Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ardie R Copas State Veterans Nursing Home during CMS and state inspections, most recent first.
A resident with significant communication limitations was prescribed Depakote and Ativan for mood and anxiety disorders without documented written consent or evidence that the representative was informed of the risks and benefits. The ADON confirmed the lack of required consents and communication.
Three residents, including one on hospice, received PRN Lorazepam orders that lacked discontinue dates or documented physician rationales for continued use beyond 14 days. Medication records showed ongoing administration of these psychotropic medications without evidence of timely physician review or justification for extending the orders.
A resident who was cognitively intact and previously able to ambulate with a hemi walker under supervision lost the ability to walk after being discharged from PT, as the facility did not implement the recommended Restorative Nursing Program or provide nursing assistance for ambulation. The resident was not included in the Walk to Dine program and had not been walked by staff since PT discharge, resulting in diminished ADL abilities without a medical reason.
Multiple residents did not receive timely or appropriate care as ordered, including a resident with a foot wound left without a dressing after a shower, a resident receiving hospice services without a current physician order, a delay in antibiotic treatment for a UTI, and a resident at high risk for skin tears not having required geri sleeves applied. Staff were unaware of or failed to follow physician orders, and there was a lack of communication and documentation regarding care provided.
A resident with a history of influenza and Parkinson's disease received a nebulizer treatment without the required post-treatment respiratory assessment and vital signs being documented by an LPN, as mandated by facility policy. Additionally, the resident was administered oxygen therapy without a physician's order, despite staff observations and interviews confirming its use.
The facility did not ensure that a licensed pharmacist conducted thorough monthly drug regimen reviews with documented physician participation, and failed to identify or address open-ended PRN Ativan orders for several residents. Documentation was inconsistent, and there was no evidence of physician approval or rationale for continued use of psychotropic medications, despite ongoing administration and care plan requirements.
The facility failed to provide timely pharmaceutical services for three residents, resulting in missed medication doses. A resident did not receive evening and morning doses due to pharmacy closure and lack of follow-up. Another resident did not receive prescribed medications due to unavailability and incorrect substitutions. A third resident experienced delays in receiving medications, with no emergency kit available and reliance on Omnicare for delivery. The facility did not document efforts to obtain medications promptly.
A resident in an LTC facility experienced a delay in receiving necessary care due to the late reporting of abnormal test results and subsequent treatment initiation. The resident, who was moderately impaired and receiving COVID-19 related medications, had an elevated temperature and tested positive for COVID-19. Despite a physician's order for medication, there was a delay in starting the treatment as the test results were not reported promptly, and the nurse scheduled the first dose for the next morning, even though the medication was available in the facility's Emergency Pharmacy Kit.
A resident with COVID-19 experienced a delay in treatment due to the facility's failure to report abnormal test results in a timely manner and initiate prescribed medications immediately. The resident's test results, indicating increased left hilar opacity, were completed in the morning but not reported to the physician until late in the evening. Despite the availability of medications in the Emergency Pharmacy Kit, the nurse scheduled the first dose for the next morning, delaying treatment.
The facility failed to provide timely pharmaceutical services for three residents, resulting in missed medication doses. A resident did not receive evening doses due to pharmacy closure on a holiday, with no follow-up documentation. Another resident experienced missed doses due to incorrect medications being available, and a third resident did not receive medications upon admission, with delayed delivery from Omnicare. The facility lacked an emergency kit and did not document a STAT request for prompt delivery.
Failure to Obtain Written Consent for Psychotropic Medications
Penalty
Summary
A review of facility records and staff interviews revealed that the facility failed to obtain written consent for psychotropic medications for one resident. The resident, who was rarely able to understand or be understood according to the most recent Minimum Data Set (MDS) assessment, was prescribed Depakote for a mood disorder and Ativan for an anxiety disorder. The medical record did not contain any documentation of consent for these medications, nor evidence that the resident's representative was informed of the risks and benefits associated with their use. During a joint record review and interview, the Assistant Director of Nursing (ADON) confirmed the absence of the required consents and lack of communication with the resident's representative.
