Inspection Report Summary
The most recent inspection on November 3, 2025, cited one deficiency related to medication records. Earlier inspections showed multiple deficiencies primarily involving staffing, training, recordkeeping, and background screening, as well as some issues with food service and visitation. There were no fines, immediate jeopardy findings, or enforcement actions listed in the available reports. Complaint investigations did not indicate any substantiated cases. The pattern of citations suggests ongoing challenges with staff training and documentation, with no clear trend of improvement or worsening in recent years.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
139% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint
Deficiencies: 1
Date: Nov 3, 2025
Visit Reason
One deficiency related to medication records was cited as Class 3.
Findings
One deficiency related to medication records was cited as Class 3.
Deficiencies (1)
Tag A0054 — MEDICATION - RECORDS
Inspection Report
Complaint
Deficiencies: 0
Date: Nov 3, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2012 to 2025 with deficiency history and inspection statuses.
Findings
The facility has undergone numerous inspections including standard, complaint, and monitor types with a mix of deficiencies cited, corrected, and some inspections with no deficiencies found.
Report Facts
Inspections on page: 36
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 20, 2025
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to document and resolve grievances raised by the Resident Council regarding requests for more ice water and snacks over a five-month period in 2025.
Complaint Details
The complaint investigation found that grievances related to resident council concerns about hydration and snacks were not documented or resolved for five months in 2025. The facility's Activities Director and Nursing Home Administrator confirmed that group concerns were not entered as grievances and thus not tracked, contrary to facility policy.
Findings
The facility did not ensure grievances from the Resident Council were documented or resolved from June through October 2025, despite multiple resident council meetings discussing the need for extra snacks and hydration. The grievance log showed no documentation of these concerns, and staff acknowledged the issues were not tracked or followed up on as grievances.
Deficiencies (1)
Failure to honor the resident's right to voice grievances without discrimination or reprisal and failure to establish a grievance policy with prompt efforts to resolve grievances.
Report Facts
Months grievances not documented: 5
Resident council meeting attendance: 20
Resident council meeting attendance: 22
Resident council meeting attendance: 25
Resident council meeting attendance: 19
BIMS score: 15
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director | Provided information about resident council meetings and grievance documentation practices | |
| Nursing Home Administrator (NHA) | Discussed grievance procedures and acknowledged lack of tracking resident council concerns as grievances |
Inspection Report
Routine
Deficiencies: 6
Date: Feb 25, 2025
Visit Reason
The inspection was conducted to assess compliance with resident rights, care and treatment standards, and advance directives, including evaluation of pain management, wound care, and assistance with activities of daily living for sampled residents.
Findings
The facility failed to honor resident rights to formulate advance directives for two residents, did not provide appropriate assistance with eating for three residents, failed to assess and provide wheelchairs for two residents, delayed notification of change in condition for one resident, inadequately assessed and managed pain for one resident, and failed to provide wound care as ordered for two residents.
Deficiencies (6)
Failed to honor resident rights to formulate advance directives for two residents (#259 and #94).
Did not ensure three residents (#13, #10, and #39) were assisted with eating according to their care plans.
Did not ensure two residents (#4 and #56) were assessed for transfers and provided wheelchairs as needed.
Did not ensure timely notification of change in condition for one resident (#29) following an alleged abuse incident.
Did not ensure one resident (#309) was assessed and managed appropriately for pain related to fracture and chronic conditions.
Did not ensure wound care was provided as ordered for two residents (#71 and #89), including missed dressing changes and uncovered wounds.
