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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sabal Palms Health & Rehabilitation during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and a history of falls experienced multiple unwitnessed falls resulting in serious injuries, including fractures, despite documented interventions such as hi/low beds, frequent checks, and use of hip protectors. Staff interviews revealed inconsistent implementation of post-fall huddles and incomplete staff training on fall reduction techniques. The facility's fall prevention program was still under development and lacked a formal policy, contributing to ongoing falls and injuries.
A resident with multiple chronic conditions and intact cognition reported that a nurse mocked her, refused timely medication, and made a demeaning gesture, causing emotional distress. The incident was not reported to state agencies as required by facility policy and federal law, and staff treated the event as a customer service issue rather than potential mental abuse.
A resident with a history of falls was found on the floor with lacerations and was assessed and treated by nursing staff, who notified the physician but delayed informing the resident's family until several hours later, contrary to facility policy requiring immediate notification after incidents and before hospital transfers.
A resident with a history of stroke and falls was found on the floor with lacerations to the forehead and shoulder. The nurse assessed the resident and documented that the provider was notified, but investigation revealed that no direct contact was made and the on-call service did not receive a message. Notification to the resident's family was also delayed, and the resident was sent to the hospital only after the family was informed and requested transfer.
The facility failed to maintain audible PEEP alarms on the ventilators of four residents requiring mechanical ventilation. Observations showed the alarms were turned off, contrary to professional standards. The residents had complex medical conditions and required extensive respiratory support. Staff interviews revealed a lack of awareness and understanding of the alarm settings, with some attributing the issue to false triggers. The facility's policy emphasized the importance of trained staff and adherence to physician orders, yet the practice of turning off alarms without proper authorization was evident.
The facility failed to provide timely physician follow-up for catheter care and recurrent UTIs for two residents. One resident, with a history of subarachnoid hemorrhage and diabetes, had multiple UTIs without timely urologist follow-up. Another resident, with a primary diagnosis of UTI, also lacked necessary urologist appointments. Facility policies on resident rights and catheter management were not followed.
A resident with ESRD had a dialysis catheter that was not properly monitored according to facility policy. Despite being off dialysis for weeks, there was no documentation of daily assessment or monitoring of the catheter site. Interviews with staff indicated a lack of physician's orders for monitoring and dressing changes, contrary to the facility's policy requiring daily assessment and documentation.
The facility failed to ensure clean and sanitary equipment and floors in two units and eleven rooms where tracheostomy residents reside. Observations revealed dust, debris, and dried liquid splatter on medical equipment, and dirty floors with black marks and stains. Interviews indicated confusion among staff regarding cleaning responsibilities, and the facility's policies were not effectively implemented.
A resident's wound was not promptly assessed or treated despite being reported by the family. The nursing staff delayed the assessment and treatment, leading to a lapse in care. Similar delays were noted in addressing other skin issues reported by the family.
Failure to Prevent Falls and Provide Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that effective fall prevention interventions were implemented and maintained for two residents identified as high risk for falls, resulting in multiple falls with major injuries. One resident, with severe cognitive impairment and a history of fractures, experienced four falls since admission, including incidents that resulted in a left elbow fracture requiring surgery and a pubic ramus fracture. Despite documented interventions such as a hi/low bed, call light within reach, frequent checks, and use of hip protectors, the resident continued to experience unwitnessed falls both in their room and in common areas. Staff interviews revealed that post-fall huddles were not consistently conducted, and there was a lack of verification of serious injury and neglect allegations, as the facility believed the care plan was followed and supervision was adequate. Another resident, also with severe cognitive impairment and a history of falls, suffered multiple falls resulting in injuries, including a lumbar compression fracture. The care plan included interventions such as non-skid socks, therapy evaluation, routine rounding, and use of a helmet and hip protectors. However, the resident was observed barefoot and fell in the hallway, and was later found on the dining room floor after another fall. Documentation showed that the resident had been hospitalized three times for recurrent falls, and staff were instructed to encourage the resident to remain in common areas, but falls continued to occur. The facility's fall prevention and post-fall assessment policies required individualized risk assessments, implementation of appropriate interventions, and review and revision of care plans following falls. However, interviews with staff indicated inconsistent knowledge and application of fall reduction programs and interventions, such as compassionate touch techniques. The facility's Fall Reduction Program was still under development and lacked a formal policy or procedure, and not all staff had received training on key interventions. These deficiencies in supervision, intervention effectiveness, and staff training contributed to the continued occurrence of falls with major injuries among high-risk residents.
