Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Palm Garden Of Orlando during CMS and state inspections, most recent first.
The facility did not ensure that the arbitration agreement allowed residents or their representatives the right to rescind within 30 days of signing. The agreement incorrectly stated rescission was within 30 days of admission, affecting 76 residents. The Director of Guest Services was unaware of the correct rescind period, and the Administrator confirmed the agreement's wording was non-compliant.
A facility failed to refer a resident with newly diagnosed mental disorders for a Level II PASARR evaluation. The resident, admitted with multiple diagnoses including bipolar disorder and schizoaffective disorder, had an outdated Level I PASARR screening. Staff interviews revealed that the clinical team did not update the screening as required by facility policy, leading to the deficiency.
The facility was cited for a repeat deficiency in PASARR screening accuracy due to insufficient auditing and oversight. Despite having a QAPI committee that met monthly to review deficiencies and address concerns, the facility failed to sustain improvements from previous corrective actions, resulting in a repeat citation at F644.
A resident with multiple health issues experienced a fall in an LTC facility due to inadequate supervision and ineffective communication between staff and hospice. Despite having physician orders for pain and anxiety management, the facility failed to administer medications timely, resulting in the resident suffering from severe pain and injuries. The resident was left unsupervised in a wheelchair, leading to a fall and subsequent harm, including fractures and hematomas.
A resident with multiple health conditions and moderate cognitive impairment fell from a wheelchair due to inadequate staffing and supervision in an LTC facility. Despite being administered medication, the resident remained agitated, and a CNA was unable to provide proper one-to-one supervision due to being assigned multiple tasks. The facility failed to complete required neurological checks and did not promptly execute an X-ray order, highlighting a deficiency in maintaining sufficient nursing staff to meet residents' needs.
A resident receiving hospice care experienced a change in condition, becoming agitated and anxious, but the facility staff failed to communicate this to the hospice provider. Despite the resident's restlessness and need for one-to-one monitoring, hospice was not contacted, and the resident's son found her without necessary oxygen. Interviews revealed that LPNs did not notify hospice, assuming it was unnecessary or already done. The facility's policy and hospice agreement required communication of such changes, which was not adhered to.
A resident with severe cognitive impairment and a history of exit-seeking behavior eloped from a facility due to inadequate supervision and failure to update the care plan. Despite multiple incidents of exit-seeking behavior, staff did not increase supervision or implement additional interventions. The resident was found by a civilian in a nearby community and returned by law enforcement.
Failure to Provide Correct Rescind Period for Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement explicitly granted residents or their representatives the right to rescind the agreement within 30 calendar days of signing it. This deficiency affected 76 out of 125 residents who signed the arbitration agreement during the survey period. The Director of Guest Services, responsible for obtaining signatures on the admission packet, including the arbitration agreement, was unaware of the specific timeframe allowed for rescinding the agreement. The arbitration agreement was presented as voluntary, but the document incorrectly stated that it could be rescinded within 30 days of the resident's admission date, rather than 30 days from the date of signing. The Administrator confirmed that the arbitration agreement was typically signed after residents were admitted to the facility. Upon reviewing the rescind clause, the Administrator acknowledged that the agreement's wording did not meet the requirement of allowing 30 days from the date of signature to rescind. This oversight meant that residents or their representatives did not have the full 30 days to reconsider their decision to enter into the arbitration agreement, as required by regulations.
Failure to Update PASARR Screening for Resident with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to refer a resident with a newly evident mental disorder for a Level II Preadmission Screening and Resident Review (PASARR) evaluation. This deficiency was identified for one of the three residents reviewed for PASARR, out of a total sample of 45 residents. The resident in question was admitted with multiple diagnoses, including Parkinson's, diabetes mellitus, bipolar disorder, depression, schizoaffective disorder, and anxiety. A significant change assessment revealed severe cognitive impairment and active diagnoses of anxiety disorder, depression, and schizophrenia. Despite these conditions, the resident's medical record only contained a Level I PASARR screening form, which was outdated and did not reflect the new mental illness diagnoses. Interviews with facility staff revealed that the Social Services Director expected a Level I PASARR screening to be completed by the hospital before admission, and the clinical team was responsible for reviewing these screenings upon admission. The Assistant Director of Nursing acknowledged that the resident's Level I PASARR was inaccurate and required updating. The facility's policy stated that if a Level II screening was indicated after admission, it was the responsibility of Social Services to coordinate with the appropriate agency to conduct the screening. However, this procedure was not followed, resulting in the failure to update the PASARR screening for the resident with newly diagnosed mental illnesses.
