Above 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 Winter Haven during CMS and state inspections, most recent first.
The facility failed to update PASRR assessments for six residents, resulting in outdated records that did not reflect current diagnoses. Observations and interviews revealed that residents with mental health conditions such as mood disorders, depression, anxiety, and dementia had PASRRs that were not updated to include these diagnoses. Staff interviews indicated inconsistent procedures for updating PASRRs, contributing to the deficiencies.
The facility failed to implement effective infection control practices, as evidenced by the lack of proper signage and PPE use for residents on precautions. Observations showed confusion among staff regarding the type of precautions required for residents with infections, leading to inconsistent adherence to protocols. The Director of Nursing acknowledged the oversight and the potential for confusion due to conflicting signage.
A resident in a LTC facility experienced a lack of dignity during meals due to staff leaving a urinal with urine on the bedside table. Despite requests for its removal, staff delayed action until after meal tray delivery. Interviews with an RN and the DON confirmed this practice was against expectations, yet no specific policy was in place to prevent such occurrences.
A resident's family reported abuse by a CNA, including yelling and physical assault. The RN Unit Manager attempted to report the incident to the Risk Manager, but poor phone reception hindered communication, and the report was not filed within the required timeframe. The resident, with a history of mental health issues, confirmed the abuse the following day.
A resident's skin condition was not accurately assessed or documented, leading to a deficiency in care. Observations showed dry, scaly skin and thick toenails, but these were not reflected in the Weekly Skin Check or nursing notes. Staff noticed the condition but did not report it to the physician, and the resident expressed pain during an examination. The facility's policy on regular skin inspections was not adequately followed.
A facility failed to complete a Trauma Informed Care Assessment for a resident with PTSD upon admission, despite the resident being cognitively intact and the presence of the screening in the medical record. The DON confirmed that such assessments should be completed by nursing, and Unit Managers are responsible for ensuring the completion of clinical admission evaluations.
A long-term care facility failed to maintain a medication error rate below 5%, with errors observed in the administration of inhalers and insulin. A nurse did not instruct a resident to rinse their mouth after using inhalers, and another nurse failed to prime an insulin pen before injection, both contrary to facility policies and manufacturer instructions. These actions contributed to an 11.54% medication error rate.
The facility failed to label and discard expired food in the 100-hall nourishment room. Expired milk cartons and unlabeled frozen dinners were found, with the Unit Manager confirming the oversight. The Certified Dietary Manager noted that food should be labeled with the resident's name. The facility's policies require proper labeling and timely disposal of food items.
The facility failed to protect a resident from witnessed physical abuse by an LPN and did not adequately respond to allegations of abuse involving two other residents. Delays in reporting and investigating the incidents, as well as insufficient immediate actions to ensure resident safety, were noted.
The facility failed to implement its Abuse, Neglect, Exploitation, and Misappropriation policy for witnessed physical abuse of a resident and allegations of abuse of two other residents. Delayed reporting, inadequate protection measures, and incomplete investigations were noted.
The facility failed to thoroughly investigate an allegation of physical abuse involving a nonverbal resident who indicated he had been hit by a male staff member. The investigation was deemed unsubstantiated based on the resident's medical diagnoses and a social service assessment. The DOQA/RM did not interview or assess other residents for signs of abuse or neglect, and the resident was discharged before a complete assessment could be conducted.
The facility failed to develop a person-centered care plan for a non-verbal resident with multiple medical diagnoses, including aphasia and dementia. Despite the resident's inability to communicate verbally and the staff's awareness of his condition, no communication plan was included in the care plan. Interviews confirmed the absence of a policy for developing such care plans, contrary to CMS RAI Manual guidelines.
Failure to Update PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) assessments were updated to include current diagnoses for six residents. Resident #74 was observed in the dining room and had a Level I PASRR that did not reflect his current diagnoses of unspecified mood disorder, seizures, major depressive disorder, and adjustment disorder with anxiety. Similarly, Resident #5, who was observed in her room and unable to answer questions, had a PASRR that was outdated and did not include her diagnoses of vascular dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and seizures. Resident #10 was admitted with diagnoses of unspecified depression and anxiety disorder, and was prescribed Trazodone, yet the PASRR completed by an acute care facility did not indicate any mental illness or intellectual disability. Resident #65 had multiple diagnoses including bipolar disorder, psychosis, mood disorder, depression, and dementia, but the PASRR did not reflect these conditions. The resident was receiving medications for these mental health issues, indicating a need for an updated PASRR. Resident #69 was admitted with Alzheimer's disease, major depressive disorder, and anxiety disorder, but the PASRR did not show any mental illness or intellectual disability. Resident #43 had diagnoses of dementia, psychosis, and major depressive disorder, yet the PASRR did not list any qualifying mental health diagnosis. Interviews with facility staff revealed a lack of consistent procedures for updating PASRRs when new diagnoses were identified, contributing to the deficiencies noted in the report.