Failure to Limit PRN Psychotropic Medication Use Without Timely Physician Review
Penalty
Summary
The facility failed to ensure that PRN (as needed) psychotropic medications, specifically Lorazepam (Ativan), did not extend beyond 14 days without a documented rationale and duration of use for three residents. For one resident admitted to hospice, an open-ended order for Ativan was initiated by hospice services without a stop date or specified duration, and there was no evidence of regular re-evaluation by a physician or practitioner. The consultant pharmacist indicated that weekly evaluations typically occur for hospice residents, but documentation supporting this was not found in the record. The Assistant Director of Nursing confirmed that the Ativan order was initiated by hospice and remained open-ended, with no recent physician or nurse practitioner evaluation since admission. Two additional residents with histories of dementia, psychosis, and other mental health conditions also had open-ended PRN Lorazepam orders without discontinue dates or documented rationales for continued use. Medication administration records showed that staff administered these medications as needed, but there was no evidence of physician review or justification for extending the orders beyond the recommended 14-day period. These findings were based on record reviews and staff interviews.
Failure to Maintain Resident Ambulation Post-PT Discharge
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident did not lose the ability to ambulate after being discharged from Physical Therapy (PT). The resident, who was cognitively intact and had previously ambulated with a hemi walker under supervision, expressed concern about not walking since PT discharge and only using a wheelchair for mobility. The resident's care plan indicated a referral to the Restorative Nursing Program (RNP) upon PT discharge, but interviews revealed that the RNP was not in place at the facility. Nursing staff acknowledged that while they could assist residents with walking post-PT, this was not being done for the resident in question. Further investigation showed that the resident was not participating in the Walk to Dine program due to limited walking distance, and no alternative ambulation support was provided. Staff interviews confirmed that the resident had not been walked by nursing staff since PT discharge, and there was no process in place to monitor or maintain the resident's ambulation abilities. As a result, the facility failed to provide necessary services to prevent a decline in the resident's ability to perform activities of daily living, specifically ambulation, without a documented medical reason.
Failure to Provide Timely and Appropriate Care and Documentation for Multiple Residents
Penalty
Summary
Resident #72, who had mild cognitive impairment and a foot infection, was ordered to receive daily wound care with betadine to the right foot, with the dressing to be changed during the evening shift and as needed for soiling or dislodgement. The care plan was revised to accommodate the family's request for evening treatments. However, after a morning shower, the resident was left without a dressing, and staff failed to notice or address the missing dressing or the condition of the foot, which was observed to be necrotic and emitting a strong odor. The responsible RN was unaware of the dressing's status and had not performed the dressing change, despite clear evidence that it was needed after the shower. Resident #69, who had a terminal diagnosis and was receiving hospice services, did not have a current physician order for hospice services in the medical record, despite a hospice consult being requested and the resident being admitted to hospice. The Assistant Director of Nursing confirmed the absence of the required order during a review of the record. Resident #25 experienced a delay in treatment for a urinary tract infection (UTI) after a urinalysis and culture indicated the need for antibiotics. Although the lab results were faxed to the physician, there was no follow-up call, and antibiotic treatment was not initiated until four days later. Additionally, Resident #38, who was at high risk for skin tears and had physician orders for geri sleeves to be applied to both arms and legs every shift, was observed without the required sleeves. Staff were unaware of the full extent of the order, and there was a lack of communication and documentation regarding the resident's refusal or acceptance of the sleeves.
Failure to Document Respiratory Assessment and Obtain Oxygen Order
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a history of influenza and Parkinson's disease. Specifically, staff did not monitor or document a respiratory assessment after administering a nebulizer treatment, as required by facility policy. The policy mandates documentation of vital signs, including oxygen saturation before and after treatment, as well as the resident's tolerance to the treatment. Record review showed that the LPN documented the administration of the nebulizer treatment but did not record the required post-treatment respiratory assessment or vital signs in the Medication Administration Record (MAR). Additionally, the facility failed to obtain a physician's order for the administration of oxygen therapy to the resident. Observations revealed the resident was receiving oxygen via nasal cannula and using a portable oxygen tank, but there was no documented order for this therapy. Staff interviews confirmed that the oxygen was applied after a low oxygen saturation reading was reported, but the necessary physician authorization was not present in the resident's records.
