Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Radiant Nursing And Rehab At Palatka during CMS and state inspections, most recent first.
A resident with COPD, HF, and dependence on supplemental oxygen was observed receiving O2 at 4 L/min via nasal cannula, but the chart contained no physician order for oxygen. The MDS and care plan both reflected oxygen therapy, and the DON confirmed there was no oxygen order in the record even though oxygen was being administered.
Failure to document oxygen administration on the MAR for two residents with PRN O2 orders. One resident with COPD and heart failure was observed wearing a nasal cannula at 2 L/min, and staff stated oxygen should be documented like a medication, including when it is worn and the O2 sat. Another resident was reported to wear O2 mostly at night, with clinical documentation showing oxygen via nasal cannula, but the June MAR had no oxygen administration entries.
Failure to implement staff monitoring after a resident dignity complaint. A CNA upset a resident during an interaction in which the resident reported being told to void in her brief. The facility documented a corrective monitoring plan for the CNA, including heightened observation, supervisory rounds, and random audits, but records did not show the plan was carried out. The DON stated she only periodically checked in with the CNA and had no documentation of the required audits or rounds.
A facility failed to ensure the accuracy of an MDS assessment for a resident, leading to an incorrect discharge record. The resident, with multiple diagnoses, was inaccurately documented as discharged to an acute hospital instead of being transferred to another SNF. This discrepancy was confirmed by the MDS Coordinator, highlighting a failure to adhere to the facility's policy on accurate MDS documentation.
The facility failed to store medications properly, as observed when a resident's Artificial Tears Ophthalmic Solution was found unsecured on their bedside table. The resident had a physician's order for the eye drops, and an LPN confirmed that such medications should not be left unsecured. The DON acknowledged the need for securing medications, noting that family members sometimes bring in eye drops without the facility's awareness.
A resident with multiple diagnoses experienced a fall while transferring from a bedside commode to a wheelchair. The LPN notified the doctor but failed to reach the family member due to an incorrect phone number and did not follow up to obtain the correct contact information. The DON did not attempt to get the correct number, assuming the resident was responsible for herself, leading to a deficiency in informing the resident representative of the change in condition.
Missing Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure a physician's order was obtained for oxygen therapy for Resident #12, who was admitted with diagnoses including chronic obstructive pulmonary disease, heart failure, and dependence on supplemental oxygen. During observation on 6/15/2026 at 11:49 AM, the resident was lying in bed receiving oxygen at 4 liters per minute via nasal cannula. When interviewed at that time, the resident stated, “I don't know the rate. I think it [oxygen] should be at 2 [liter/minute].” Review of the clinical record showed the MDS indicated oxygen therapy on admission and while a resident, and the care plan addressed oxygen therapy related to ineffective gas exchange. Review of the physician orders showed no order for oxygen in the record. During interview on 6/16/2026 at 1:58 PM, the DON stated the resident was on oxygen and did not know why there was no order, and verified that no oxygen order was present. The DON also stated that physician orders have to be written and followed. The facility policy stated oxygen shall be administered only upon the order of a licensed practitioner and documented in accordance with physician orders and applicable regulations.
Failure to Document Oxygen Administration on MAR
Penalty
Summary
The facility failed to document oxygen administration on the MAR for two residents who had physician orders for oxygen therapy. Resident #6 was admitted with diagnoses including COPD and unspecified heart failure, and had an order for oxygen via nasal prongs at 2 L/min PRN, with permission to remove it ad lib. During observations on 6/15/2026 and 6/16/2026, Resident #6 was seen wearing a nasal cannula attached to an oxygen concentrator delivering oxygen at 2 L/min. The resident stated she had COPD and needed oxygen, and later stated she put the oxygen on and took it off herself while staff checked the rate weekly when tubing was changed. Record review for Resident #6 showed multiple oxygen saturation readings on the vital sign form from 4/01/2026 through 6/16/2026, but the MAR/TAR for that same period did not document oxygen administration. Staff stated that for a resident with a PRN oxygen order, the expectation was to document when oxygen was worn, the oxygen saturation level, and the reason for oxygen use, and that oxygen should be documented on the MAR. The ADM, ADON, and RN also stated oxygen was to be treated similarly to a medication and documented accordingly. Resident #33 had a physician order dated 01/07/2026 for oxygen at 2 L/min via nasal cannula PRN, with permission to remove it ad lib for ADLs. An oxygen concentrator with nasal cannula tubing was observed in the resident’s room, and staff stated he wore oxygen mostly at night. The resident stated he wore oxygen at night to help him breathe. Oxygen saturation documentation showed oxygen being administered via nasal cannula on 06/13/2026 and 06/16/2026, but the June 2026 MAR contained no documentation of oxygen administration despite the clinical record showing it was being used.
