Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakpark Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, dementia, major depressive disorder, anxiety disorder, and an amnestic disorder had hospital discharge and facility physician orders for daily Nuplazid to treat delusions, and a care plan directing that medications be given as ordered and behavioral health consults obtained as indicated. The MAR showed Nuplazid was not administered on multiple days and marked as awaiting pharmacy delivery, while also being signed out as given on other days, and behavior monitoring later documented aggressiveness and resistance to care. Progress notes recorded that the medication could not be delivered due to high cost and that a family member was asked to supply it. Pharmacy records showed only a three-day supply was ever delivered and documented that the DON twice instructed the pharmacy not to send Nuplazid. There was no documentation that psychiatry evaluated the resident in the facility or that follow-up occurred after the noted agitation, despite facility policy requiring medications to be administered as ordered and deviations documented with physician notification.
On several night shifts, the facility did not meet minimum CNA staffing requirements, resulting in delays for resident care such as assistance with personal needs and water. Staffing records and staff interviews confirmed that the number of CNAs present was below both regulatory standards and the facility's own staffing plan, with efforts made to fill gaps using agency staff or by reassigning existing staff.
Several residents with cognitive impairments and histories of falls experienced repeated falls without new or revised interventions being added to their care plans. Despite facility policy requiring individualized updates after each fall, care plans were not modified, and there was no documentation from providers indicating that additional interventions were unnecessary. The DON confirmed that care plans should have been updated but were not, resulting in a failure to ensure adequate supervision and accident prevention.
Failure to Provide Ordered Psychotropic Medication and Mental Health Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with multiple mental health and neurological diagnoses received ordered psychotropic medication and appropriate mental health services. The resident was admitted with Parkinson’s disease, major depressive disorder, anxiety disorder, dementia, and an amnestic disorder, and hospital discharge instructions showed an order for Nuplazid 34 mg daily. Facility physician orders also reflected Nuplazid 34 mg daily for delusions. The care plan identified alteration in neurological status related to Parkinson’s and dementia, and a mood problem, with interventions including administering medications as ordered, obtaining behavioral health consults as ordered or indicated, and monitoring and reporting significant mood and behavior changes to the physician. However, the MAR for a portion of December showed Nuplazid was not administered on multiple days and was documented as “waiting on delivery from pharmacy” on several dates. Despite this, the MAR also showed Nuplazid as signed out as administered on other dates during the same period, and behavior monitoring documented only insomnia and wandering initially, followed by aggressiveness and avoidance/resisting care on later dates. Progress notes indicated that on one date the resident was agitated, hitting and kicking staff, and that Nuplazid could not be delivered due to high cost, with psychiatry reportedly aware and new orders awaited; a later note documented that a family member was called to supply Nuplazid. Pharmacy records showed only a three-day supply of Nuplazid was ever delivered and that the DON had twice called instructing the pharmacy not to send the medication. There was no documentation that psychiatry actually saw the resident in the facility, and no follow-up documentation related to the progress note about agitation and medication unavailability. The DON and NHA confirmed the resident did not receive the ordered Nuplazid for several days, that psychiatry did not see the resident, and that there was no facility policy related to psychiatry services or mental health care, despite an existing policy requiring medications to be administered as ordered and deviations to be documented with physician notification.
Insufficient CNA Staffing on Multiple Night Shifts
Penalty
Summary
The facility failed to provide a sufficient number of certified nurse assistants (CNAs) during four night shifts out of twenty-seven reviewed, as evidenced by staffing records and interviews. On the specified dates, the number of CNAs scheduled did not meet the minimum regulatory requirement of one CNA per twenty residents, given the facility's census of over 170 residents. Staffing records showed only seven CNAs present during these shifts, which was below the facility's own staffing plan and regulatory standards. Interviews with staff confirmed that the schedule is based on census and that shortages occasionally occur, with attempts made to fill gaps using agency staff or by having the staffing coordinator work as a CNA when needed. A resident reported delays in receiving assistance with personal care and water, citing a specific incident where it took several hours to receive water after requesting it at night. Staff interviews corroborated that while the facility generally maintains adequate staffing, there have been instances of CNA shortages. The staffing coordinator confirmed reliance on agency staff and efforts to ensure coverage, but acknowledged that there were shifts with fewer than the planned number of CNAs. These findings were supported by a review of daily schedule and punch reports for the relevant period.
Failure to Update Care Plans and Implement Post-Fall Interventions
Penalty
Summary
The facility failed to implement post-fall interventions to prevent future falls for four residents who were identified as being at risk for falls. In multiple instances, after residents experienced falls, there was no evidence that new or revised interventions were added to their care plans. For example, one resident with diagnoses including sarcopenia, atrial fibrillation, and syncope experienced two falls, but the care plan was not updated with new interventions after either event. The Director of Nursing (DON) confirmed that no new interventions were added following these incidents, despite facility policy requiring individualized care plan updates after falls. Another resident, who was severely cognitively impaired and had a history of falls, was found on the floor with a head injury. Review of her care plan and medical record revealed that no new interventions were added after her fall, and there was no documentation from a physician indicating that additional interventions were unnecessary. Similarly, a resident with moderate cognitive impairment and a history of falls suffered a fall resulting in a large bruise, but the care plan was not updated to address the incident or to add interventions to reduce future risk. The DON acknowledged that the care plan should have been updated but was not. A fourth resident, also with moderate cognitive impairment and multiple comorbidities, experienced several falls. Although the interdisciplinary team discussed adding new interventions after one of the falls, the care plan was not updated to reflect these changes. Facility policy requires that each resident have an individualized plan of care that is reviewed and modified as needed to include appropriate fall interventions. The failure to update care plans and implement new interventions after falls represents a deficiency in ensuring the environment is free from accident hazards and that adequate supervision and interventions are provided to prevent accidents.
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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 Palm Harbor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Mark Village | 0.8 mi | — | 0 | 0 |
| Aviata At Countryside | 1.3 mi | — | 0 | 0 |
| Aviata At The Palms | 1.4 mi | — | 11 | 4 |
| Palm Garden Of Clearwater | 1.9 mi | — | 0 | 0 |
| Westchester Gardens Health & Rehabilitation | 2.3 mi | — | 1 | 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 August 2026) and official state health department websites.