Failure to Ensure Proper Physician Participation and PRN Psychotropic Medication Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed comprehensive monthly drug regimen reviews with proper physician participation and documentation for several months. Specifically, for three out of six months reviewed, there was no clear evidence that physicians had reviewed, approved, or denied the pharmacist's recommendations. The documentation forms used were inconsistent, with missing or unclear columns for physician approval, and in some cases, it was not possible to determine who had approved the recommendations. The consultant pharmacist acknowledged the lack of clear documentation and could not provide an alternative method to demonstrate physician participation in the review process. Additionally, the pharmacist failed to identify and address the use of as-needed (PRN) Ativan orders without a documented duration of use for three residents. For these residents, orders for Lorazepam (Ativan) were open-ended, lacking stop dates or documented rationales from physicians to extend the medication. The pharmacy reviews did not include recommendations regarding these PRN psychotropic medication orders, despite facility policies and pharmacy suggestions indicating the need for 30-day stop dates for such medications. The records for the affected residents showed ongoing administration of PRN Lorazepam without appropriate physician documentation or pharmacy intervention. Care plans indicated that the pharmacist was responsible for medication review, but there was no evidence of recommendations or follow-up regarding the continued use of these psychotropic medications. The deficiency was identified through review of records, pharmacy documentation, and interviews with the consultant pharmacist.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide timely pharmaceutical services for three residents, resulting in missed medication doses. Resident #2 was admitted with several medication orders, but did not receive the evening doses on the day of admission and the following morning due to the unavailability of drugs. The facility's pharmacy was closed for a holiday, and although a request was faxed to Omnicare, there was no follow-up or documentation of physician notification. Resident #5 did not receive prescribed medications on multiple occasions due to unavailability. The facility had Acidophilus instead of the prescribed Rhamnosus, and some nurses administered a pill form of a medication instead of the prescribed liquid form. There was no documentation of efforts to clarify or obtain the correct medications. Resident #6 also experienced delays in receiving medications. Despite being a new admit and expressing concern about the unavailability of medications, the facility did not have an emergency kit and relied on Omnicare for delivery. Progress notes indicated communication with Omnicare and hospice, but there was no documentation of a STAT request for prompt delivery. The facility's failure to follow procedures for acquiring and administering medications in a timely manner led to these deficiencies.
Plan Of Correction
Resident #2 was not negatively affected by the findings. Resident #5 was discharged to home on 3.5.25. Resident #6 was discharged to hospice house on 2.10.25. All residents have the potential to be affected. On [date], an audit was conducted by the Director of Nursing of all resident medications administration records from 3.13.2025 to 3.25.25 for missed doses. Education was provided by Staff Development Coordinator/Designee to the nurses on the facility protocol regarding pharmaceutical services related to acquiring and administering medications in a timely manner. The DON/Designee will conduct a weekly audit of electronic medication administration records for 4 weeks, then randomly. All findings will be reviewed at the QAPI meeting for 3 months or until compliance is achieved.
Delay in Reporting Test Results and Treatment Initiation
Penalty
Summary
The facility failed to provide timely necessary care and services to a resident, as evidenced by a delay in reporting abnormal test results and subsequent delay in treatment. The resident, who was admitted with various diagnoses, was assessed as moderately impaired for skills of daily decision-making and was receiving medications related to COVID-19. The care plan included administering medications as ordered and monitoring for signs of distress. However, the resident exhibited an elevated temperature and tested positive for COVID-19, which was reported to the practitioner, and droplet precautions were implemented. Despite a physician's order for medication to be administered, there was a delay in starting the treatment. The test results indicating increased opacity were completed but not reported to the physician in a timely manner, leading to a delay in initiating the prescribed medication. The Director of Nursing (DON) was unable to explain why the abnormal results were not faxed or received promptly. Additionally, the nurse who received the order scheduled the first dose for the next morning instead of administering it immediately, despite the availability of the medication in the facility's Emergency Pharmacy Kit.