Failure to Report Alleged Mental Abuse as Required by Policy
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically regarding mental abuse, for one resident. The resident filed a grievance alleging that a nurse mocked her, refused to provide medication promptly, and made a gesture indicating she was 'crazy' in front of her and a family member. The resident described feeling angry, disgusted, and disrespected by the nurse's actions, which she considered unprofessional and undignified. Despite these allegations, there was no evidence that the incident was reported to state agencies as required by facility policy and federal regulations. Record review showed that the resident was cognitively intact, with a BIMS score of 15, and had multiple chronic medical conditions, including atrial fibrillation, COPD, diabetes, and anxiety. The resident's progress notes did not indicate any changes in mood or behavior following the incident, and there were no care plans addressing behavioral issues or confabulation, contrary to statements made by facility leadership. The facility's report tracking log confirmed that no abuse, neglect, or exploitation allegations were reported for this resident during the relevant period. Interviews with facility staff, including the Risk Manager and DON, revealed a lack of clarity regarding what constitutes a reportable event. The Risk Manager acknowledged upon review that the incident should have been reported but was instead treated as a customer service issue rather than potential mental abuse. The facility's policy clearly defines mental abuse and outlines mandatory reporting requirements, which were not followed in this case.
Failure to Immediately Notify Resident Representative After Fall and Injury
Penalty
Summary
A deficiency was identified when the facility failed to immediately notify a resident's representative about a change in condition following a fall. The resident, who had a history of cerebral infarction and falls, was found lying on the floor with a laceration to the right forehead and right shoulder. The nurse assessed the resident, applied steri strips, and notified the on-call physician, but documented that the resident's daughter would be notified in the morning rather than immediately. The resident was later sent to the hospital for a head injury. Interviews with facility leadership confirmed that the nurse delayed notification to the resident's daughter, stating she did not believe the situation was critical enough to warrant waking the family member. Facility policy required immediate notification of the resident's family or representative in the event of an incident or accident, as well as when the resident is to be transported to the hospital. The delay in notification was not in accordance with this policy.
Failure to Immediately Notify Provider After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify a resident's primary care provider following a change in condition after a fall. The resident, who had a history of cerebral infarction and falls, was found on the floor with lacerations to the right forehead and shoulder. The nurse on duty assessed the resident, applied steri-strips, and documented that the physician was notified. However, subsequent investigation revealed that the nurse did not actually speak to the physician, but instead left a voicemail with the on-call service, which was not received. The nurse also delayed notifying the resident's daughter until several hours after the incident. Facility policy required the nurse to contact the resident's practitioner to inform them of the incident, report injuries, and obtain further orders as needed. Interviews with facility leadership and review of documentation confirmed that the physician was not properly notified, and the on-call service had no record of a message. The nurse's account of the events was inconsistent, and the lack of immediate provider notification resulted in the resident being sent to the hospital only after the family was informed and expressed concern.
Failure to Maintain Audible PEEP Alarms for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to ensure that the positive end-expiratory pressure (PEEP) alarm was audible on the ventilators of four residents who required mechanical ventilation support. Observations revealed that the PEEP alarm was turned off on the ventilators of these residents, which is contrary to professional standards. The residents involved had complex medical conditions, including metachromatic leukodystrophy, cerebral palsy, respiratory failure, and dependence on mechanical ventilation. Resident #61 was observed with a tracheostomy tube connected to a ventilator displaying a PEEP OFF sign. The resident's care plan required monitoring for respiratory distress and maintaining oxygen saturation levels above 94%. Similarly, Resident #184 was found with the PEEP alarm off, despite having severe cognitive impairments and requiring extensive respiratory support. Interviews with staff revealed a lack of awareness and understanding of why the alarms were turned off, with the respiratory therapist confirming the alarms were off and attributing it to potential false triggers like hiccups or water in the tubing. Further observations showed that Residents #101 and #130 also had their PEEP alarms turned off. Staff interviews indicated that alarms were frequently triggered and sometimes reset themselves, but there was no clear protocol for turning them off without a physician's order. The facility's policy on mechanical ventilation emphasized the importance of trained staff and adherence to physician orders, yet the practice of turning off alarms without proper authorization was evident. This deficiency highlights a significant lapse in ensuring the safety and proper respiratory care of residents reliant on mechanical ventilation.
Failure in Timely Physician Follow-Up for Catheter Care
Penalty
Summary
The facility failed to provide timely physician follow-up for catheter care and recurrent urinary tract infections (UTIs) for two residents. Resident #165, who was admitted with a primary diagnosis of nontraumatic subarachnoid hemorrhage and secondary diagnoses including Type 2 Diabetes and obstructive uropathy, had orders for monthly catheter changes and prophylactic antibiotics for recurrent UTIs. Despite a urology note from December 2022 recommending follow-up in three months, no further urologist follow-up was documented until July 2024. During this period, Resident #165 experienced multiple UTIs, indicating a lack of timely medical oversight. Resident #60, admitted with a primary diagnosis of a urinary tract infection and secondary conditions such as atrial fibrillation and diabetic neuropathy, also had orders for monthly catheter changes. However, no follow-up appointments with a urologist were arranged, as confirmed by a staff interview. The facility's policies on resident rights and urinary catheter management emphasize the need for informed participation in treatment and continual assessment of catheter use, which were not adhered to in these cases.
