Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of October 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.
Failure to Address Resident Council Food Temperature Grievances: Residents and the Resident Council repeatedly voiced concerns that meals were served cold or lukewarm, but the grievance log and meeting minutes documented only one dietary grievance. Cognitively intact residents and other council members said the issue had been raised at multiple meetings for months without resolution. During breakfast observation, meals were transported on carts without an added heat source and staff did not serve the trays with urgency, with the last meal served at 8:49 AM.
A facility failed to prepare and serve pureed diet items at the ordered consistency for residents on the 200 unit. During lunch and breakfast observations, pureed vegetables, eggs, and sausage were seen pooling on plates and appearing liquid or thick-liquid in consistency, and the CDM acknowledged the foods should have been thicker.
Failure to Obtain Informed Consent for Psychotropic Medications: The DON acknowledged that two residents did not have informed consent for all prescribed psychotropic medications. One resident with dementia, Parkinson's disease, anxiety, and depression had orders for hydroxyzine and sertraline, but no consent was found. Another resident with dementia, Parkinson's disease, and major depressive disorder had orders for mirtazapine and quetiapine, but the record contained consent only for quetiapine.
Residents reported that meals were served cold, and an observed breakfast tray pass on one unit took nearly an hour to complete because trays were left unattended and staff assistance was delayed. A CNA stated she could not manage the tray pass alone and had repeatedly asked for help, while the Unit Manager acknowledged awareness of the prolonged tray pass and the residents’ complaints. The grievance policy required staff to assist with and document grievances, but no grievance had been filed on behalf of the CNA’s concerns.
Accepted pharmacy recommendation not processed for vitamin D monitoring: A resident with depression and palliative care needs had a physician-ordered vitamin D supplement, and pharmacy recommended checking a 25-hydroxyvitamin D level and adjusting the dose accordingly. The MD accepted the recommendation and ordered the lab, but the record showed no evidence the vitamin D level was obtained, and a later pharmacy review found the order still had not been processed; the DON acknowledged the lapse.
Medication Error Rate Exceeded the Allowed Threshold: Surveyors found a 9.38% medication error rate during observed med passes, with 3 errors in 32 opportunities. An LPN selected Aspirin 81 mg instead of the ordered 325 mg, gave only 1 tablet of ordered Vitamin D 25 mcg when 5 tablets were required, and an RN omitted an ordered Vitamin B12 dose. The Unit Manager and DON were informed of the errors.
Improper Holding of Vegetables Reduced Nutritive Value. A Cook and the CDM observed carrots hot held on the cook top range and mixed vegetables held in a steamer for lunch service, with the carrots expected to remain held for more than 3 hours before plating. The CDM acknowledged that holding the vegetables for extended periods would diminish their nutritional value.
Failure to provide meals according to resident preferences: Two cognitively intact residents with nutritional concerns, including one with cancer and one with malnutrition, repeatedly received scrambled eggs despite documented and stated preferences for fried eggs. Observations showed the meal tickets and served trays did not match the residents’ breakfast preferences, and one resident stated she would not eat the food provided.
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 Address Resident Council Food Temperature Grievances
Penalty
Summary
The facility failed to respond to and resolve grievances voiced by residents and members of the Resident Council regarding the temperature of food served in residents’ rooms and in the dining area. Residents who were cognitively intact, including one resident with a BIMS score of 15 and another with a BIMS score of 15, stated that meals were served cold, including food that seemed like it had just come out of the refrigerator. The Resident Council President stated that the Resident Council and Food Committee had been raising concerns about food temperature for several months, and that there should have been more documented complaints because residents had been complaining for about four months. Review of the grievance log and meeting minutes showed only one documented dietary grievance from 09/22/25, with no other grievances documented by or on behalf of the Resident Council or Food Committee. During a Resident Council meeting, multiple residents, including residents with BIMS scores of 15 and 14 and one resident documented as alert and oriented, stated that the food was usually cold to lukewarm and that the concern had been mentioned at every meeting without a solution. During breakfast observation, food carts were transported on the unit in insulated cambro carts without an additional heat source, staff showed no urgency in serving the meals, and the last meal was not served until 8:49 AM. The CDM stated that complaints about cold food had been ongoing since arrival and that there was no follow-through with residents to obtain input on the concern.
