Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Tampa during CMS and state inspections, most recent first.
Surveyors found expired and undated medications stored in multiple medication carts and a medication room, including expired insulin pens, inhalers, suppositories, ondansetron, hydrochlorothiazide, tizanidine, and Aplisol Tuberculin. Staff, including an RN, LPN, and DON, acknowledged the expired or discontinued medications should have been removed, and that opened inhalation solutions should have been dated when opened.
A resident with hemiplegia, quadriplegia, and bilateral hand contractures was observed multiple times with a specialized call light placed on the side of the bed or mattress and out of reach rather than by her head. The resident could not reach the call light when asked, and staff confirmed it should be positioned by her head so she could use it.
Care plans were not developed to address two residents’ specific needs. One resident had PTSD documented in the chart and psych notes, but staff and the care plan team confirmed there were no goals or interventions for trauma-related behaviors or symptom monitoring. Another resident had a hallway camera facing into the room and staff reported that two staff members always enter for care, but the care plan did not include video monitoring or the two-person entry requirement.
A resident with multiple diagnoses and a PRN oxycodone order was sent out on leave of absence with only one tablet remaining, despite documented moderate pain and the resident reporting that the medication was not enough to manage her pain while away. Staff interviews showed inconsistent practices about checking medication supply, contacting the pharmacy, or delaying the leave, and the DON stated he was unaware the resident lacked sufficient pain medication. The facility policy stated it would provide enough ordered medication to cover the time the resident was absent.
A resident with PTSD was not assessed or monitored for trauma-related behaviors, and staff were unaware of the diagnosis or what specific behaviors to watch for. Records showed the diagnosis in the MDS and psych notes, but there was no PTSD care plan, behavior monitoring plan, or documentation of specific triggers, and direct care staff said they had not been trained or informed about the resident's trauma history.
A resident’s pharmacy recommendations were not reviewed or signed by the attending physician or medical director for both PRN hydrocodone-acetaminophen and insulin glargine. The pharmacist said the pain medication frequency should have been changed, while the AP said he did not remember discussing the recommendations and expected them to be placed in his folder at each nursing station. The DON said he signs pharmacy recommendations but does not verify whether the AP approved or denied them.
Failure to provide therapy screening after a decline in self-feeding. A resident had a family-requested ST referral after difficulty self-feeding was reported, but therapy did not evaluate the resident within the expected 24-48 hours. MDS data showed the resident needed supervision or touching assistance with eating, meal intake was low, and observations found the resident asleep with uneaten breakfast and lunch trays at the bedside. The DOR said the referral was not seen, and the DON confirmed therapy should have evaluated the resident after the referral was received.
A resident with a history of stroke, Afib, cognitive communication deficit, and type 2 DM was denied readmission after a hospital stay, despite prior indication from the facility that her return was expected and no documented clinical reason preventing it. The family reported the facility refused to take her back at the last moment, causing an extra hospital day and anxiety while they urgently sought another SNF. The ADA told the hospital CM the facility could not accommodate the resident’s diet and later referenced vague clinical limitations that could not be defined, while the DON stated the denial was marked as a clinical services issue because the family strongly advocated for the resident’s preferences regarding daily routine and therapy. The facility physician stated there was no medical or dietary reason the resident could not be readmitted, and the resident’s orders reflected a regular diet with vegetarian options, consistent with the facility assessment and policies that state it can accommodate individualized, cultural, and religious dietary needs.
