Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Palm City Nursing & Rehab Center during CMS and state inspections, most recent first.
A facility failed to implement a care plan for a resident on hospice with fluid restrictions. Despite orders, the resident had access to various fluids, and staff were unaware of the restrictions. The care plan contradicted the fluid restrictions by encouraging oral fluid intake. Interviews revealed a lack of communication and coordination among staff, with no policy in place to address fluid restrictions, relying instead on physician orders.
A facility failed to document catheter care for a resident with severe cognitive impairment and an indwelling urinary catheter. Despite a care plan to prevent infections, there was no record of care provided over a specific period. Interviews revealed staff confusion about documentation procedures, contributing to the deficiency.
The facility failed to monitor weights accurately for two residents, leading to significant discrepancies and unaddressed weight loss. One resident was not weighed weekly as required, resulting in large unverified weight fluctuations. Another resident experienced an 11.17% weight loss without facility intervention. Additionally, the facility did not adhere to fluid restrictions for a hospice resident, with staff unaware of the restrictions and no facility policy in place.
The facility failed to document the removal of narcotic medications in the MARs for three residents. Discrepancies were found during a review, where medications like Tramadol, Lorazepam, and Alprazolam were removed but not documented as administered. These issues were reported to the DON.
The facility failed to maintain a medication error rate below 5%, with errors affecting two residents. One resident received Depakote outside the prescribed time frame, while another had Lisinopril inappropriately withheld without physician-approved parameters. The DON acknowledged discrepancies in medication administration schedules and the lack of documented parameters for withholding medications.
The facility failed to secure medications for two residents, with one having medications at the bedside and another with cough drops in an open drawer. An LPN left an inhaler unattended during administration, and a medication cart was left unlocked. Staff acknowledged these lapses, which violated medication security protocols.
The facility failed to administer Parkinson's medications timely for three residents, as per physician's orders. Medications for Parkinson's were frequently administered late, affecting residents' conditions. Interviews with staff revealed inconsistencies in handling late medication administration.
Failure to Implement Fluid Restriction Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was noncompliant with fluid restrictions. The resident, who was admitted to hospice care, had a history of coronary artery disease, heart failure, and other significant health issues. Despite having a fluid restriction order, the resident was observed with various fluids in their room, and staff were unaware of the restrictions. The care plan for nutrition and hydration contradicted the fluid restrictions, as it included an intervention to encourage oral fluid intake. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's care plan. The Registered Dietitian was unaware of the fluid restrictions, and the Director of Nursing acknowledged the resident's noncompliance but had not contacted the physician to address the issue. The Nurse Practitioner indicated that hospice was supposed to discontinue the fluid restrictions, but this was not reflected in the care plan or communicated to the staff. The facility did not have a policy to address fluid restrictions, relying instead on physician orders. The MDS Coordinator admitted to the absence of a care plan addressing the resident and family's noncompliance with fluid restrictions. The care plan was only updated to remove the encouragement of oral fluid intake after surveyor intervention, highlighting the facility's failure to ensure that care plans were accurate and reflective of the resident's current needs.
Deficiency in Catheter Care Documentation
Penalty
Summary
The facility failed to ensure proper documentation and ongoing care to prevent infection for a resident with an indwelling urinary catheter. The resident, who was admitted with diagnoses including unspecified dementia and neuromuscular dysfunction of the bladder, had a severe cognitive impairment as indicated by a BIMS score of 4. Despite having a care plan that included catheter care with warm water and soap, there was no documentation from the CNAs indicating that catheter care was provided from July 8 to July 17. The care plan aimed to decrease the risk of urinary tract infections and other complications related to the catheter, but the lack of documentation suggests that the care may not have been consistently provided. Interviews with various staff members, including CNAs and the MDS coordinator, revealed inconsistencies in the understanding and documentation of Foley catheter care. While CNAs reported providing daily catheter care, they indicated that there was no specific place to document this care in the facility's system. The MDS coordinator acknowledged that there was no designated area for CNAs to document Foley care, despite it being listed in the care plan and Kardex. This lack of documentation and clarity in the facility's procedures contributed to the deficiency in providing appropriate catheter care for the resident.
Failure to Monitor Weights and Adhere to Fluid Restrictions
Penalty
Summary
The facility failed to monitor and ensure accurate weights for two residents, leading to significant discrepancies in their recorded weights. Resident #29, who was admitted with severe cognitive impairment and multiple health conditions, was not weighed weekly as per the facility's protocol for new admissions. There were large fluctuations in the resident's documented weight, including a 70-pound gain and a 96-pound loss, without any verification or re-weighing to confirm accuracy. The facility did not identify the weight loss, implement interventions, or document any refusal by the resident to be weighed. Similarly, Resident #78, who was cognitively intact and had a history of weight loss, was not weighed for over three months, contrary to the care plan's requirements. The resident experienced an 11.17% weight loss, which was not identified by the facility, and no interventions were implemented to address this loss. The resident's care plan included orders for double portions and fortified foods, but there was no order for monitoring weights, and the resident reported a significant drop in weight without facility acknowledgment. Additionally, the facility failed to adhere to fluid restrictions for Resident #10, who was on hospice care and had a fluid restriction order. Observations revealed the resident had access to assorted fluids, including bottled beverages, despite the restrictions. Interviews with staff indicated a lack of awareness and communication regarding the resident's fluid restrictions, and the facility did not have a policy to address such restrictions, relying solely on physician orders.