Report Facts
Residents sampled for advance directives: 22
Dressing changes missed: 6
BIMS score: 9
BIMS score: 13
BIMS score: 14
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Interviewed regarding discrepancy in advance directive documentation for Resident #94. |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding emergency contact information and assistance with eating for residents. |
| Social Service Director (SSD) | Interviewed about advance directive process and discrepancy for Resident #94. | |
| Assistant Administrator (AA) | Former Admissions Director | Interviewed about admitting nurse responsibilities and advance directive discrepancies. |
| Director of Nursing (DON) | Interviewed about admitting nurse duties, advance directives, wound care, and pain management. | |
| Director of Rehabilitation (DOR) | Interviewed about therapy assessments and resident mobility needs. | |
| Staff Q | Licensed Practical Nurse (LPN) | Interviewed regarding assistance needs for residents during meals. |
| Staff P | Certified Nursing Assistant (CNA) | Interviewed regarding resident assistance with eating and vision issues. |
| Staff V | Registered Nurse (RN) | Interviewed regarding pain management for Resident #309. |
| Staff W | Registered Nurse (RN)/Weekend Supervisor | Interviewed regarding pain assessment practices. |
Inspection Report
Routine
Census: 14
Deficiencies: 11
Date: Feb 25, 2025
Visit Reason
Routine inspection of Palms at Sebring Nursing and Rehabilitation to assess compliance with resident rights, care planning, medication management, wound care, safety, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meal service, inaccurate advance directive documentation, failure to provide proper beneficiary notifications, privacy breaches of resident medical information, inaccurate Minimum Data Set (MDS) assessments, incomplete and outdated care plans, inadequate treatment and care including feeding assistance and wound care, unsafe storage of medications and sharps, failure to implement antibiotic stewardship protocols, and failure to accommodate resident food preferences.
Deficiencies (11)
Residents at a single table were not served meals at the same time, causing dignity issues during meal service.
Facility failed to honor resident rights to formulate advance directives for two residents due to inaccurate documentation and failure to follow court-appointed guardianship orders.
Facility failed to provide correct Medicaid/Medicare beneficiary notifications to residents prior to changes in skilled services.
Facility did not ensure privacy of residents' personal health information due to unlocked computer screens and visible resident information on medication carts and nurses' station.
Facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for multiple residents.
Facility failed to develop and implement comprehensive care plans that meet all residents' needs, including timely revisions and updates.
Facility failed to provide appropriate treatment and care including feeding assistance, transfer assessments, notification of change in condition, pain assessment, and wound care.
Facility failed to ensure environment was free of accident hazards related to unsecured razors and scissors in resident rooms and smoking materials.
Facility failed to implement antibiotic stewardship protocols including ensuring antibiotic orders had complete information and end dates.
Facility failed to ensure medications were stored properly in locked medication carts and not left unsecured in resident rooms.
Facility failed to ensure food preferences were honored for residents including provision of requested beverages and appropriate food textures.
Report Facts
Residents in dining room: 14
Deficiencies cited: 11
Medication doses: 750
Medication doses: 2
Medication doses: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Certified Nursing Assistant | Interviewed regarding meal service and dignity issues |
| Staff N | Certified Nursing Assistant | Interviewed regarding meal service and dignity issues |
| Food Service Director | Interviewed regarding meal service and food preferences | |
| Director of Nursing | Interviewed regarding meal service, advance directives, care planning, medication management, wound care, and antibiotic stewardship | |
| Staff A | Certified Nursing Assistant | Interviewed regarding Resident #94's cognitive status |
| Staff B | Registered Nurse | Interviewed regarding Resident #94's cognitive status and advance directives |
| Staff C | Licensed Practical Nurse | Interviewed regarding emergency contact information and meal assistance |
| Social Service Director | Interviewed regarding advance directives and resident rights | |
| Assistant Administrator | Interviewed regarding advance directives and admission process | |
| Staff D | Certified Nursing Assistant | Interviewed regarding Resident #94's behavior |
