Cycle 1
Health 2024-11-07 · Fire 2024-11-07
3 health deficiencies
Top issue: Administration (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Orlando, FL
Palm Garden Of Orlando
4-star overall rating with 3-star inspections with $73,226 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
654 N Econlockhatchee Trail, Orlando, FL
(407) 273-6158
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
132
Certified beds
Average residents
125
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Palm Garden Health And Rehabilitation
Operator or chain grouping
Approved since
1987-09-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.66
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.40
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
3.89
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,761
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9852
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.90
Baseline 19.14% · Performance 19.63% · Measure score 3.90 · Achievement 3.90 · Improvement 0
Healthcare-associated infections
1.36
Baseline 5.61% · Performance 7.43% · Measure score 1.36 · Achievement 1.36 · Improvement 0
Total nurse turnover
3.81
Baseline 43.24% · Performance 48.09% · Measure score 3.81 · Achievement 3.81 · Improvement 0
Adjusted total nurse staffing
2.47
Baseline 4.06 hours · Performance 3.78 hours · Measure score 2.47 · Achievement 2.47 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.66% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 248 · Observed rate 11.69% · Lower 95% interval 7.89% |
| Discharge to community | 63.04% |
50.57%
12.5 pts better
|
Better than the National Rate · Eligible stays 239 · Observed rate 51.46% · Lower 95% interval 54.99% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 195 · Denominator 195 |
| Falls with major injury | 1.03% |
0.77%
0.3 pts worse
|
Numerator 2 · Denominator 195 |
| Discharge self-care score | 53.02% |
53.69%
0.7 pts worse
|
Numerator 79 · Denominator 149 |
| Discharge mobility score | 50.34% |
50.94%
0.6 pts worse
|
Numerator 75 · Denominator 149 |
| Pressure ulcers or injuries, new or worsened | 1.03% |
2.29%
1.3 pts better
|
Numerator 2 · Denominator 195 · Adjusted rate 0.86% |
| Healthcare-associated infections requiring hospitalization | 7.43% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 149 · Observed rate 8.72% · Lower 95% interval 4.47% |
| Staff COVID-19 vaccination coverage | 2.9% |
8.2%
5.3 pts worse
|
Numerator 7 · Denominator 241 |
| Staff flu vaccination coverage | 21.16% |
42%
20.8 pts worse
|
Numerator 95 · Denominator 449 |
| Discharge function score | 53.69% |
56.45%
2.8 pts worse
|
Numerator 80 · Denominator 149 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 121 · Denominator 121 |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 22.33% |
25.2%
2.9 pts worse
|
Numerator 23 · Denominator 103 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.8%
2.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
2.6%
0.6 pts worse
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 4.2% · Q3 1.1% · Q4 1.1% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
5.9%
1 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 6.8% · Q3 7.1% · Q4 4.7% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.6% |
15.7%
1.9 pts worse
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 20.2% · Q3 16.5% · Q4 18.6% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.1% |
9.8%
2.7 pts better
|
16.7%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 5.8% · Q3 8.3% · Q4 7.7% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.4% |
11.7%
1.3 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 12.3% · Q3 14.7% · Q4 5.7% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
9.8%
0.1 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 10.5% · Q3 16.2% · Q4 0.0% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.4%
0.3 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 1.0% · Q4 0.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
0.8%
0.5 pts worse
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.1% · Q3 0.0% · Q4 1.1% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.8% |
12.5%
4.7 pts better
|
19.8%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 9.9% · Q3 10.8% · Q4 4.3% · 4Q avg 7.8% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.1%
2.5 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.8% · Q3 1.9% · Q4 5.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
94.3%
4.6 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 99.5% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
9.3%
1.6 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 8.8% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 1.4% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.6% |
26.2%
5.6 pts better
|
23.9%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 25.2% · Expected 29.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-16 · Fire 2023-02-16
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-03-25 · Fire 2021-03-25
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-06
E · Potential for more than minimal harm
2021-03-25
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2021-04-23
E · Potential for more than minimal harm
2021-03-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-04-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-07
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-07
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-07
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-12-06
G · Actual harm
2024-09-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-30
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-09-30
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-10-24
J · Immediate jeopardy
2024-07-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-25
D · Potential for more than minimal harm
2023-02-16
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-02-16
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-02-16
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-02-16
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-03-13
E · Potential for more than minimal harm
2021-03-25
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-04-23
E · Potential for more than minimal harm
2021-03-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-04-23
D · Potential for more than minimal harm
2021-03-25
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2021-04-23
D · Potential for more than minimal harm
2021-03-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-04-23
D · Potential for more than minimal harm
2021-03-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-04-23
Penalties and ownership
What sits behind the stars
$62,381
2024-09-30
Fine
Fine · fine $62,381
Fine
$10,845
2024-07-25
Fine
Fine · fine $10,845
Fine
Ownership
Palm Garden Healthcare Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Bomberger, Jeffrey
Corporate Officer · Individual
Chalmers, James
Corporate Officer · Individual
Greene, Robert
Corporate Officer · Individual
Hovey, Greg
Operational/Managerial Control · Individual
James O. Mccarver Qtip Business Marital Trust U/A Dated June 22, 2001,
5% Or Greater Indirect Ownership Interest · Organization
James O. Mccarver Residuary Trust Share U/A Dated 06/22/2001
5% Or Greater Indirect Ownership Interest · Organization
Mccarver, Patsy
5% Or Greater Indirect Ownership Interest · Individual
Nuriel, Gabriel
Operational/Managerial Control · Individual
Patsy E. Mccarver Trust U/A Dated June 22, 2001 As Amended, Patsy E
5% Or Greater Indirect Ownership Interest · Organization
Pgorl Re, LLC
5% Or Greater Security Interest · Organization
Regions Bank
5% Or Greater Security Interest · Organization
Regions Bank
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
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Solaris Healthcare East Orlando
Orlando, FL
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Lotus Nursing And Rehabilitation Center
Orlando, FL
3-star overall rating with 2-star inspections with $3,282 in total fines with 9 recent health deficiencies
#3
Life Care Center Of Orlando
Orlando, FL
4-star overall rating with 4-star inspections with 2 recent health deficiencies
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