Cycle 1
Health 2025-05-15 · Fire 2025-05-15
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Largo, FL
Palm Garden Of Pinellas
1-star overall rating with 1-star inspections with $10,039 in total fines with 15 recent health deficiencies
200 16th Ave Se, Largo, FL
(727) 585-9377
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Palm Garden Health And Rehabilitation
Operator or chain grouping
Approved since
1991-06-24
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
0.57
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.81
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
3.66
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.33
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.50
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
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.86
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,763
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.16
Baseline 19.95% · Performance 19.97% · Measure score 3.16 · Achievement 3.16 · Improvement 0
Healthcare-associated infections
2.24
Baseline 6.13% · Performance 7.17% · Measure score 2.24 · Achievement 2.24 · Improvement 0
Total nurse turnover
2.64
Baseline 50.00% · Performance 52.89% · Measure score 2.64 · Achievement 2.64 · Improvement 0
Adjusted total nurse staffing
2.27
Baseline 3.96 hours · Performance 3.72 hours · Measure score 2.27 · Achievement 2.27 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.87% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 190 · Observed rate 16.32% · Lower 95% interval 9.92% |
| Discharge to community | 48.06% |
50.57%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 182 · Observed rate 40.11% · Lower 95% interval 40.72% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.42% |
95.27%
4.2 pts better
|
Numerator 171 · Denominator 172 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 172 |
| Discharge self-care score | 72% |
53.69%
18.3 pts better
|
Numerator 90 · Denominator 125 |
| Discharge mobility score | 48.8% |
50.94%
2.1 pts worse
|
Numerator 61 · Denominator 125 |
| Pressure ulcers or injuries, new or worsened | 2.33% |
2.29%
About the same
|
Numerator 4 · Denominator 172 · Adjusted rate 1.98% |
| Healthcare-associated infections requiring hospitalization | 7.17% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 124 · Observed rate 7.26% · Lower 95% interval 4.75% |
| Staff COVID-19 vaccination coverage | 0.68% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 146 |
| Staff flu vaccination coverage | 26.72% |
42%
15.3 pts worse
|
Numerator 66 · Denominator 247 |
| Discharge function score | 47.2% |
56.45%
9.2 pts worse
|
Numerator 59 · Denominator 125 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 49 · Denominator 49 |
| Transfer of health information to patient | 98.7% |
96.28%
2.4 pts better
|
Numerator 76 · Denominator 77 |
| Resident COVID-19 vaccinations up to date | 11.11% |
25.2%
14.1 pts worse
|
Numerator 11 · Denominator 99 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
2.1
1.2 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · 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 | 99.0% |
99.2%
0.2 pts worse
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
2.6%
3.3 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.6% · Q3 7.1% · Q4 5.7% · 4Q avg 5.9% · 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 | 3.4% |
5.9%
2.5 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.7% · Q3 0.0% · Q4 8.1% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.0% |
15.7%
2.7 pts better
|
19.6%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 16.0% · Q3 11.6% · Q4 11.8% · 4Q avg 13.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.5% |
9.8%
3.3 pts better
|
16.7%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 9.8% · Q3 4.8% · Q4 7.6% · 4Q avg 6.5% · 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 | 6.4% |
11.7%
5.3 pts better
|
16.3%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.7% · Q3 14.0% · Q4 0.0% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.9% |
9.8%
2.9 pts better
|
14.9%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 7.2% · Q3 4.9% · Q4 5.6% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
0.8%
0.1 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.2% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.3% |
12.5%
19.8 pts worse
|
19.8%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 37.1% · Q3 39.1% · Q4 26.2% · 4Q avg 32.3% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.1%
1.5 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.3% · Q3 2.5% · Q4 5.1% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
94.3%
3.8 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 97.0% · Q3 98.1% · Q4 98.7% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
9.3%
0.4 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 10.0% · Expected 12.5% · 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 1.2% · Q3 1.1% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.2% |
94.7%
0.5 pts worse
|
79.7%
14.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
26.2%
1 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 31.4% · Expected 27.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-30 · Fire 2023-03-30
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-07-01 · Fire 2021-07-01
7 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-03-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-12
D · Potential for more than minimal harm
2023-03-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-03-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-29
D · Potential for more than minimal harm
2021-07-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-31
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-15
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 2025-06-14
F · Potential for more than minimal harm
2025-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-14
E · Potential for more than minimal harm
2025-05-15
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-06-14
E · Potential for more than minimal harm
2025-05-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-06-14
E · Potential for more than minimal harm
2025-05-15
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-06-14
E · Potential for more than minimal harm
2025-05-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-14
E · Potential for more than minimal harm
2025-05-15
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 2025-06-14
E · Potential for more than minimal harm
2025-05-15
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-06-14
E · Potential for more than minimal harm
2025-05-15
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-14
D · Potential for more than minimal harm
2025-05-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-14
D · Potential for more than minimal harm
2025-05-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-06-14
D · Potential for more than minimal harm
2025-05-15
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 2025-06-14
D · Potential for more than minimal harm
2025-05-15
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-06-14
D · Potential for more than minimal harm
2025-05-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-06-14
D · Potential for more than minimal harm
2025-05-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-06-14
J · Immediate jeopardy
2024-04-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-11
J · Immediate jeopardy
2024-04-10
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 2024-04-11
E · Potential for more than minimal harm
2023-03-30
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 2023-04-30
E · Potential for more than minimal harm
2023-03-30
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-30
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-30
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-30
D · Potential for more than minimal harm
2023-03-30
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-04-30
D · Potential for more than minimal harm
2021-07-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-07-31
D · Potential for more than minimal harm
2021-07-01
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-07-31
D · Potential for more than minimal harm
2021-07-01
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-07-31
D · Potential for more than minimal harm
2021-07-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-10-07
D · Potential for more than minimal harm
2021-07-01
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-10-07
D · Potential for more than minimal harm
2021-07-01
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2021-10-07
Penalties and ownership
What sits behind the stars
$5,019
2024-04-10
Fine
Fine · fine $5,019
Fine
$5,020
2024-04-10
Fine
Fine · fine $5,020
Fine
Ownership
Mccarver, Patsy
5% Or Greater Direct Ownership Interest · Individual
Palm Garden Healthcare Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Patsy E. Mccarver Trust U/A Dated June 22, 2001 As Amended, Patsy E
5% Or Greater Indirect Ownership Interest · Organization
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
Bacha, Mouna
Operational/Managerial Control · Individual
Bomberger, Jeffrey
Corporate Officer · Individual
Chalmers, James
Corporate Officer · Individual
Greene, Robert
Corporate Officer · Individual
Mitchell, Sandra
Operational/Managerial Control · Individual
Pgpin Re LLC
5% Or Greater Security Interest · Organization
Regions Bank
5% Or Greater Security Interest · Organization
Regions Bank
5% Or Greater Mortgage Interest · Organization
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#3
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