| Business Office Manager | Interviewed regarding Resident #259 guardianship paperwork | |
| Nursing Home Administrator | Interviewed regarding Resident #259 guardianship paperwork | |
| Staff Q | Certified Nursing Assistant | Interviewed regarding privacy and computer screen locking |
| Staff R | Licensed Practical Nurse | Interviewed regarding privacy and computer screen locking |
| Staff W | Registered Nurse | Interviewed regarding wound care |
| Staff F | Certified Nursing Assistant | Interviewed regarding razor use and storage |
| Staff G | Certified Nursing Assistant | Interviewed regarding razor use and storage |
| Staff B | Registered Nurse | Interviewed regarding razor use and storage |
| Staff H | Activity Director | Interviewed regarding razor use and storage |
| Staff I | Certified Nursing Assistant | Interviewed regarding razor use and storage |
| Staff T | Certified Nursing Assistant | Interviewed regarding smoking paraphernalia |
| Staff S | Licensed Practical Nurse | Interviewed regarding smoking paraphernalia |
| Staff U | Licensed Practical Nurse | Interviewed regarding food preferences and wheelchair use |
| Staff J | Certified Nursing Assistant | Interviewed regarding transfer assistance |
| Staff P | Certified Nursing Assistant | Interviewed regarding feeding assistance |
| Staff C | Licensed Practical Nurse | Interviewed regarding feeding assistance |
| Staff AA | Registered Nurse | Interviewed regarding notification of change in condition |
| Staff Z | Licensed Practical Nurse | Interviewed regarding wound care |
| Staff X | Registered Nurse | Interviewed regarding wound care |
| Staff V | Registered Nurse | Interviewed regarding pain management |
| Staff U | Licensed Practical Nurse | Interviewed regarding pain management |
| Staff C | Licensed Practical Nurse | Interviewed regarding pain management |
| Staff W | Registered Nurse | Interviewed regarding pain management |
| Staff R | Licensed Practical Nurse | Interviewed regarding antibiotic stewardship |
| Consultant Pharmacist | Interviewed regarding pharmacy recommendations and medication cart checks |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 9, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility issuing an inaccurate reason on a thirty-day Nursing Home Transfer and Discharge Notice for one resident (#4).
Complaint Details
The complaint involved the facility issuing an inaccurate discharge notice for Resident #4, citing non-payment and improved health as reasons, whereas the actual reason was the resident being combative. The Nursing Home Administrator confirmed the notice was not accurate. Resident #4 was cognitively intact but combative, refusing care and medication, and bedbound by choice.
Findings
The facility failed to ensure the protection of Resident #4's right to remain at the facility by issuing a discharge notice with inaccurate reasons, including non-payment and improved health, while the actual reason was the resident being combative. Interviews and record reviews confirmed discrepancies in the discharge notice and the resident's condition.
Deficiencies (1)
Failure to transfer or discharge a resident without an adequate reason and provide accurate documentation and specific information when a resident is transferred or discharged.
Report Facts
Residents Affected: 1
Date of survey completed: Jan 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Stated the reason for the 30-day discharge notice was that the resident was combative and confirmed the Nursing Home Transfer and Discharge notice was not accurate. |
| Business Office Manager | Business Office Manager (BOM) | Stated Resident #4 did not owe any money to the facility. |
| Social Worker | Social Worker (SW) | Presented the 30-day notice and stated Resident #4 did not want to be transferred to the listed nursing facility. |
| Director of Nursing | Director of Nursing (DON) | Described Resident #4 as combative, refusing care and medication, bedbound by choice, and stated the resident's health had not improved enough for discharge. |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Oct 29, 2024
Visit Reason
Multiple Class 3 deficiencies related to staffing, training, records, and background screening were cited.
Findings
Multiple Class 3 deficiencies related to staffing, training, records, and background screening were cited.
Deficiencies (11)
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0082 — TRAINING - HIV/AIDS
Tag A0083 — TRAINING - FIRST AID AND CPR
Tag A0084 — TRAINING - ASSIS SELF-ADMIN MEDS & MED MGMT
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Tag A0160 — RECORDS - FACILITY
Tag A0161 — RECORDS - STAFF
Tag CZ000 — INITIAL COMMENTS
Tag CZ814 — BACKGROUND SCREENING CLEARINGHOUSE
Tag CZ875 — ALZHEIMER DISEASE/DEMENTIA; TRAINING
Inspection Report
Complaint
Deficiencies: 2
Date: Apr 5, 2024
Visit Reason
Two Class 3 deficiencies related to food service and resident records were cited.