Expired and Undated Medications Found in Carts and Medication Room
Penalty
Summary
The facility did not ensure medications were stored in accordance with current professional standards in 4 of 6 medication carts and 1 of 2 medication storage rooms. Surveyors observed expired medications and improperly stored medication products in the C Wing Medication Room, including bisacodyl suppositories that expired in 2/2026 and a syringe of Aplisol Tuberculin in the refrigerator that expired 5/2/2026. In the C Wing Team 2 Medication Cart, surveyors found expired medication cards for hydrochlorothiazide and ondansetron. In the A Wing Team 3 Medication Cart, surveyors found 8 expired insulin pens, 6 boxes of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution that had been opened but were not dated, 2 boxes of expired bisacodyl suppositories, 2 Trelegy inhalers that were opened and not dated, and medication cards for Tamsulosin HCL, tizanidine, and ondansetron that had expired. Surveyors also observed an expired ondansetron medication card in the A Wing Team 1 Medication Cart and multiple boxes of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution in the A Wing Team 2 Medication Cart that had been opened without expiration dates, including one opened on 12/5/2025 and another opened on 1/22/2026. Staff M, RN stated the unit managers were responsible for maintaining the medication carts and said the expired medications should have been discarded. Staff N, LPN stated the floor nurses were responsible for maintaining the carts, was not aware the insulin pens were expired, and said the inhalation solution boxes should have been dated when opened and the discontinued medication cards removed. The DON stated the expired insulins were unacceptable and that discontinued or expired medications should have been removed and sent back to the pharmacy.
Call Light Not Kept Within Reach
Penalty
Summary
The facility did not ensure a specialized call light was within reach for one resident who was sampled for call lights. On 5/4/2026 and again on 5/6/2026, the resident was observed lying in bed with a red call light and press pad placed on the right side of the bed rather than resting on the pillow next to her head, and she could not reach the call light or press pad when asked. During a later observation on 5/6/2026, the call light was again lying on the right side of the mattress and out of reach while the resident stated she was uncomfortable and wanted the fan placed on her. Record review showed the resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, quadriplegia, and contractures of both hands. Her MDS indicated a BIMS score of 13 and functional limitations with impairments on both sides of her upper and lower extremities, with dependence for all self-care needs and mobility. Her care plan included an intervention for pain related to contractures that called for the wedge call light to be within reach of her head. Staff interviews confirmed the call light should be by the resident’s head so she could use it, and the ED stated the expectation was that the call light be within the resident’s reach at all times.
Care Plans Missing PTSD, Video Monitoring, and Two-Person Entry Needs
Penalty
Summary
The facility failed to develop care plans with goals and interventions for two residents. For one resident, the record showed diagnoses including Post Traumatic Stress Disorder (PTSD), Alzheimer’s disease, and seizures, and the resident was receiving psychiatric services. Review of the nurse progress notes from 3/1/2026 through 5/7/2026 did not show documentation that the resident was presenting with PTSD, and there was no documentation describing specific trauma-related behaviors. Psychological follow-up notes identified PTSD and listed monitoring for symptoms such as intrusive thoughts, avoidance, hyperarousal, changes in behavior, and need for medication therapy, but the care plan did not include a problem area, goals, or interventions related to PTSD. Interviews with the assigned nurse and the care plan coordinators confirmed that the resident had a documented PTSD diagnosis but was not care planned for trauma-related needs. The care plan coordinators stated they assess residents and develop problem areas with goals and interventions based on interdisciplinary assessments, but they had not developed any assessments, behavior monitoring plans, or care plan entries for PTSD. The social service director also confirmed the resident had a PTSD diagnosis and stated the admission process should include review of past diagnoses with the family or decision maker to ensure appropriate care planning, but this had not been done for this resident. For the second resident, the record showed dementia and total care needs, and the resident’s room had a wall-mounted video camera positioned across from the room so the resident could be within view. The resident’s POA requested the camera to verify care, and staff reported that two staff members always enter the room for care. However, the care plan did not include a problem area, goals, or interventions related to video monitoring or the need for two staff members to enter the room together. Interviews with CNA, LPN, social work, the MDS care plan team, and the NHA confirmed staff were not informed about the camera being used, the care plan team had not discussed it, and the resident was not formally care planned for the two-person entry expectation.