Failure to Implement Staff Monitoring After Resident Dignity Complaint
Penalty
Summary
The facility failed to implement the documented corrective monitoring plan after a CNA upset Resident #1 during an interaction in which the resident, visibly upset, reported that she had a horrible night and was told to void in her brief. The investigative file and the resident’s report identified Staff A as the CNA involved, and the facility’s 1:1 Counseling/Education document dated 4/16/2026 stated that Staff A would be placed on heightened observation for 60 days, with supervisory rounds, random observation audits, and ongoing evaluation of policy adherence. However, review of the investigative files and Staff A’s personnel record found no documentation that the corrective/monitoring plan had been implemented. During interview, the DON stated she periodically checked in with Staff A but did not have documentation of the random audits or monthly supervisor rounds specified in the plan.
Inaccurate MDS Assessment for Resident Discharge
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident, leading to a deficiency in the discharge assessment process. The resident in question was admitted with multiple diagnoses, including altered mental status, COPD, seizures, cerebral infarction, transient cerebral ischemic attack, anxiety disorder, dysphagia, and osteoarthritis. The MDS titled 'Discharge Return Not Anticipated' inaccurately documented that the resident was discharged to an acute hospital, while in reality, the resident was transferred to another skilled nursing facility. This discrepancy was confirmed during an interview with the MDS Coordinator. The facility's policy on Resident Assessment Instruments (RAI) mandates comprehensive and accurate documentation of MDS assessments, which was not adhered to in this case. The policy requires that any person completing any portion of the MDS assessment certifies its accuracy, and the resident assessment coordinator is responsible for ensuring the completion of MDS assessments for each resident. Despite these procedures, the MDS for the resident was not accurately completed, resulting in a failure to provide a standardized and reproducible assessment of the resident's functional capacities.
Improper Storage of Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored according to accepted professional principles in one of four hallways. During an observation, a bottle of Artificial Tears Ophthalmic Solution was found on the bedside table of a resident who was sleeping. The resident had a physician's order for the eye drops to be administered four times a day for dry eyes and irritation. A Licensed Practical Nurse (LPN) confirmed that eye drops should not be left unsecured at the bedside. The Director of Nursing (DON) acknowledged that medications need to be secured and mentioned that sometimes family members bring in eye drops without the facility's knowledge. The facility's policy requires all medications to be stored in locked compartments under proper conditions.
Failure to Inform Resident Representative of Change in Condition
Penalty
Summary
The facility failed to inform the resident representative following a change in the resident's condition for one of the sampled residents. Resident #1, who has multiple diagnoses including acute and chronic respiratory failure, COPD, type 2 diabetes, and chronic kidney disease, experienced a fall while transferring from a bedside commode to a wheelchair. The CNA assisted the resident to the floor, and no apparent injuries were noted. The LPN notified the medical doctor and attempted to contact the family member, but the call did not go through. The LPN did not follow up to obtain a correct phone number and did not inform the resident about the failed attempt to reach her daughter. The Director of Nursing was aware of the incorrect phone number but did not attempt to get the correct number, assuming the resident was responsible for herself and did not need to inform the family. The facility's policy and procedures require prompt notification of the resident, attending physician, and resident representative of any changes in the resident's condition or status. Despite this policy, the staff did not follow through with obtaining the correct contact information for the resident's family member and did not notify the resident about the failed attempt to reach her daughter. This failure to communicate and adhere to the facility's policy resulted in a deficiency in informing the resident representative of a significant change in the resident's condition.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 30 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Palatka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palatka Center For Rehabilitation And Healing | 1.8 mi | ★★★★★ | 17 | 0 |
| The Pavilion At Crescent Lake | 17.5 mi | ★★★★★ | 13 | 0 |
| Moultrie Creek Nursing And Rehab Center | 23.3 mi | ★★★★★ | 0 | 0 |
| Aviata At Green Cove Springs | 23.7 mi | ★★★★★ | 0 | 0 |
| Clyde E Lassen State Veterans Nursing Home | 24.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Radiant Nursing And Rehab At Palatka.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.