Findings
Two Class 3 deficiencies related to food service and resident records were cited.
Deficiencies (2)
Tag A0093 — FOOD SERVICE - DIETARY STANDARDS
Tag A0162 — RECORDS - RESIDENT
Inspection Report
Deficiencies: 1
Date: Jun 6, 2023
Visit Reason
The inspection was conducted to review the facility's compliance with medical record documentation standards, specifically regarding the transfer of a resident to the hospital upon the resident's request.
Findings
The facility failed to maintain a complete and accurately documented medical record for one resident, including lack of documentation of the hospital transfer, resident's condition upon transfer, and family notification. The Director of Nursing confirmed no transfer form was completed and no policy existed for medical records documentation related to transfers.
Deficiencies (1)
Failure to have a complete and accurately documented medical record for one resident, including no documentation of hospital transfer, resident condition upon transfer, or family notification.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Wrote the last documented nursing note and involved in the transfer of Resident #1 to the hospital. |
| Director of Nursing | Interviewed regarding lack of documentation and policies related to resident transfer. |
Inspection Report
Routine
Deficiencies: 6
Date: Jan 12, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to catheter care, trauma-informed care, dementia care, food safety, binding arbitration agreements, and vaccination policies at Palms at Sebring Nursing and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to provide and document appropriate catheter care for one resident, failure to provide trauma-informed care and dementia care plans, improper food storage and handling practices, failure to inform residents about the right to refuse binding arbitration agreements, and failure to provide or document pneumococcal, influenza, and COVID-19 vaccinations for several residents.
Deficiencies (6)
Failure to provide and document appropriate catheter care for one resident (#25) out of six residents with indwelling catheters.
Failure to ensure trauma-informed care for one resident (#25) out of thirty-one sampled residents with PTSD diagnosis.
Failure to develop a resident-centered care plan related to dementia care for one resident (#21) out of 21 residents with dementia-related diagnosis.
Failure to store food in accordance with professional standards, including expired, unlabeled, and undated food items and dietary staff not wearing hair net.
Failure to inform residents or representatives explicitly of the right to refuse binding arbitration agreements for three residents (#12, #41, and #24).
Failure to provide or document pneumococcal, influenza, and COVID-19 vaccinations for multiple residents.
Report Facts
Twice daily shifts not documented for catheter care order 1 in December 2022: 23
Twice daily shifts not documented for catheter care order 2 in December 2022: 22
Twice daily shifts not documented for catheter care order 1 in January 2023: 7
Twice daily shifts not documented for catheter care order 2 in January 2023: 8
Number of residents sampled for dementia care: 21
Number of residents sampled for trauma-informed care: 31
Number of residents sampled for pneumococcal, flu, and COVID vaccinations: 5
Number of residents with vaccination deficiencies: 3
Number of residents with flu vaccination deficiencies: 3
Number of residents with COVID-19 vaccination deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Admission Coordinator | Named in binding arbitration agreement deficiency and interview regarding arbitration agreement |
| Staff B | Registered Nurse (RN), MDS Coordinator | Interviewed regarding catheter care documentation, trauma-informed care, vaccination documentation |
| Staff F | Licensed Practical Nurse (LPN) | Interviewed and observed regarding catheter care for Resident #25 and food storage observations |
| Staff H | Licensed Practical Nurse (LPN), Care Team Manager (CTM) | Interviewed regarding catheter care documentation and trauma-informed care for Resident #25 |
| Staff J | Certified Nursing Assistant (CNA) | Interviewed regarding knowledge of Resident #25's PTSD diagnosis |
| Social Services Director (SSD) | Social Services Director | Interviewed regarding responsibility for dementia care planning |
| Interim Director of Nursing (IDON) | Interim Director of Nursing | Interviewed regarding dementia care plan requirements |
| Dietary Staff C | Dietary Staff | Interviewed regarding expired milk in kitchen |
| Dietary Staff D | Dietary Staff | Observed not wearing hair net in kitchen |
| Dietary Staff E | Dietary Staff | Interviewed regarding unlabeled and undated food items in kitchen |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Dec 12, 2022
Visit Reason
Multiple Class 3 deficiencies related to staffing, training, records, and visitation were cited.