Pureed Diet Foods Served at Incorrect Consistency
Penalty
Summary
The facility failed to prepare and serve foods in a form designed to meet the needs of residents ordered pureed diets. During lunch observations on the 200 unit, the pureed vegetables were seen pooling on the plate, running into other foods, and appearing to have a liquid consistency. In the kitchen, a scoop of the pureed vegetables poured out when tilted, and the Certified Dietary Manager acknowledged that the vegetables should have been a thicker consistency. During breakfast observations on the 200 unit, the pureed eggs and pureed sausage also pooled on the plate and had a liquid consistency. In the kitchen, servings of the pureed eggs and sausage pooled together and were the consistency of a thick liquid, and the Certified Dietary Manager acknowledged that these foods should have been thicker.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications for 2 of 5 residents reviewed for unnecessary medications, affecting Resident #83 and Resident #128. The facility policy stated that psychotropic medications require psychoactive medication consent signed by the resident or resident representative. For Resident #128, the record showed diagnoses including right femur fracture, Parkinson's disease, repeated falls, dementia, depression, UTI, anxiety, and acute posthemorrhagic anemia, and physician orders included Hydroxyzine HCl 25 mg every 8 hours as needed for anxiety and Sertraline HCl 100 mg daily for depression. The DON stated that consent should be obtained and uploaded into the record, but no informed consent for the psychotropic medications was located, and the DON acknowledged that the resident did not have informed consent for the prescribed psychotropic medications. For Resident #83, the record showed diagnoses including aftercare following joint replacement surgery, Parkinson's disease, major depressive disorder, and unspecified dementia, and the MDS documented moderate cognitive impairment. Physician orders included Mirtazapine 15 mg at bedtime for depression and Quetiapine 12.5 mg twice daily for dementia. The medical record contained only one psychoactive medication consent dated 12/31/25 for Quetiapine 12.5 mg twice daily. The DON acknowledged that the resident was on more than one psychotropic medication and did not have informed consent for all of the psychotropic medications prescribed.
Delayed Tray Pass and Unaddressed Food Temperature Complaints
Penalty
Summary
The facility failed to honor residents’ right to voice grievances and failed to ensure meals were provided in a timely manner, as shown by repeated complaints that food was served cold and by a prolonged tray pass on the 100 unit. The facility’s grievance policy stated that grievances could be submitted orally or in writing and that staff were to encourage and assist residents or their representatives to file a grievance and document oral grievances on the grievance report. However, the record showed that Resident #127, who had cancer and a BIMS score of 15, complained on two occasions that food was always cold when served, and Resident #109, who had GERD and a BIMS score of 14, reported that food was served cold most of the time. Resident #108, who had depression and a BIMS score of 14, also reported that the facility’s food was served cold. During observation of breakfast tray pass on the 100 unit, one CNA passed trays and left multiple trays unattended on the food cart in the hallway, a second CNA later passed several trays and left the unit, and a third CNA arrived to assist with tray pass for residents in the back hallway. Tray service for the unit was not completed until nearly one hour after it began. Staff H stated she could not handle the tray pass alone, had repeatedly asked for help, and had three total care residents to feed while also needing to cut up food and set up trays. Staff I, the Unit Manager, acknowledged awareness of the prolonged tray pass and residents’ complaints about cold food, and stated no grievance had been filed on behalf of Staff H despite her concerns about needing assistance.