Inadequate Pain Medication Provided During Leave of Absence
Penalty
Summary
The facility did not ensure safe, appropriate pain management for a resident who required pain medication. Resident #11, who had diagnoses including unspecified abnormalities of gait and mobility, ulcerative colitis, hydronephrosis with renal and ureteral calculous obstruction, and chronic obstructive pulmonary disease, reported that she left the facility on a leave of absence with only one oxycodone tablet remaining from her prescription. She stated she experienced pain while away from the facility and that one tablet was not enough to manage her pain. She also stated a family member gave her Tylenol, but it did not relieve her pain, and she was not offered the option to delay the leave of absence until her prescription was refilled. The resident’s active order was for oxycodone HCL 5 mg by mouth every 4 hours as needed for pain, and her care plan identified a potential for pain related to a history of back pain with sciatica. The MAR showed oxycodone was administered as needed when pain was documented at 5 or higher, and on the day she left, her pain level was documented as 6. Staff interviews showed the LPN believed the resident’s family was expected to manage pain if medication ran out during leave, while other nursing staff stated they would review orders, check medication availability, contact the pharmacy, and encourage delaying leave if medication was insufficient. The DON stated he was unaware the resident did not have enough pain medication and said the expectation would be to ask about delaying the leave, contact the physician for an alternative medication, or check the EDK. The facility policy stated it would provide the number of doses needed to cover the period the resident would be absent.
Failure to Assess and Care Plan PTSD-Related Behaviors
Penalty
Summary
The facility failed to ensure that one resident with a diagnosis of PTSD was assessed and monitored for trauma-related behaviors and that care staff were aware of the diagnosis and the specific behaviors to observe. During multiple observations, the resident was found lying in bed in her room with her eyes closed and the call light within reach, and staff who passed by stated she preferred to stay in her room but did not know why she did not spend much time out of her room. Record review showed the resident had diagnoses including Alzheimer's, seizures, traumatic brain injury, and PTSD, with psychiatric services ordered. The most recent MDS identified PTSD as an active diagnosis and documented no behaviors during the review period. However, nurse progress notes from the reviewed period did not document PTSD-related behaviors or identify specific trauma behaviors to monitor. Psychological follow-up notes stated the resident had a history of PTSD, anxiety, and Alzheimer's and directed monitoring for PTSD symptoms such as intrusive thoughts, avoidance, hyperarousal, changes in behavior, and need for medicinal therapy. The resident's care plan did not include a problem area, goals, or interventions related to PTSD. Interviews with the CNA, LPN, care plan coordinators, and Social Service Director confirmed they were unaware the resident had PTSD or what specific trauma-related behaviors to look for, and they stated the diagnosis had not been communicated to them through care plans or shift report. The care plan coordinators also confirmed that PTSD had been documented in the MDS and psychological notes, but no care plan had been developed for it and no assessments or behavior monitoring plans were in place to support the resident's possible trauma-related behaviors.
Unreviewed Pharmacy Recommendations for Medication Regimen
Penalty
Summary
The facility did not ensure medication recommendations were reviewed for one resident sampled for unnecessary medications. Pharmacy recommendations for the resident’s hydrocodone-acetaminophen order, dated 3/12/2026-3/13/2026, were not signed by the attending physician or medical director and recommended reducing PRN analgesic therapy until the lowest effective dose was achieved. The resident’s active order on 5/6/2026 remained hydrocodone-acetaminophen 10-325 mg, 1 tablet by mouth every 6 hours as needed for pain. Pharmacy recommendations dated 2/13/2026-2/14/2026 for the resident’s insulin glargine order were also not signed by the attending physician or medical director and recommended adjusting the diabetes regimen by starting metformin 250 mg BID with food and increasing insulin glargine to 15 units SQ in the morning. The resident’s active order on 5/6/2026 remained insulin glargine 10 units SQ in the morning, and no order for metformin was found. During interviews, the pharmacist said the pain medication frequency should have been changed, the attending physician said he would not review recommendations unless they were placed in his folder at each nursing station and did not remember speaking with staff about the recommendations, and the DON said he signs pharmacy recommendations but does not check whether the physician approved or denied them.