Failure to Document Narcotic Medication Removal
Penalty
Summary
The facility failed to ensure proper documentation of narcotic medication removal in the medication administration records (MARs) for three of the six residents reviewed. During a medication storage review, discrepancies were found in the records of three residents. For one resident, Tramadol 50 mg was ordered to be administered every 8 hours as needed for pain. However, the controlled medication utilization record showed that Tramadol was removed on two occasions, but there was no corresponding documentation in the MARs to indicate that the medication was administered to the resident. Similarly, another resident had an order for Lorazepam 0.5 mg every 4 hours as needed for anxiety, but the removal of the medication was not documented in the MARs. Additionally, a third resident had an order for Alprazolam 0.25 mg by mouth once a day as needed for anxiety, and again, the removal of the medication was not documented in the MARs. These discrepancies were identified during a review process and were brought to the attention of the Director of Nursing.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with a calculated error rate of 6.25% during a medication pass observation. Two residents were affected by these errors. For Resident #32, the error involved the administration of Depakote Sprinkles Delayed Release 125mg outside the prescribed time frame. The medication was given at 4:30 PM, despite the last dose being administered at 2:00 PM, which did not align with the facility's guidelines for medication administration times. The Director of Nursing (DON) acknowledged the discrepancy in the medication administration schedule, noting that the 'prior to bedtime' frame was not consistently documented or followed. For Resident #99, the error involved the inappropriate holding of Lisinopril 10mg without physician-approved parameters. The RN decided to withhold the medication based on a blood pressure reading of 114/73, citing nursing judgment, despite the absence of any documented parameters for withholding the medication. The DON confirmed that holding a medication without specific parameters or physician consultation could be considered not following the doctor's orders. These actions contributed to the facility's failure to adhere to proper medication administration protocols, resulting in a medication error rate exceeding the acceptable threshold.
Medication Security Lapses in LTC Facility
Penalty
Summary
The facility failed to secure medications at the bedside for two residents, Resident #72 and Resident #83. Resident #72, who had an intact cognitive response, was observed with a box of medications including Vicks Vapocool cough drops, Opcon-A eye allergy relief drops, and a bottle of Ibuprofen on a table across from the foot of her bed. Despite the resident's claim that staff were aware of the medications and that she did not use them often, the medications were not secured. Staff L, an LPN, acknowledged the oversight and indicated that the medications should not have been at the bedside. Similarly, Resident #83, who had severe cognitive impairment, was found with Ricola cough drops in the open top drawer of the nightstand next to her bed. Staff L confirmed that the resident should not have had the cough drops at the bedside, especially since she was on a soft diet. During a medication administration for Resident #102, the facility failed to secure medication when an LPN left an Anoro Ellipta inhaler on a dresser out of her sight while she went into the resident's bathroom. The LPN acknowledged that she should have kept the inhaler in her sight at all times and admitted that residents are not allowed to have medications at the bedside. She stated that all medications should be locked up, and if she saw medications at the bedside, she would consult her supervisor. Additionally, the facility failed to secure a medication cart, as it was left unlocked and unattended outside a resident's room. Staff A, an LPN, admitted that the cart was assigned to her and acknowledged that she left it unlocked and unattended, which was against the facility's protocol. This series of observations and interviews highlights the facility's failure to adhere to medication security protocols, resulting in unsecured medications at the bedside and during administration.
Failure to Administer Parkinson's Medications Timely
Penalty
Summary
The facility failed to administer Parkinson's medications timely for three residents, as per the physician's orders. The procedural guidelines of the facility require medications to be administered within 60 minutes of the scheduled time unless otherwise specified by the physician. However, for Resident #310, medications such as Entacapone, Sinemet (Carbidopa-Levodopa), and Ropinirole were frequently administered late, sometimes by more than two hours. This delay in medication administration was noted over several days, affecting the resident's condition, as reported by the spouse, who observed negative effects on the resident's mobility and episodes of dyskinesia. Resident #21, diagnosed with Dementia and Parkinsonism, also experienced delays in receiving medications like Carbidopa-Levodopa and Mirapex. The medications were administered late on multiple occasions, with delays ranging up to one hour and 34 minutes. The resident's cognitive impairment made it difficult to assess the direct impact of these delays, but the failure to adhere to the scheduled medication times was evident in the documentation. Similarly, Resident #25, who also had Dementia and Parkinsonism, faced delays in receiving Carbidopa-Levodopa. The medication was administered late on numerous occasions, with delays extending up to one hour and 38 minutes. Interviews with staff members, including LPNs and the Director of Nursing, revealed a lack of clarity and consistency in handling late medication administration, with some staff unsure about the implications of administering medications outside the prescribed time frame.
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What surveyors actually found near you
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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 City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Edge Health And Rehabilitation | 2 mi | ★★★★★ | 0 | 0 |
| Solaris Healthcare Parkway | 3 mi | ★★★★★ | 8 | 0 |
| Stuart Rehabilitation And Healthcare | 3.6 mi | ★★★★★ | 6 | 0 |
| Seabranch Health And Rehabilitation Center | 6.2 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Port Saint Lucie | 8.1 mi | ★★★★★ | 15 | 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 July 2026) and official state health department websites.