Accepted pharmacy recommendation not processed for vitamin D monitoring
Penalty
Summary
The facility failed to ensure that a pharmacy recommendation accepted by the physician was processed and implemented for Resident #108, who was admitted with diagnoses including depression and had a BIMS score of 14, indicating cognitive intactness. The resident’s physician order dated 12/11/24 included Vitamin D 25 mcg (1000 units), five tablets by mouth once daily for vitamin supplementation, and the care plan dated 03/01/25 documented that the resident was receiving palliative care related to occlusion of the right vertebral artery with medications to be administered as ordered. A pharmacy medication regimen review in August 2025 recommended monitoring the resident’s 25-hydroxyvitamin D level on the next convenient lab day and adjusting the vitamin D dose accordingly. The attending physician accepted the recommendation and ordered a vitamin D level, but the clinical record lacked documented evidence that the level was obtained, with the most recent vitamin D level on record dated 03/27/25. A later pharmacy review in November 2025 documented that the accepted recommendation still had not been processed, and the DON acknowledged on 01/15/26 that the August 2025 and November 2025 pharmacy recommendations related to obtaining a vitamin D level had not been processed.
Medication Error Rate Exceeded the Allowed Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent. Surveyors identified a 9.38% medication error rate, with 3 medication errors found during 32 observed medication administration opportunities, affecting Residents #14 and #108. During an observed medication pass with an LPN, Aspirin 81 mg was removed from the cart instead of the ordered Aspirin 325 mg, and the nurse was unable to locate the correct dose in the cart. The nurse later stated the 325 mg strength was not available and that he would call the doctor because the medication would need to be put on hold. During the same observation, the LPN also administered only 1 tablet of Vitamin D 25 mcg (1000 units) when the physician order required 5 tablets by mouth. In a separate observed medication pass with an RN, an active order for Vitamin B12 1000 mcg, 1 tablet by mouth, was not administered. The omission was identified during reconciliation immediately after the pass, and the RN acknowledged the medication had been omitted. The Unit Manager and DON were later informed of the three medication errors observed involving two licensed nurses.
Improper Holding of Vegetables Reduced Nutritive Value
Penalty
Summary
The facility failed to prepare foods in a manner to preserve nutritive value. During an initial kitchen tour, a 6-inch deep one-third sized hotel pan of carrots was observed being hot held on the cook top range, and the Cook stated the carrots had been finished at 8:45 AM for lunch service that day. The Certified Dietary Manager acknowledged that the carrots would be held more than 3 hours before being plated and served. The Cook stated the carrots were prepared so they would be soft for residents to eat, and also stated they typically would only take about 20 minutes to cook. During the same tour, a full-sized 6-inch deep hotel pan of mixed vegetables was observed in the steamer for the lunch meal, and the Cook stated they were also intended for service that day. The Certified Dietary Manager acknowledged that holding the carrots and mixed vegetables for extended amounts of time would diminish their nutritional value.
Failure to Provide Meals According to Resident Preferences
Penalty
Summary
The facility failed to provide food in accordance with residents’ stated preferences for 2 of 7 residents reviewed for food concerns. Resident #127, who was admitted with diagnoses including cancer and had a quarterly MDS documenting a BIMS score of 15, was identified in the care plan as being at risk for decreased nutritional status, dehydration, and weight loss, with an intervention to cater to food preferences and textures to increase intake. During observation on 01/14/26, the resident was upset and stated she was not going to eat the food provided because her everyday breakfast was fried eggs and she had been given scrambled eggs, which she said she hated. Observation showed Resident #127 received a scrambled egg sandwich with bacon on wheat bread, while the meal ticket indicated her breakfast preference was fried egg with wheat bread every morning, with no toast and no cheese. Resident #37, who was admitted with diagnoses including malnutrition and had a quarterly MDS documenting a BIMS score of 15, was identified in the care plan as being at nutritional risk related to variable intake and severe protein-calorie malnutrition. During observation on 01/14/26, the resident stated she had requested fried eggs but kept receiving scrambled eggs, and said she had discussed this with the dietitian multiple times. On 01/15/26, the dietetic technician was informed of both residents’ concerns about receiving scrambled eggs instead of their stated preference for fried eggs.
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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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 | ★★★★★ | 0 | 0 |
| Seabranch Health And Rehabilitation Center | 6.2 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Port Saint Lucie | 8.1 mi | ★★★★★ | 12 | 0 |
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