Failure to Provide Therapy Screening After Decline in Self-Feeding
Penalty
Summary
The facility did not provide specialized rehabilitative services for a resident with a documented decline in self-feeding. On 4/30/2026, a communication note stated the family reported the resident was having a difficult time self-feeding and requested a ST referral, and a referral was submitted on the resident’s behalf. The resident’s quarterly and annual MDS assessments indicated she required supervision or touching assistance with eating, and a culinary profile evaluation on 4/30/2026 documented average meal intake of 25% with eating assistance listed as independent. Observations on 5/4/2026 showed the resident sleeping at both breakfast and lunch with trays left on the bedside table and uneaten. The resident’s weight history showed a loss of 7.23% in 34 days, from 134.1 pounds on 4/2/2026 to 124.4 pounds on 5/6/2026. During interview, the SLP stated the resident was eating, had not had a decline in self-feeding, required full setup from staff, and was not being seen for therapy services. The DOR stated the resident had been discharged from PT on 2/11/2026 and ST on 3/23/2026, that therapy referrals were to be evaluated within 24-48 hours, and that a referral dated 4/30/2026 had not been seen or screened. The DON stated therapy should have evaluated the resident within 24-48 hours of receiving the referral.
Failure to Readmit Hospitalized Resident Without Valid Clinical Justification
Penalty
Summary
The deficiency involves the facility’s failure to allow a hospitalized resident to return after an acute care stay, despite having previously indicated an expectation of return and lacking a documented clinical reason for denial. The resident had been admitted with diagnoses including cerebral infarction, paroxysmal atrial fibrillation, cognitive communication deficit, and type 2 diabetes with hyperglycemia, and had a physician order for a vegetarian diet that was later changed to a regular diet with vegetarian options such as cheese and peanut butter. The facility issued a transfer notice stating that the resident had transferred to the hospital and that her return was expected, and that no further action was required unless she wished to appeal the transfer. The facility assessment and policies indicated that the facility provides person-centered care and accommodates religious, cultural, and ethnic dietary needs and restrictions. During the resident’s hospitalization, the hospital case manager documented that the facility indicated it was unable to take the resident back, which required the case manager to work with the resident and family to find another SNF. The resident’s family member reported that the facility refused readmission at the last moment, causing the resident to remain in the hospital an extra day and creating stress and anxiety as the family scrambled to locate another facility. The family member stated that the facility was unhappy with them because they were vocal and advocating for the resident’s needs and preferences, including dietary concerns. Interviews with facility staff revealed inconsistent and unsupported reasons for the denial of readmission. The Admissions Director Assistant stated the resident was denied return due to the resident’s diet and the family’s dissatisfaction with how the facility accommodated the diet, and later referenced unspecified “clinical accommodations” and “limitations” that could not be defined or recalled. The DON stated that clinical concerns are directed to him and that the family’s advocacy regarding the resident’s daily schedule and therapy preferences made planning difficult, but acknowledged that this did not interfere with the resident’s plan of care or ordered services. The DON further stated the denial was categorized as a clinical services issue because the family demanded the resident’s preferences be followed. The facility physician, however, stated there was no medical reason the resident could not be readmitted, including no diet-related reason, and the resident’s transfer documentation and orders did not identify special dietary instructions that the facility could not meet, in contrast to the facility’s stated capacity to accommodate individualized and cultural dietary needs.
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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 Tampa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blue Palms Health And Rehabilitation Center At Fle | 0.3 mi | ★★★★★ | 1 | 0 |
| Fairway Oaks Center | 0.5 mi | ★★★★★ | 7 | 0 |
| Excel Care Center | 1 mi | ★★★★★ | 1 | 0 |
| The Bristol Care Center | 1.2 mi | ★★★★★ | 3 | 0 |
| Aviata At Fletcher | 2.8 mi | ★★★★★ | 4 | 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 August 2026) and official state health department websites.