Plan Of Correction
Resident #1 was discharged from the facility on 2.1.2025. All residents with ordered have the potential to be affected. On , an audit was conducted by a Registered Nurse to ensure results were reported to the provider timely. Education by Staff Development Coordinator/Designee to the nurses on the facility protocol for tracking and reporting results. DON/Designee will conduct weekly audit of electronic medication administration records for 4 weeks, then randomly. All findings will be reviewed at the QAPI meeting for 3 months or until compliance is achieved.
Delay in Reporting Test Results and Treatment Initiation
Penalty
Summary
The facility failed to provide timely necessary care and services to a resident, as evidenced by a delay in reporting abnormal test results and subsequent delay in treatment. The resident, who was admitted with a diagnosis that included COVID-19, had an elevated temperature and tested positive for COVID-19. The physician ordered medications, including Paxlovid, to be administered immediately. However, the medication was not initiated until the following day, despite the availability of the drugs in the facility's Emergency Pharmacy Kit. The delay was attributed to the nurse scheduling the first dose for the next morning instead of administering it immediately. Additionally, there was a failure in the process of obtaining and reporting test results. The test results, which indicated increased left hilar opacity, were completed in the morning but were not reported to the physician until late in the evening. The Director of Nursing was unable to explain why the abnormal results were not received or reported in a timely manner, highlighting a lapse in the facility's process for tracking and communicating test results.
Plan Of Correction
Resident #1 was discharged from the facility on 2.1.2025. All residents with ordered have the potential to be affected. On , an audit was conducted by a Registered Nurse to ensure results were reported to the provider timely. Education by Staff Development Coordinator/Designee to the nurses on the facility protocol for tracking and reporting , results. DON/Designee will conduct weekly audit of electronic medication administration records for 4 weeks, then randomly. All findings will be reviewed at the QAPI meeting for 3 months or until compliance is achieved.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide timely pharmaceutical services for three residents, resulting in missed medication doses. Resident #2 was admitted with several medication orders, but did not receive the evening doses of prescribed medications due to unavailability. The facility's Director of Nursing (DON) confirmed that the onsite pharmacy was closed on a holiday, and there was no documentation of follow-up with the pharmacy or physician notification regarding the unavailability of medications. Resident #5 also experienced missed medication doses due to the facility not having the correct medications. The DON revealed that the facility had Acidophilus instead of the prescribed Rhamnosus, leading to inconsistent administration by nurses. Additionally, the liquid form of a medication was unavailable, and some nurses used a pill form instead. There was no documentation from the pharmacy or nurses to clarify or obtain the correct medications in a timely manner. Resident #6 did not receive prescribed medications upon admission due to unavailability. Progress notes indicated communication with Omnicare and hospice, but the medications were not delivered promptly. The DON confirmed the absence of an emergency kit and that all medications were delivered by Omnicare, with no documentation of a STAT request for prompt delivery.
Plan Of Correction
Resident #2 was not negatively affected by the findings. Resident #5 was discharged to home on 3.5.25. Resident #6 was discharged to hospice house on 2.10.25. All residents have the potential to be affected. On [date], an audit was conducted by the Director of Nursing of all resident medications administration records from 3.13.2025 to 3.25.25 for missed doses. Education was provided by Staff Development Coordinator/Designee to the nurses on the facility protocol regarding pharmaceutical services related to acquiring and administering medications in a timely manner. The DON/Designee will conduct a weekly audit of electronic medication administration records for 4 weeks, then randomly. All findings will be reviewed at the QAPI meeting for 3 months or until compliance is achieved.
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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 Port Saint Lucie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Port St Lucie Rehabilitation And Healthcare | 9.2 mi | ★★★★★ | 0 | 0 |
| Palm Garden Of Port Saint Lucie | 10 mi | ★★★★★ | 0 | 0 |
| Tiffany Hall Nursing And Rehab Center | 10 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Port Saint Lucie | 10.4 mi | ★★★★★ | 15 | 0 |
| Savannas Park Health And Rehabilitation Center | 10.8 mi | ★★★★★ | 21 | 0 |
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