Inadequate Infection Control Practices and Signage
Penalty
Summary
The facility failed to implement an effective infection control program, as evidenced by the lack of proper education and signage regarding transmission-based precautions (TBP) and personal protective equipment (PPE) for staff. Observations revealed that outside Resident #44's room, there was no indication of the type of PPE required or when it should be worn. Interviews with staff indicated confusion about the resident's precautionary status, with some staff believing the resident was on contact precautions due to a wound, while the resident mentioned precautions for a yeast infection. The physician's orders did not support the staff's understanding, as they only indicated enhanced barrier precautions for Candida Auris. Similarly, Resident #83's room lacked signage for precautions, and PPE was not available at the doorway. Staff were observed entering the room without PPE, and it was later confirmed that enhanced barrier precautions should have been in place due to the resident's feeding tube and wounds. The Director of Nursing acknowledged that transmission-based precautions were reviewed during orientation, but the oversight in implementing these precautions for Resident #83 was evident. Additionally, there was confusion regarding infection control signage, as two different signs were posted outside a shared room, leading to inconsistent adherence to precautions. A housekeeper was observed not wearing a gown despite a sign indicating the need for special contact precautions. Interviews with staff revealed misunderstandings about the applicability of PPE requirements, with some believing it only applied to clinical staff. The Director of Nursing recognized the potential for confusion due to conflicting signage and took steps to address it, but the deficiency in infection control practices was clear.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for a resident, identified as Resident #66, who was observed with a urinal containing urine on his bedside table during mealtime. Despite being well-groomed and showing no signs of distress, the resident expressed dissatisfaction with the situation, stating that he had repeatedly asked staff to remove the urinal before meals. However, staff consistently left the urinal on the table, promising to remove it only after delivering meal trays to other residents. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed that the staff were expected to clean bedside tables and remove urinals before serving meals. Both staff members acknowledged that the presence of a urinal during mealtime was inappropriate and not in line with the facility's expectations. The facility did not have a specific policy addressing this issue, contributing to the deficiency in providing a dignified dining experience for the resident.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for a resident. On June 12, 2023, a family member of the resident called the facility to report that a Certified Nursing Assistant (CNA) was yelling, throwing things, and physically assaulting the resident. The Registered Nurse (RN) Unit Manager, Staff M, was informed of the allegation and attempted to report it to the Risk Manager, Staff L, over the phone. However, due to poor phone reception, the communication was not clear, and the Risk Manager did not follow up immediately. The next day, the Risk Manager contacted the family member and the resident, who confirmed the allegations of abuse. The resident involved had a history of major depressive disorder, anxiety disorder, and schizophrenia, with intact cognition as per the Minimum Data Set (MDS) Assessment. The facility's policy requires that all allegations of abuse be reported immediately, but no later than two hours from the time of the allegation. Despite this policy, the report was not filed within the required timeframe, leading to a deficiency in the facility's handling of the abuse allegation.
Failure to Accurately Document and Assess Skin Condition
Penalty
Summary
The facility failed to accurately assess and document the skin condition of a resident, leading to a deficiency in care. During an observation, it was noted that the resident's feet were extremely dry with a scale-like overgrowth of skin, and the toenails were thick, yellowed, and long. Despite these visible conditions, the resident's Weekly Skin Check and nursing notes inaccurately documented the skin as intact and did not mention the condition of the feet. Interviews with staff revealed that a CNA had noticed the condition and applied lotion, while an RN had observed the overgrowth of skin but did not report it to the physician. The RN initially thought it was dry skin and attempted to soften it with lotion. The RN/Unit Manager confirmed that the weekly skin assessment should have noted the condition of the feet, and upon further examination, the resident expressed pain when the sock was removed, indicating discomfort that had not been previously documented. The dermatology report from a prior visit had identified keratoderma on the resident's feet and prescribed Halobetasol cream. However, the facility's documentation failed to reflect the ongoing skin issues accurately. The facility's policy on skin care and wound management emphasizes regular skin inspections and documentation, which were not adequately followed in this case, leading to a deficiency in the resident's care.