Repeat Deficiency in PASARR Screening Accuracy
Penalty
Summary
The facility failed to ensure that its Quality Assessment & Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) committee conducted effective performance improvement activities to maintain the accuracy of Preadmission Screening and Resident Review (PASARR). The policy and procedure, dated February 20, 2018, required the center to take action aimed at performance improvement, measure its success, and track performance to ensure sustained improvements. However, the facility was cited for a deficiency at F644 due to PASARR screening inaccuracies and standard of care issues during the previous recertification survey conducted from February 13, 2023, to February 16, 2023. During the current survey, similar concerns were identified, leading to a repeat deficiency at F644 due to insufficient auditing and oversight. The Administrator acknowledged that the facility held monthly QAPI committee meetings to review cited deficiencies and address concerns as they were identified. Despite this, the repeated citation from the previous recertification survey indicated that the process had failed, as the QAPI committee's performance improvement plan did not bring the facility back into compliance.
Inadequate Pain Management and Supervision Leads to Resident Harm
Penalty
Summary
The facility failed to ensure effective communication and collaboration between the interdisciplinary team and hospice, resulting in inadequate care for a resident before and after a fall. The resident, who had a history of heart failure, type 2 diabetes, neuropathy, anxiety, and anemia, experienced a fall that led to a skin tear on her nose. Despite having physician orders for pain management and anxiety medication, the facility did not administer the prescribed medications effectively, leading to the resident experiencing significant pain and agitation. The resident's care plan included directives to collaborate with hospice and medicate for pain and discomfort as indicated. However, the facility did not follow these directives, as evidenced by the lack of timely administration of pain and anxiety medications after the resident's fall. The resident's family reported that she was left in a wheelchair without oxygen and was not immediately taken back to her room after the fall. The facility staff failed to communicate effectively with the hospice team and the resident's family, resulting in a delay in appropriate medical intervention. Interviews with facility staff revealed that the resident was left unsupervised in a wheelchair, leading to her fall. The staff admitted to being busy and unable to provide the necessary one-to-one supervision. The facility's failure to follow physician orders and provide timely pain management resulted in the resident suffering from severe pain and injuries, including fractures and hematomas, which were later confirmed at the hospital. The lack of communication and coordination between the facility and hospice contributed to the resident's inadequate care and subsequent harm.
Inadequate Staffing Leads to Resident Fall and Insufficient Care
Penalty
Summary
The facility failed to maintain sufficient nursing staff to provide necessary care and services, resulting in a fall incident involving a resident with multiple health conditions, including heart failure, type 2 diabetes, neuropathy, anxiety, and anemia. The resident, who had moderate cognitive impairment and required supervision for activities of daily living, became anxious and attempted to leave her bed. Despite being administered anti-anxiety and pain medication, the resident remained agitated, leading to a one-to-one supervision intervention that was inadequately executed due to staffing shortages. On the night of the incident, the resident was placed in a wheelchair by an LPN to keep her close while the nurse worked. However, the CNA assigned to supervise the resident was already responsible for another one-to-one supervision and other residents, making it impossible to provide adequate attention. Consequently, the resident fell from the wheelchair, sustaining a skin tear to her nose. The facility's Director of Nursing later informed the resident's family that staff could not prevent falls as they could not be with the resident at all times, suggesting the family consider hiring a private companion. Further investigation revealed that the facility did not complete all required neurological checks following the fall, and an X-ray order was not promptly executed. Interviews with staff indicated that the facility was short-staffed, with too many residents at risk of falls and not enough personnel to provide necessary supervision. The facility's assessment document stated that staffing needs were evaluated and adjusted as needed, but the incident demonstrated a failure to meet these standards, resulting in inadequate care and supervision for the resident.
