Below 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 The Palms At Florence during CMS and state inspections, most recent first.
A resident with COPD, dysphagia, sepsis, and CHF developed SOB, tachypnea, and hypoxia, and O2 was started after an SpO2 of 85% on RA improved to 95%. The chart lacked documentation of continued monitoring after the intervention. Later, the resident again had rapid breathing and cold extremities, could not have an SpO2 obtained, was sent to the hospital for hypoxia, and stopped breathing before EMS arrived; the DON stated the facility charted by exception.
Daily nurse staffing information was not posted in a prominent, readily accessible location for residents and visitors. The posting was kept behind the East nurses' station, where it was not visible or accessible during multiple observations. The DON stated he was unsure of the exact policy requirements and confirmed the staffing sheet was only posted in that location, while the Administrator said it was placed there because that wing was central to the entrance used by most visitors.
Grease trap maintenance was cited after surveyors observed the trap leaking a black oil-like substance into the surrounding soil and grass, with solidified grease also present. Facility policy called for quarterly pumping and cleaning, and staff interviews confirmed the trap was believed to be cleaned quarterly, with receipts available from the cleaning company.
Failure to Notify Physician of Respiratory Change: A resident with COPD, dysphagia, sepsis, and heart failure developed acute respiratory distress with tachypnea, SOB, and O2 sat of 85% on room air. Staff initiated O2 at 2 L NC and the resident improved, but there was no documentation that the MD was notified of the change in condition; the DON stated the facility charted by exception and used the physician’s book if the resident improved.
Medication administration errors exceeded the allowed rate when an LPN failed to prime a Lantus pen according to manufacturer directions for one resident and another resident received only one spray per nostril of an ordered nasal spray dose. The first resident had Type 2 DM with diabetic CKD, and the second resident had asthma, acute respiratory failure with hypoxia, and emphysema. During observation, the LPN confirmed the insulin pen was primed incorrectly, and the nasal spray was not given as ordered.
Improper Priming of Lantus Insulin Pen: An LPN failed to prime a Lantus SoloStar pen correctly before giving insulin to a resident with DM, CKD, and severe cognitive impairment. The LPN held the pen horizontal instead of pointing the needle upward during the safety test, and later could not confirm the resident received the full accurate dose of the ordered insulin.
Improper storage of biologicals was identified in 2 of 4 treatment carts. Surveyors found an opened calcium alginate dressing and an opened bottle of normal saline labeled do not reuse in one cart, and expired Aptima Multitest Swab Specimen Collection Kits in another cart. An LPN confirmed the dressing should have been sealed or discarded and the saline should have been discarded after use, and the DON confirmed the expired kits.
Failure to Document Continued Monitoring After Respiratory Decline
Penalty
Summary
The facility failed to ensure continued monitoring for a resident after a change in condition and the initiation of oxygen. The resident had diagnoses including pneumonitis due to inhalation of food and vomit, COPD, dysphagia, sepsis, and chronic diastolic CHF. The physician’s orders included monitoring for signs and symptoms of infection and notifying the MD/NP if concerns arose. A skilled evaluation note documented difficulty breathing, tachypnea, shortness of breath, and vital signs including a pulse of 108 and respirations of 24 with oxygen saturation of 95% on nasal cannula. Later that night, the resident was observed with rapid breathing and an oxygen saturation of 85% on room air. Oxygen at 2 liters via nasal cannula was started, the saturation increased to 95%, and respirations were documented as even and unlabored. The note stated a message was placed in the doctor’s book to assess at the next visit. Review of the chart showed no documentation of continued monitoring after oxygen was initiated. A later nurse’s note documented rapid breathing, cold extremities, inability to obtain oxygen saturation, and vital signs of blood pressure 138/63, pulse 78, temperature 97 degrees Fahrenheit, and respirations 24; the resident was responsive but nonverbal, the on-call service was contacted, and an order was received to send the resident to the hospital for hypoxia. Before EMS arrived, the resident stopped breathing and CPR was initiated. An LPN stated the resident had been checked multiple times during the shift and vital signs were in range, but there was no documentation in the vital signs section or nurse’s notes to reflect ongoing monitoring, and the DON stated the facility charted by exception.
Daily Nurse Staffing Posting Not Readily Accessible
Penalty
Summary
The facility failed to ensure the daily nurse staffing information was posted in a prominent place readily accessible to residents and visitors. Review of the facility policy titled, Nurse Staffing Posting Information, showed the information was to be made available in a readable format and posted in a place readily accessible to residents, staff, and visitors. During observations on 06/02/26 and 06/04/26, the daily nurse staffing posting was located behind the East Nurses' Station and was not visible or accessible to residents or visitors. During a later observation with the Administrator and DON present, the posting was still behind the East Nurses' Station and physically out of reach. The DON stated he was unsure of the exact policy requirements and confirmed the document was only posted behind the East Nurses' Station. The Administrator stated the posting was placed there because that wing was central to the entrance used by most visitors, but did not confirm or provide evidence that it was visible or accessible to residents or visitors.