Failure to Monitor Dialysis Catheter
Penalty
Summary
The facility failed to properly assess and monitor a dialysis catheter for a resident with End Stage Renal Disease (ESRD) who had been off dialysis for a couple of weeks. The resident, who was admitted with diagnoses including ESRD, urinary tract infection, and Type II Diabetes Mellitus with diabetic neuropathy, had a dialysis catheter site on the upper right chest wall. Despite the presence of the catheter, there was no documentation of daily assessment or monitoring of the dialysis shunt site from July 1, 2024, through July 23, 2024, as required by the facility's policy. Interviews with staff revealed that there was an expectation for a physician's order to monitor the dialysis site and change the dressing until the catheter was removed, but no such order was in place. The facility's policy, which mandates daily assessment and documentation of the shunt site, was not followed. The Director of Nursing confirmed that the resident's dialysis catheter was still in place and that there should have been a physician's order for monitoring and dressing changes.
Failure to Maintain Clean and Sanitary Equipment and Floors
Penalty
Summary
The facility failed to ensure clean and sanitary equipment and floors in two units and eleven rooms where tracheostomy residents reside. Observations revealed that various medical equipment, including oxygen concentrators, suction canisters, IV poles, and fans, were covered in dust, debris, and dried liquid splatter. Additionally, floors in several rooms and common areas had black marks, stains, and spills. Photographic evidence was obtained to document these conditions. Interviews with staff, including a Licensed Practical Nurse (LPN) and the interim Director of Nursing (DON), indicated confusion and lack of clarity regarding the responsibility for cleaning medical equipment. The LPN stated that housekeeping was supposed to wipe down surfaces, but nurses should also clean equipment if they noticed it was dirty. The DON admitted she was unaware of who was responsible for cleaning the equipment and agreed that the current state of the equipment was unacceptable. Further interviews with the Environmental Services (EVS) Director revealed that housekeeping staff were hesitant to clean medical equipment for fear of disrupting its use. The EVS Director also mentioned that there was no policy on floor maintenance, and deep cleaning was done on a rotational basis. The facility's policies on maintaining a clean environment and cleaning resident-care equipment were reviewed, showing that staff were responsible for cleaning and disinfecting equipment according to infection control principles. However, these policies were not being effectively implemented, leading to the observed deficiencies.
Failure to Timely Address Resident's Wound
Penalty
Summary
The facility failed to identify, assess, and respond in a timely manner to a resident's change in condition related to a wound. Resident #1, who was admitted with a primary diagnosis of a nondisplaced intertrochanteric fracture of the left femur, had a care plan that included interventions for skin integrity issues. Despite these interventions, the resident developed a wound on the back of her right leg that was not promptly addressed by the nursing staff when first reported by the resident's family member on 03/12/24. The family member observed the wound weeping and reported it to the nurses, but no immediate action was taken to assess or treat the wound at that time. Interviews with staff revealed that the family had reported the wound to Staff A, RN, and Staff B, RN, but neither nurse assessed the wound immediately. Staff B recalled the family bringing the resident to the desk and reporting the drainage, but deferred the assessment to Staff A, who was coming on shift. Staff A later confirmed that she did not assess the wound until 03/14/24, two days after the initial report. By that time, the wound had clear drainage and redness, and an order for wound care and antibiotics was obtained. However, there was no documentation of the initial report or any immediate actions taken on 03/12/24. Further review of the resident's records showed a similar pattern of delayed response to changes in condition. In February, the resident's family had reported an infection in the resident's right thumb, which was also not promptly addressed. The facility's Director of Nursing (DON) and Regional Nurse Consultant (RNC) acknowledged the lapses in timely response and documentation. The DON confirmed that the CNAs had not reported any changes in the resident's skin condition, and no alerts were received regarding the changes. The facility's policy on reporting changes in a resident's condition was not followed, leading to a delay in addressing the resident's wound and other skin issues.
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 346 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — 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 Largo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tierra Pines Center | 1.1 mi | ★★★★★ | 0 | 0 |
| East Bay Rehabilitation Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Palm Garden Of Pinellas | 1.9 mi | ★★★★★ | 2 | 0 |
| Aviata At Bryan Dairy | 2 mi | ★★★★★ | 4 | 4 |
| Palm Garden Of Largo | 2.3 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sabal Palms Health & Rehabilitation.
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 July 2026) and official state health department websites.