Cycle 1
Health 2024-06-20 · Fire 2024-06-20
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.
Winter Haven, FL
Palm Garden Of Winter Haven
4-star overall rating with 3-star inspections with $24,395 in total fines with 8 recent health deficiencies
1120 Cypress Gardens Blvd, Winter Haven, FL
(863) 293-3100
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Palm Garden Health And Rehabilitation
Operator or chain grouping
Approved since
1987-07-09
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
0.77
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.76
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.55
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
0.58
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
0.86
CMS adjusted RN staffing hours
Adjusted total hours
4.19
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
6%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,286
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.05% · Performance 23.34% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.09% · Performance 10.20% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.79
Baseline 53.45% · Performance 35.92% · Measure score 6.79 · Achievement 6.79 · Improvement 5.63
Adjusted total nurse staffing
2.88
Baseline 3.94 hours · Performance 3.90 hours · Measure score 2.88 · Achievement 2.88 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.54% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 104 · Observed rate 18.27% · Lower 95% interval 9.01% |
| Discharge to community | 43.77% |
50.57%
6.8 pts worse
|
No Different than the National Rate · Eligible stays 91 · Observed rate 35.16% · Lower 95% interval 35.4% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 92.78% |
95.27%
2.5 pts worse
|
Numerator 90 · Denominator 97 |
| Falls with major injury | 1.03% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 97 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 33 · Denominator 66 |
| Discharge mobility score | 43.94% |
50.94%
7 pts worse
|
Numerator 29 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 3.09% |
2.29%
0.8 pts worse
|
Numerator 3 · Denominator 97 · Adjusted rate 2.61% |
| Healthcare-associated infections requiring hospitalization | 10.2% |
7.12%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 16.67% · Lower 95% interval 6.43% |
| Staff COVID-19 vaccination coverage | 3.82% |
8.2%
4.4 pts worse
|
Numerator 6 · Denominator 157 |
| Staff flu vaccination coverage | 11.18% |
42%
30.8 pts worse
|
Numerator 18 · Denominator 161 |
| Discharge function score | 43.94% |
56.45%
12.5 pts worse
|
Numerator 29 · Denominator 66 |
| Transfer of health information to provider | 98.18% |
95.95%
2.2 pts better
|
Numerator 54 · Denominator 55 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.5% |
25.2%
7.7 pts worse
|
Numerator 7 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 2.0% |
2.6%
0.6 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.4% · Q3 0.0% · Q4 1.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
3.7%
2.1 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.2% · Q3 0.0% · Q4 1.2% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.9%
1.2 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.7% · Q3 2.6% · Q4 7.3% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.9% |
15.7%
0.2 pts worse
|
19.6%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 18.1% · Q3 14.3% · Q4 16.5% · 4Q avg 15.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.8% |
9.8%
5 pts better
|
16.7%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 9.1% · Q3 1.5% · Q4 2.9% · 4Q avg 4.8% · 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 | 7.0% |
11.7%
4.7 pts better
|
16.3%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 4.3% · Q3 12.0% · Q4 0.0% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
9.8%
1.1 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 5.3% · Q3 8.5% · Q4 7.8% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.4%
0.9 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.0% · Q3 2.0% · Q4 1.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
0.8%
0.9 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.3% · Q3 1.2% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.3% |
12.5%
6.8 pts worse
|
19.8%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 13.9% · Q3 19.8% · Q4 19.9% · 4Q avg 19.3% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
5.1%
0.3 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.0% · Q3 6.4% · Q4 4.9% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
94.3%
4.1 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 98.7% · Q3 98.7% · Q4 98.6% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
9.3%
1.2 pts worse
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 11.3% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.4% · Q3 1.1% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.2% |
94.7%
1.5 pts better
|
79.7%
16.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
26.2%
2.4 pts better
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 25.8% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-10 · Fire 2022-03-10
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-12-18 · Fire 2020-12-18
9 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2020-12-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-01-14
D · Potential for more than minimal harm
2020-12-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-01-14
D · Potential for more than minimal harm
2020-12-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-01-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-06-20
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-07-20
E · Potential for more than minimal harm
2024-06-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-06-20
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 2024-07-20
D · Potential for more than minimal harm
2024-06-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-06-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-06-20
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-06-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-06-20
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 2024-07-20
G · Actual harm
2024-04-04
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 2024-05-01
G · Actual harm
2024-04-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-04
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 2024-05-01
D · Potential for more than minimal harm
2024-02-11
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 2024-02-27
E · Potential for more than minimal harm
2022-03-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-04-04
D · Potential for more than minimal harm
2022-03-10
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 2022-04-04
D · Potential for more than minimal harm
2022-03-10
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2022-04-04
E · Potential for more than minimal harm
2020-12-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-01-14
D · Potential for more than minimal harm
2020-12-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-03-18
D · Potential for more than minimal harm
2020-12-18
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 2021-01-14
D · Potential for more than minimal harm
2020-12-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-01-14
D · Potential for more than minimal harm
2020-12-18
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 2021-01-14
D · Potential for more than minimal harm
2020-12-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-01-14
D · Potential for more than minimal harm
2020-12-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-01-14
D · Potential for more than minimal harm
2020-12-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2021-03-18
Penalties and ownership
What sits behind the stars
$24,395
2024-04-04
Fine
Fine · fine $24,395
Fine
Ownership
Palm Garden Healthcare Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Bomberger, Jeffrey
Corporate Officer · Individual
Chalmers, James
Corporate Officer · Individual
David, Waseem
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
Pgwin Re, LLC
5% Or Greater Security Interest · Organization
Regions Bank
5% Or Greater Security Interest · Organization
Regions Bank
5% Or Greater Mortgage Interest · Organization
Washington, Tunya
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Life Care Center Of Winter Haven
Winter Haven, FL
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Lake Mariam Health And Rehabilitation Center
Winter Haven, FL
1-star overall rating with 1-star inspections with Special Focus status with $353,123 in total fines with 36 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
Astoria Health And Rehabilitation Center
Winter Haven, FL
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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