Cycle 1
Health 2023-11-16 · Fire 2023-11-16
9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Tampa, FL
Palm Garden Of Tampa
3-star overall rating with 2-star inspections with 9 recent health deficiencies
3612 E 138th Ave, Tampa, FL
(813) 972-8775
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Palm Garden Health And Rehabilitation
Operator or chain grouping
Approved since
1987-11-19
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
0.44
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.61
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
0.40
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.82
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,862
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.91% · Performance 21.55% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.54
Baseline 6.81% · Performance 7.37% · Measure score 1.54 · Achievement 1.54 · Improvement 0
Total nurse turnover
4.73
Baseline 45.61% · Performance 44.35% · Measure score 4.73 · Achievement 4.73 · Improvement 0.11
Adjusted total nurse staffing
2.63
Baseline 4.22 hours · Performance 3.83 hours · Measure score 2.63 · Achievement 2.63 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.83% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 329 · Observed rate 12.46% · Lower 95% interval 9.24% |
| Discharge to community | 59.06% |
50.57%
8.5 pts better
|
Better than the National Rate · Eligible stays 328 · Observed rate 52.44% · Lower 95% interval 52.13% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.41% |
95.27%
1.1 pts better
|
Numerator 188 · Denominator 195 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 195 |
| Discharge self-care score | 49.64% |
53.69%
4 pts worse
|
Numerator 68 · Denominator 137 |
| Discharge mobility score | 31.39% |
50.94%
19.5 pts worse
|
Numerator 43 · Denominator 137 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 195 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.37% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 182 · Observed rate 7.69% · Lower 95% interval 5.03% |
| Staff COVID-19 vaccination coverage | 18.75% |
8.2%
10.6 pts better
|
Numerator 27 · Denominator 144 |
| Staff flu vaccination coverage | 19.5% |
42%
22.5 pts worse
|
Numerator 31 · Denominator 159 |
| Discharge function score | 49.64% |
56.45%
6.8 pts worse
|
Numerator 68 · Denominator 137 |
| Transfer of health information to provider | 98.31% |
95.95%
2.4 pts better
|
Numerator 116 · Denominator 118 |
| Transfer of health information to patient | 97.92% |
96.28%
1.6 pts better
|
Numerator 47 · Denominator 48 |
| Resident COVID-19 vaccinations up to date | 11% |
25.2%
14.2 pts worse
|
Numerator 11 · Denominator 100 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 3.8 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.2 · Expected 2.2 · 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 | 97.9% |
99.2%
1.3 pts worse
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
2.6%
2.1 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.1% · 4Q avg 0.5% · 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 | 2.1% |
5.9%
3.8 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.2% · Q3 1.2% · Q4 2.4% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.1% |
15.7%
2.6 pts better
|
19.6%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 18.1% · Q3 4.7% · Q4 7.0% · 4Q avg 13.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.1% |
9.8%
7.7 pts better
|
16.7%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.8% · Q3 2.9% · Q4 1.4% · 4Q avg 2.1% · 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 | 10.8% |
11.7%
0.9 pts better
|
16.3%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 26.2% · Q3 4.2% · Q4 3.9% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.4% |
9.8%
2.4 pts better
|
14.9%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 7.4% · Q3 9.6% · Q4 4.0% · 4Q avg 7.4% · 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 | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 5.7% |
12.5%
6.8 pts better
|
19.8%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.6% · Q3 3.6% · Q4 5.9% · 4Q avg 5.7% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
5.1%
1.9 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.7% · Q3 3.2% · Q4 1.5% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
94.3%
4.3 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 99.0% · Q3 98.7% · Q4 99.0% · 4Q avg 98.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
9.3%
2.3 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 7.5% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.2% |
94.7%
1.5 pts worse
|
79.7%
13.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| 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 28.0% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-09-23 · Fire 2021-09-23
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2020-01-16 · Fire 2020-01-16
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-09-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-10-23
D · Potential for more than minimal harm
2020-01-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-02-16
D · Potential for more than minimal harm
2020-01-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-02-16
D · Potential for more than minimal harm
2020-01-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-16
D · Potential for more than minimal harm
2020-01-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-02-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-11-16
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-16
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 2023-12-15
E · Potential for more than minimal harm
2023-11-16
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-16
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 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-12-15
D · Potential for more than minimal harm
2021-09-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-10-23
D · Potential for more than minimal harm
2021-09-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-10-23
D · Potential for more than minimal harm
2021-09-23
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 2021-10-23
D · Potential for more than minimal harm
2021-09-23
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 2021-10-23
D · Potential for more than minimal harm
2021-09-23
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-10-23
D · Potential for more than minimal harm
2021-09-23
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 2021-10-23
D · Potential for more than minimal harm
2021-09-23
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-10-23
D · Potential for more than minimal harm
2021-09-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-10-23
D · Potential for more than minimal harm
2021-09-23
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 2021-10-23
D · Potential for more than minimal harm
2021-09-23
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 2021-10-23
D · Potential for more than minimal harm
2020-01-16
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2020-02-16
D · Potential for more than minimal harm
2020-01-16
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 2020-02-16
D · Potential for more than minimal harm
2020-01-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-02-16
D · Potential for more than minimal harm
2020-01-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-02-16
D · Potential for more than minimal harm
2020-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-16
Penalties and ownership
What sits behind the stars
Ownership
Palm Garden Healthcare Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Bomberger, Jeffrey
Corporate Officer · Individual
Chalmers, James
Corporate Officer · Individual
Farooqui, Zubair
Operational/Managerial Control · Individual
Greene, Robert
Corporate Officer · 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
Patsy E. Mccarver Trust U/A Dated June 22, 2001 As Amended, Patsy E
5% Or Greater Indirect Ownership Interest · Organization
Pgtpa Re, LLC
5% Or Greater Security Interest · Organization
Ramdayal, Hope
Operational/Managerial Control · Individual
Regions Bank
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
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Blue Palms Health And Rehabilitation Center At Fle
Tampa, FL
3-star overall rating with 2-star inspections with $16,801 in total fines with 12 recent health deficiencies
#2
Fairway Oaks Center
Tampa, FL
1-star overall rating with 2-star inspections with 15 recent health deficiencies
#3
Excel Care Center
Tampa, FL
4-star overall rating with 3-star inspections with 6 recent health deficiencies
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