Findings
Multiple Class 3 deficiencies related to staffing, training, records, and visitation were cited.
Deficiencies (8)
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0082 — TRAINING - HIV/AIDS
Tag A0086 — TRAINING - ADRD
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Tag A0162 — RECORDS - RESIDENT
Tag CZ814 — BACKGROUND SCREENING CLEARINGHOUSE
Tag CZ841 — IN-PERSON VISITATION
Inspection Report
Routine
Deficiencies: 7
Date: Apr 23, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident safety, care, and environment, including smoking area safety, care planning, pressure ulcer treatment, fall prevention, respiratory care, medication storage, and hospice care.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, including unsafe smoking areas and disrepair in resident rooms and dining areas. Deficiencies were noted in care planning for respiratory care and smoking interventions, pressure ulcer treatment and infection management, fall prevention interventions, respiratory therapy provision, secure storage of refrigerated controlled substances, and documentation and coordination of hospice care.
Deficiencies (7)
Unsafe smoking areas with cigarette butts on the ground and in non-fire rated trash cans, seating equipment in disrepair, and multiple resident rooms with soiled floors, cracked tiles, unbagged plungers, and walls in disrepair.
Failure to develop and implement a care plan for respiratory care and smoking interventions for residents #30 and #59.
Inadequate pressure ulcer care for resident #40, including delayed antibiotic treatment due to PICC line placement delays, improper wound cleaning and dressing application, and lack of timely wound assessments.
Failure to implement new fall prevention interventions after resident #8's fall on 4/3/21, despite multiple prior falls and severe cognitive impairment.
Failure to provide necessary respiratory care for resident #30, including lack of CPAP therapy provision as ordered and improper storage of nebulizer equipment.
Inadequate security of refrigerated controlled substances on the first and second floors, with locked controlled substance boxes not secured to the refrigerators.
Failure to maintain hospice documentation including benefit of election, hospice plan of care, and indication of hospice personnel involvement for residents #282 and #17.
Report Facts
Resident rooms with deficiencies: 12
Residents sampled for care and services for pressure ulcers: 2
Residents sampled for falls: 3
Residents sampled for respiratory care: 1
Medication refrigerators observed: 2
Hospice residents sampled: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse | Named in pressure ulcer care deficiency related to wound treatment and dressing application |
| Staff A | Licensed Practical Nurse | Mentioned in relation to smoking resident and medication room observation |
| Staff K | Registered Nurse | Mentioned in medication room observation and hospice care record review |
| Staff G | Licensed Practical Nurse | Mentioned in relation to PICC line and antibiotic order for resident #40 |
| Staff I | Licensed Practical Nurse, MDS Coordinator | Mentioned in fall prevention care plan review |
| Staff J | Registered Nurse, MDS Coordinator | Mentioned in care plan review for respiratory care |
| Staff L | Certified Nursing Assistant | Mentioned in observation of room cleanliness and housekeeping duties |
| Staff H | Certified Nursing Assistant | Mentioned in relation to dressing changes for resident #40 |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding CPAP order and hospice care documentation |
| Director of Nursing | Director of Nursing | Interviewed regarding wound care, medication storage, CPAP therapy, and hospice documentation |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding smoking policy and hospice documentation |
| Advanced Registered Nurse Practitioner | Advanced Registered Nurse Practitioner | Interviewed regarding respiratory care and hospice care expectations |
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