Failure to Communicate Change in Condition to Hospice
Penalty
Summary
The facility failed to communicate with the hospice provider when a change in condition was identified for a resident receiving hospice services. The resident, who had diagnoses including heart failure, type 2 diabetes, neuropathy, anxiety, and anemia, was admitted to the facility and had a care plan for hospice services. The care plan directed nurses to collaborate with hospice regarding care and notify hospice, the physician, and family with any changes as needed. However, on the night of the incident, the resident became confused, agitated, and anxious, requiring one-to-one monitoring and administration of Ativan for anxiety. Despite the resident's change in condition, the facility staff did not contact hospice to report the resident's restlessness and agitation. The resident's son later found her sitting in a wheelchair without the necessary oxygen and questioned why hospice was not called for assistance. Interviews with the facility's LPNs revealed that they did not contact hospice, believing it was unnecessary or assuming it had already been done by previous staff. The hospice manager confirmed that the facility could have called hospice to check medications and suggest other interventions. The facility's Director of Nursing acknowledged that the one-to-one intervention was ineffective and that the nurse should have notified her or other management staff for guidance. The facility's policy required prompt notification of changes in a resident's condition to the attending physician and hospice, which was not followed in this case. The hospice agreement also stipulated that the facility was responsible for communicating any changes in the hospice patient's condition to hospice personnel.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to implement appropriate interventions to mitigate the risk of elopement and provide adequate supervision for a resident with severe cognitive impairment. This deficiency led to the resident exiting the facility unsupervised. The resident, who had a history of exit-seeking behavior and was identified as at risk for elopement, was able to leave the facility without staff knowledge. The resident's care plan for wandering behavior and elopement risk had not been updated despite multiple incidents of exit-seeking behavior. On the evening of the incident, the resident exhibited escalating exit-seeking behaviors, including attempting to open exit doors and setting off alarms. Despite these behaviors, the staff did not increase supervision or implement additional interventions. The resident was last seen by staff on the facility's screened porch, where he was left unsupervised. He managed to pull back lattice panels and push through the screen to exit the facility. The facility's failure to recognize the resident's escalating behaviors and provide adequate supervision resulted in the resident being found by a civilian in a nearby community. The civilian reported the resident's aggressive behavior and called emergency services. The resident was returned to the facility by law enforcement, highlighting the facility's lack of adequate supervision and intervention for residents at risk of elopement.
Removal Plan
- Resident #1 was discovered to be missing and the facility implemented its elopement policy and procedures.
- Resident #1 returned to the facility with local law enforcement. He was assessed on return to the facility and was noted to have an abrasion to his right shin and a lightly discolored area on his right foot. A head count was conducted to verify the safety of all residents. The required notifications were made to the physician and family. Resident #1 was placed on 1:1 supervision.
- The Executive Director checked all doors and alarms to ensure they were working properly. The area where resident #1 exited was identified and secured.
- Resident #1 was re-evaluated for elopement risk and the plan of care was updated to reflect 1:1 supervision.
- Education on elopement policy and procedure provided to staff by nursing administration with 100% completion achieved.
- Notebooks at each nurse's station and reception desk for residents at risk for elopement were reviewed and updated by nursing administration.
- The facility re-evaluated all residents' elopement risk and there were no newly identified concerns. A quality review audit of the 8 residents who were at risk for elopement revealed no concerns related to their electronic wandering devices, care plans and physicians' orders. The elopement binders were reviewed to ensure identified residents at risk were in the books.
- The facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting and conducted a Root Cause Analysis and reviewed recommendations to develop a plan for correction to include education, drills and audits. The ad hoc QAPI committee including the Medical Director approved the recommendations.
- The facility conducted 5 elopement drills that covered all three shifts.
- Interviews were conducted with 22 staff members (10 CNAs representing two shifts, 3 RNs, 4 LPNs, 1 Unit Manager, 1 Unit Secretary, 1 RN Educator, 2 Housekeepers). Staff interviews revealed they were knowledgeable of the elopement policy and procedures and supervision of residents at risk for elopement.
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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 Orlando
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Solaris Healthcare East Orlando | 1.6 mi | — | 0 | 0 |
| Lotus Nursing And Rehabilitation Center | 1.8 mi | — | 0 | 0 |
| Life Care Center Of Orlando | 3.4 mi | — | 2 | 0 |
| Avante At Orlando Inc | 3.8 mi | — | 3 | 0 |
| Winter Park Care And Rehabilitation | 4.3 mi | — | 2 | 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.