifically, a box of bananas was found on the floor in the dry storage area, and several food items in the walk-in refrigerator were not labeled or dated. Additionally, some food items were improperly stored with other items placed on top, breaking the seal and exposing them to potential contamination. Temperature logs for refrigerators and freezers were incomplete, with multiple missing dates in the dining room and activity room. The Certified Dietary Manager confirmed that all food items should be labeled and dated, and temperature logs should be completed daily. The facility's policies on food labeling, dating, and temperature monitoring were not followed, leading to these deficiencies. Photographic evidence supported these findings, and the Certified Dietary Manager acknowledged the issues and the unethical practice of completing temperature logs retroactively.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to complete accurate Preadmission Screening and Resident Review (PASRR) forms for four residents, leading to deficiencies in the documentation of mental disorders or intellectual disabilities. Resident #19 was admitted with diagnoses of Major Depressive Disorder and Dementia, but the PASRR Level I Screen did not mark these diagnoses correctly. Similarly, Resident #15's PASRR form failed to indicate dementia, despite the resident having multiple mental health diagnoses, including post-traumatic stress disorder and bipolar disorder. Resident #59's PASRR form did not reflect any mental illness, even though the resident had been diagnosed with anxiety disorder and major depressive disorder. Additionally, Resident #24's PASRR form incorrectly marked the absence of a primary diagnosis of dementia, despite the resident's severe cognitive impairment and behavioral issues related to dementia. The deficiencies were confirmed during an interview with Staff T, the Care Plan Specialist, who acknowledged the inaccuracies in the PASRR forms for the residents mentioned. Staff T explained her process of checking new admissions and updating PASRR forms with new diagnoses but admitted to the errors in the current cases. Furthermore, the Director of Nursing revealed that the facility did not have a PASRR policy in place, which may have contributed to the oversight and inaccuracies in the PASRR documentation for the residents.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. On two out of three units and in all three medication carts, medications were not stored properly. Pills were found in medication cups on bedside tables in two rooms, and loose pills were discovered in the drawers of medication carts. Expired medications, such as Acetaminophen suppositories and Ibuprofen, were found in the carts, and some medications lacked expiration dates. Additionally, non-medication items like a blood pressure monitor, pulse oximeter, and other miscellaneous items were stored with medications, which is against the facility's policy. Interviews with staff, including RNs and LPNs, revealed that the night shift was responsible for cleaning the medication carts and ensuring no expired or loose medications were present. However, this was not done, leading to the deficiencies observed. The Director of Nursing was unaware of these issues and confirmed that medications should not be left at the bedside unless a resident is approved to self-administer, which was not the case for the residents involved. The facility's policy requires medications to be stored in an orderly manner and expired or discontinued medications to be destroyed or returned, which was not adhered to in this instance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices across two out of three units, as observed through incorrect transmission-based precaution signs, lack of hand hygiene during tray pass, improper storage of respiratory masks, and improper personal protective equipment (PPE) usage. On multiple occasions, respiratory masks were left uncovered on bedside tables for extended periods, indicating a lapse in infection control protocols. Additionally, there was a failure to post appropriate isolation precaution signage in a timely manner for a resident with multiple cancer diagnoses and a pending stool sample for enteric pathogen PCR. The report highlights several instances where staff did not adhere to proper PPE protocols. For example, a CNA entered a resident's room with a contact precaution sign without wearing PPE and failed to perform hand hygiene between resident interactions. This resident had a current diagnosis of a urinary tract infection and was on antibiotics, necessitating contact precautions. Another CNA entered a different resident's room, who was on contact precautions for C-Diff and MRSA, without donning PPE, and used alcohol-based hand sanitizer instead of soap and water, contrary to the requirements for C-Diff precautions. Interviews with staff revealed confusion and misunderstanding regarding the appropriate use of PPE and the specific requirements for contact precautions versus enhanced barrier precautions. The Infection Preventionist and Director of Nurses acknowledged discrepancies in the signage and the need for proper storage of respiratory equipment. The facility's policy on transmission-based precautions was not consistently followed, contributing to the deficiencies observed during the survey.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #257, who reported having to sleep on an unmade bed after an incident involving a full urinal. The resident stated that they had to use an almost full urinal, which spilled, and when the CNA arrived, she expressed frustration and indicated that she would have to shower the resident. The resident refused the shower, wanting to return to bed, but the CNA stripped the bed and did not return to remake it. Consequently, the resident had to sleep on a bare mattress, wearing a large sweater for warmth. The incident was corroborated by the resident's roommate and another CNA, Staff K, who found the resident on the bare mattress. The resident's admission record indicated recent admission with diagnoses including benign prostatic hyperplasia and a need for assistance with personal care. The Director of Nursing acknowledged that the situation was unacceptable and stated that the facility lacked a specific policy on dignity or resident rights, although they claimed to follow regulations.