Grease Trap Not Properly Maintained
Penalty
Summary
Dispose of garbage and refuse properly was cited after surveyors observed the facility’s grease trap leaking a black oil-like substance into the soil and grass around the trap, along with solidified grease that had dried into a white substance. Review of the facility’s undated grease trap pumping and maintenance policy stated that grease traps are to be pumped, cleaned, and maintained on a quarterly basis. Facility receipts showed the grease tank was cleaned on 01/07/26 and 03/31/26. During interview, the Certified Dietary Manager stated she was unsure how often the grease trap is cleaned but believed it was done quarterly, and the Executive/Regional Director stated the grease trap is cleaned quarterly and the cleaning company can provide receipts of recent cleanings.
Failure to Notify Physician of Respiratory Change
Penalty
Summary
The facility failed to ensure the physician was notified of a change in respiratory status for Resident 164. The resident was admitted with diagnoses including pneumonitis due to inhalation of food and vomit, COPD, dysphagia, sepsis, a pulmonary nodule, immunodeficiency, and chronic diastolic heart failure. The facility policy required accurate documentation of resident status and included charting for changes in condition. The resident’s ongoing physician orders directed staff to monitor for signs and symptoms of infection, including cough, congestion, fever, changes in vital signs, changes in mental status, and shortness of breath, and to notify the MD and/or NP if these concerns arose. Nursing notes showed that the resident developed difficulty breathing with tachypnea, shortness of breath, and rapid breathing, with oxygen saturation documented at 85% on room air and respiratory rate of 26. Oxygen was initiated at 2 liters via nasal cannula, after which saturation increased to 95% and respirations were noted to be even and unlabored. Review of the record found no documentation that the physician was notified of this change in condition when the intervention was started. During interview, the DON stated the facility charted by exception and that if the resident improved after an intervention, the incident would be entered in the physician’s book; if there was no improvement, the physician would be notified.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication administration error rate below 5 percent, with 2 errors identified in 26 opportunities for error. Review of the facility’s insulin pen policy stated that insulin pens are to be primed prior to each use, and the manufacturer’s instructions for the Lantus Pen required a safety test with the pen held upright so air bubbles rise to the top of the needle. During an observed medication pass, an LPN prepared to administer 24 units of Lantus insulin to a resident with Type 2 diabetes mellitus with diabetic chronic kidney disease. The LPN removed the cap, cleaned the pen, attached the needle, and primed the pen while holding it downward toward the floor rather than upward as directed. In interview, the LPN confirmed the pen had been primed downward and could not ensure the resident received the ordered dose of insulin. The facility also failed to ensure another resident received a nasal spray as ordered. During an observed medication pass, an LPN prepared to administer Azelastine HCl solution ordered as 2 sprays in both nostrils twice daily to a resident with mild intermittent asthma, acute respiratory failure with hypoxia, and emphysema. The resident received only one spray in each nostril, and the LPN did not ask the resident to take the additional spray or otherwise ensure the ordered dose was given. Later that day, the LPN received a new order for one spray in each nostril, which was after the observed 9:00 AM medication pass.
Improper Priming of Lantus Insulin Pen
Penalty
Summary
The facility failed to ensure a Lantus insulin pen was primed correctly before administration for one resident receiving insulin during medication pass. Facility policy stated insulin pens must be primed prior to each use to avoid collection of air in the insulin reservoir, and the manufacturer’s instructions for the Lantus SoloStar pen directed that the needle be held pointing up during the safety test so air bubbles rise to the top of the needle and the most accurate dose can be delivered. The resident had diagnoses including diabetes mellitus, long-term use of insulin, long-term use of hypoglycemic drugs, and chronic kidney disease, and the most recent MDS documented a BIMS score of 00 out of 15, indicating severe cognitive deficits. During observation, an LPN removed the pen cap, wiped the hub with alcohol, attached the needle, removed the outer needle cover, dialed up 2 units, and held the pen horizontal while pressing the injection button to prime it before administering the ordered 24 units of Lantus. In interview, the LPN confirmed she held the pen horizontal to prime it and could not confirm the resident received the full accurate dose of Lantus insulin.
Improper Storage of Biologicals in Treatment Carts
Penalty
Summary
The facility failed to store biologicals appropriately in 2 of 4 treatment carts. Review of the facility policy on storage of medications requiring refrigeration stated that staff should observe proper storage and labeling requirements for all medications and vaccines during daily tasks and remove expired medications from active stock according to facility policy. During observation of the Northeast Treatment Cart, surveyors found an opened calcium alginate dressing and an opened 250 milliliter bottle of normal saline 0.9% sodium chloride USP that was labeled "do not reuse" and stated it contained no antimicrobial agent or added substance. During interview, an LPN confirmed the dressing should have been placed in a bag and sealed or discarded and stated the normal saline should have been discarded after use. During observation of the [NAME] Treatment Cart, surveyors found Aptima Multitest Swab Specimen Collection Kits with an expiration date of 03/31/26. The DON confirmed these findings during interview.
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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 Florence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Veteran Village | 5.9 mi | ★★★★★ | 0 | 0 |
| Southland Health Care Center | 6.5 mi | ★★★★★ | 2 | 0 |
| Heritage Post Acute | 7 mi | ★★★★★ | 7 | 0 |
| Faith Healthcare Center | 7.8 mi | ★★★★★ | 4 | 0 |
| Honorage Nursing Center | 9.2 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 October 2026) and official state health department websites.