Failure to Complete Trauma Informed Care Assessment for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) was appropriately assessed for trauma-informed care upon admission. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, was admitted with a diagnosis of PTSD. However, the Trauma Informed Care Screening was not completed as required by the facility's policy. The Director of Nursing (DON) confirmed that a Trauma Informed Care Assessment should be completed by nursing upon admission, and that Unit Managers are responsible for ensuring the completion of clinical admission evaluations. Despite the presence of the Trauma Informed Care Screening in the medical record, it was not completed, which is a deviation from the facility's policy that mandates the completion of a Brief Trauma Questionnaire (BTQ) for all newly admitted residents.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by observations of medication administration errors involving two residents. During the observation of a registered nurse administering medications to a resident, it was noted that the nurse did not instruct or assist the resident to rinse their mouth after using two inhalers, Breo Ellipta and Combivent Respimat, as required by the medication administration policy and manufacturer instructions. This omission could potentially lead to adverse effects such as fungal infections, as Breo Ellipta contains an inhaled corticosteroid. Another incident involved a registered nurse administering insulin to a resident without priming the insulin pen, contrary to the manufacturer's instructions and the facility's policy. The nurse failed to prime the pen before injection, which is necessary to ensure the correct dosage is delivered. The resident's blood glucose level was checked, and the appropriate dose was selected according to the sliding scale, but the lack of priming could result in an incorrect dose being administered. The facility's policies on medication administration, including the use of metered dose inhalers and insulin injections, were not followed correctly by the staff. The Director of Nursing confirmed the correct procedures, which include priming insulin pens and allowing time between inhaler administrations, were not adhered to during the observed incidents. These failures contributed to the facility's medication error rate exceeding the acceptable threshold.
Failure to Label and Discard Expired Food in Nourishment Room
Penalty
Summary
The facility failed to ensure proper labeling and disposal of expired food items in the 100-hall nourishment room. During an observation, two cartons of milk were found to be expired, and two frozen dinners were in the freezer without any identification of the resident's name or room number. The Unit Manager confirmed that the expired milk should have been discarded and mentioned that kitchen staff are usually responsible for checking the nourishment rooms. The Certified Dietary Manager stated that the food in the freezer should have been labeled with the resident's name. The facility's Food Labeling and Dating Refrigeration policy, which was not dated, requires that food items be labeled and discarded according to the manufacturer's use-by-date or within seven days, whichever is earlier. Additionally, the Resident Personal Food policy mandates that food brought in by family members or visitors must be labeled with the resident's name and date.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident from witnessed physical abuse by a staff member and failed to protect two other residents following allegations of abuse. In one instance, a Licensed Practical Nurse (LPN) was observed by another LPN verbally threatening and physically slapping a resident. The observing LPN did not immediately report the incident or remove the resident from danger, leading to a delay in addressing the abuse. The Director of Quality Assurance/Risk Manager (DOQA/RM) was eventually notified, and the police were called, but the initial response was inadequate in ensuring the resident's immediate safety. In another case, a resident was found with a new skin injury on the inside of their lip. The resident, who was nonverbal but could communicate by nodding or shaking their head, indicated that a male staff member had hit them. Despite this, the investigation by the DOQA/RM was inconclusive, as no male staff members were identified as having contact with the resident during the relevant time frame. The resident was discharged before a thorough assessment could be completed, leaving the allegation unsubstantiated. A third incident involved a resident alleging verbal abuse by a Certified Nursing Assistant (CNA) during an evening shift. The allegation was reported during a Resident Council meeting, but there was a delay in the DOQA/RM becoming aware of the incident and initiating an investigation. The grievance form lacked specific details about the time and date of the incident, and the investigation did not promptly identify the CNA involved. This delay in response and lack of immediate action to protect the resident from further abuse highlights significant deficiencies in the facility's handling of abuse allegations.