Failure to Develop Care Plans for Splint Management and Vision Impairment
Penalty
Summary
The facility failed to develop a care plan for splint management for Resident #9, who was observed multiple times without the required palm guard on their right hand. Despite a physician's order for the resident to wear the palm protector at all times, it was frequently found on the bedside table or elsewhere in the bed, and the resident reported that staff did not assist in putting it on. The Director of Nursing acknowledged that the care plan should have been updated to reflect the resident's refusal or non-compliance with wearing the splint, but it was not. Additionally, the facility lacked a specific care plan policy, relying solely on the Resident Assessment Instrument manual. Resident #59, who had moderately impaired vision, also lacked a care plan addressing her vision needs. She was observed struggling to locate her glasses and expressed difficulty in reading materials such as newsletters and menus. Although her vision care plan had been marked as resolved in April 2023, it was confirmed by the MDS Coordinator that the resident still had vision loss and no current care plan was in place. The oversight was acknowledged, and the care plan was subsequently updated, but the deficiency remained at the time of the survey.
Failure to Provide Physician-Ordered Splint Management
Penalty
Summary
The facility failed to ensure that a resident received physician-ordered splint management to prevent the worsening of a contracture. Resident #9, who was admitted with multiple diagnoses including a contracture of the right hand, was observed multiple times without the required palm guard. The resident reported that staff removed the palm guard and did not assist in putting it back on, despite the physician's order for it to be worn at all times except for hygiene. Interviews with staff revealed confusion regarding the resident's orthotic device, with some staff believing the resident used a carrot splint instead of the palm guard. The occupational therapy notes indicated that the palm guard was deemed more beneficial than the carrot splint, and the resident was instructed to wear it consistently. However, there was no documentation in the Medication Administration Record, Treatment Administration Record, or care plan regarding the palm guard or splint management. The Director of Nursing acknowledged that the care plan should have been updated to reflect the resident's needs and any refusals to wear the splint. The facility's policy on restorative nursing programming includes splint or brace assistance, but there was a lack of adherence to this policy in the case of Resident #9. The absence of a care plan policy and reliance solely on the Resident Assessment Instrument manual contributed to the oversight in managing the resident's contracture care.
Failure to Provide Balanced Vegetarian Diet
Penalty
Summary
The facility failed to provide a well-balanced special diet for a resident on a vegetarian diet, who prefers fish, and was on a select menu. On multiple occasions, the resident's meal trays lacked protein options, which is a critical component of a balanced diet. For instance, during a lunch observation, the resident's selected seasoned pasta was struck out by staff, and no protein was provided, leaving the resident with only vegetables and carbohydrates. The resident expressed dissatisfaction with the limited vegetarian options, stating that she often felt hungry after meals and had to rely on snacks and food brought by her family. The resident's care plan indicated a nutritional risk related to her diagnoses and required serving the diet as ordered. However, the menu selection sheets for a specific week showed no protein options for lunch and dinner meals. Interviews with the resident confirmed her ongoing hunger and lack of sufficient meal options, particularly protein. The Senior Director of Culinary Operations acknowledged the deficiency, noting that the resident's meals should have included a protein option and that the current offerings were inadequate.
Falsification of Documentation and Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure ethical conduct by staff, as evidenced by the falsification of documentation related to the dining room reach-in refrigerator temperature log. On multiple occasions, the temperature log was found incomplete, with missing entries for several days. However, upon a subsequent observation, the log was filled in with temperatures for the previously missing dates, suggesting that someone had retroactively completed the log. The Certified Dietary Manager acknowledged that this practice was unethical and could lead to inaccurate temperature documentation, which is against the facility's policy requiring daily temperature checks and logs. Additionally, the facility failed to provide accurate documentation of services for a resident with significant medical conditions, including dementia and diabetes. The resident's records inaccurately documented frequent transfers and locomotion activities, despite interviews with staff and family indicating that the resident remained in bed and did not have a wheelchair. The Director of Nursing confirmed that the resident could not tolerate being out of bed and had not been evaluated for a wheelchair, contradicting the documented care activities. The facility's Code of Conduct policy emphasizes the importance of maintaining accurate and complete records, which was not adhered to in these instances. The discrepancies in documentation and the lack of ethical conduct in record-keeping highlight significant deficiencies in the facility's compliance with its own policies and procedures.
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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 Sun City Center
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Plaza West | 0.4 mi | ★★★★★ | 0 | 0 |
| Sun Terrace Health Care Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Bayshore Pointe Nursing And Rehab Center | 14.4 mi | ★★★★★ | 1 | 0 |
| Hawthorne Center For Rehabilitation And Healing Of | 14.9 mi | ★★★★★ | 0 | 0 |
| Vivo Healthcare Gandy | 15.3 mi | ★★★★★ | 6 | 1 |
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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 August 2026) and official state health department websites.