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement its Abuse, Neglect, Exploitation, and Misappropriation policy and procedure for witnessed physical abuse of one resident and allegations of physical and verbal abuse of two other residents. The first incident involved a resident who was verbally abused and physically slapped on the back of the head by an LPN. The incident was witnessed by another LPN who reported it to the Director of Quality Assurance (DOQA) after a delay. The DOQA called the police, who arrived and arrested the abusive LPN. The resident was not immediately seen by a psychologist or physician following the incident, despite being on medication for mental health issues and having a history of cerebral vascular accident and other conditions. The DOQA substantiated the allegation after interviewing staff and reviewing statements, but the facility's response was delayed and incomplete in several aspects, including the failure to immediately protect the resident and notify the supervisor in a timely manner. In the second incident, a resident was found with a new skin injury on the inside of his lip. The resident, who was nonverbal but could communicate by nodding or shaking his head, indicated that he had been hit by a male staff member. The DOQA and other staff members investigated the incident, but no male staff members were identified as having contact with the resident during the relevant time frame. The investigation was deemed unsubstantiated based on the resident's medical diagnoses of dementia and seizures, as well as social service assessments indicating the resident's disorientation. However, the investigation was incomplete as not all residents were assessed for injuries, and the resident was discharged before a thorough assessment could be completed. The facility's failure to promptly and adequately respond to these incidents of abuse and neglect highlights significant deficiencies in their implementation of policies and procedures designed to protect residents. The delayed reporting, inadequate immediate protection measures, and incomplete investigations demonstrate a lack of adherence to the facility's own guidelines and regulatory requirements, putting residents at risk of harm and failing to ensure their safety and well-being.
Failure to Thoroughly Investigate Allegation of Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident who was nonverbal but could communicate by nodding or shaking his head. The incident was reported when a staff member noticed a new skin injury on the inside of the resident's lip. The resident indicated through nodding that he had been hit by a male staff member during the day. However, the facility's investigation did not identify any male staff members who had contact with the resident during the specified time frame. The allegation was reported to the Department of Children and Families (DCF) and law enforcement, but the investigation was deemed unsubstantiated based on the resident's medical diagnoses of dementia and seizures, and a social service assessment indicating the resident was not oriented to time frames. The Director of Quality Assurance and Risk Management (DOQA/RM) conducted interviews with male staff members who had contact with the resident within 72 hours prior to the allegation. Only one male staff member, an LPN, matched the demographic description provided by the resident. The LPN denied witnessing any abuse or being aware of any new skin issues. The DOQA/RM did not follow up with the resident to show a picture of the LPN to confirm if he was the alleged perpetrator, as the resident had already been discharged home. Additionally, the DOQA/RM did not interview or assess other residents for signs of abuse or neglect. The investigation was further hampered by the resident's discharge on the same day the allegation was made, preventing a complete skin assessment and psychological evaluation. The DOQA/RM, who was new to the role and had limited experience, acknowledged that there were several steps she would have liked to complete before the resident's discharge. The facility's failure to conduct a thorough investigation and assess other residents for potential abuse or neglect contributed to the deficiency identified in the report.
Failure to Develop Person-Centered Care Plan for Non-Verbal Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a non-verbal resident, identified as Resident #3, who had medical diagnoses including aphasia following cerebral infarction, hemiplegia, hemiparesis, unspecified dementia, and chronic obstructive pulmonary disease. Despite the resident's inability to communicate verbally, the care plan did not include any focus, goals, or interventions related to the resident's non-verbal status and ability to answer yes and no questions. The Minimum Data Set (MDS) assessments documented that the resident was rarely or never understood, yet no communication plan was developed for the resident. Interviews with the Social Services Assistant, Director of Nursing, and MDS Coordinator revealed that they were aware of the resident's non-verbal status and his ability to nod or use gestures to communicate. However, they confirmed that no communication care plan was in place. The Regional Nurse Consultant and Regional MDS/LPN also confirmed the absence of a policy and procedure for the development and implementation of a care plan, stating that the facility follows the Resident Assessment Instrument (RAI). The CMS RAI Manual emphasizes the need for the MDS to be combined with other relevant information to develop an individualized care plan, which was not done in this case.
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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 Winter Haven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Winter Haven | 0.2 mi | ★★★★★ | 0 | 0 |
| Lake Mariam Health And Rehabilitation Center | 0.6 mi | ★★★★★ | 4 | 2 |
| Astoria Health And Rehabilitation Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Winter Haven Health And Rehabilitation Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Spring Lake Rehabilitation Center | 2.9 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.