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 Garden Of Port Saint Lucie during CMS and state inspections, most recent first.
A facility failed to complete necessary assessments and documentation for a resident with multiple diagnoses, including cerebral atherosclerosis and hypertension, leading to a transfer to a higher level of care due to family concerns. The resident was later diagnosed with myxedema coma. Additionally, the facility did not document blood glucose levels and insulin administration for another resident with Diabetes Mellitus Type 2, missing critical notifications to the physician. Interviews confirmed the lack of documentation and assessments, contributing to the deficiencies identified.
The facility failed to document respiratory evaluations before and after administering nebulizer treatments for two residents. One resident with COPD and other conditions received Albuterol treatments without documented assessments, while another resident with cerebral atherosclerosis and other diagnoses received Ipratropium-Albuterol treatments without documented evaluations.
The facility failed to document the removal and administration of Hydrocodone for two residents in the MARs, despite records showing the medication was removed. Discrepancies were noted between the Controlled Medication Utilization Record and the MARs, and unit managers were informed of these documentation lapses.
A resident with multiple health issues, including paralysis, did not receive the increased Occupational Therapy sessions ordered by a physician. Despite the order being signed, the facility continued with the previous therapy schedule due to an oversight by the OT department. The resident's significant other expressed concerns about the lack of progress in rehabilitation.
A facility failed to document vital signs as ordered for a resident with multiple health conditions, including HTN and anxiety. Despite physician orders to obtain vital signs every shift, the MAR showed no documentation of the vital signs, although they were signed off as completed. The vital signs record lacked entries after a certain date, except when the resident was transferred to the hospital. The nursing progress notes also did not include any vital signs documentation, and the DON confirmed that all available documentation was provided.
Two residents with UTIs caused by ESBL bacteria did not receive proper infection control measures during pericare. A CNA failed to change gloves and perform hand hygiene between tasks for one resident, while another CNA did not wear PPE, allowing her uniform to contact the bed. The facility's infection control protocols were not followed, despite the residents' positive ESBL status.
Deficiencies in Resident Assessments and Documentation
Penalty
Summary
The facility failed to complete necessary assessments and documentation for Resident #303, who was admitted for long-term care with multiple diagnoses including cerebral atherosclerosis, hypertension, and hyperlipidemia. Despite a significant weight gain and the presence of edema, discoloration of extremities, and respiratory issues, there were no follow-up assessments or documentation of physician notifications. The resident's care plan included monitoring for complications related to hypertension and diuretic use, but there were no additional care plans addressing the edema. Vital signs were not documented as ordered, and the resident was eventually transferred to a higher level of care due to family concerns about speech and extremity conditions. The hospital diagnosed the resident with myxedema coma, a severe hypothyroid condition. The facility also failed to document blood glucose levels and the administration of insulin per sliding scale for Resident #36, who had a diagnosis of Diabetes Mellitus Type 2. The resident's care plan included specific orders for blood glucose monitoring and insulin administration, but there were missing records of blood glucose levels and no documentation of physician notification when levels were critically low. The electronic Medication Administration Record (eMAR) showed several instances where blood glucose levels were not recorded, and insulin was not documented as administered according to the sliding scale. Interviews with the Director of Nursing confirmed the lack of documentation and assessments for both residents. The facility did not maintain adequate records of vital signs, assessments, and physician notifications, leading to deficiencies in the care provided to these residents. The lack of documentation and follow-up on significant changes in residents' conditions contributed to the deficiencies identified in the report.
Failure to Document Respiratory Evaluations for Nebulizer Treatments
Penalty
Summary
The facility failed to ensure proper evaluation of the respiratory status of two residents before and after administering respiratory treatments. The facility's policy on medication administration, specifically for nebulizer treatments, requires evaluations of respiratory status, including breath sounds, cough effort, sputum production, heart rate, and respiratory rate, both prior to and following treatment. However, for two residents, these evaluations were not documented as completed. One resident, who was admitted with multiple diagnoses including COPD, hypertension, pneumonia, myocardial infarction, dementia, acute upper respiratory infection, and heart failure, had an order for Albuterol Sulfate Inhalation Nebulization Solution to be administered twice daily for shortness of breath. Despite the treatments being administered as ordered, there was no documentation of respiratory assessments before and after the treatments. Similarly, another resident with diagnoses including cerebral atherosclerosis, hypertension, anxiety, edema, palliative care, and hyperlipidemia, received Ipratropium-Albuterol Inhalation Solution as needed for wheezing. The treatments were administered on several occasions, but again, there was no documentation of respiratory evaluations before or after the treatments.
Failure to Document Narcotic Administration in MARs
Penalty
Summary
The facility failed to ensure that narcotic removal was accurately recorded in the Medication Administration Records (MARs) for two residents. For Resident #97, a clinical record review revealed a physician order for Hydrocodone 5-325 mg to be administered by mouth every 4 hours as needed for non-acute pain. However, discrepancies were found between the Controlled Medication Utilization Record and the July 2024 MARs, indicating that the medication was removed on two occasions without corresponding documentation in the MARs. The second-floor Unit Manager acknowledged this discrepancy during a review and interview. Similarly, for Resident #63, a clinical record review showed a physician order for Hydrocodone 5-325 mg, 1 tablet by mouth every 4 hours as needed for non-acute pain. A discrepancy was noted where the Controlled Medication Utilization Record indicated the medication was removed, but the July 2024 MARs lacked documentation of this removal and administration. The first-floor Unit Manager was informed of this documentation lapse during an interview.
Failure to Implement Physician-Ordered Therapy Services
Penalty
Summary
The facility failed to provide therapy services as ordered by the physician for a resident who was admitted with multiple diagnoses, including Type 2 Diabetes Mellitus, Hypertension, Parkinson's Disease, and a Cognitive Communication Deficit. The resident had undergone neck surgery and was paralyzed in both extremities. Despite a physician's order on 07/05/24 to increase Occupational Therapy (OT) sessions to five times a week, the facility did not implement this order. The resident's significant other expressed concerns about the lack of progress in the resident's rehabilitation and the desire for the resident to regain mobility and return home. The Director of Therapy Services confirmed that the resident was receiving Physical Therapy twice a week and OT three times a week, contrary to the physician's order. The order to increase OT was signed by the physician on 07/08/24, but the Director of Therapy Services acknowledged that the order had not been initiated due to an oversight by the OT department. The process for handling physician orders involves the OT department receiving the order, performing recertification, and entering it into the electronic medical record, followed by scheduling by the Director of Therapy Services. The failure to implement the order was attributed to a technique error in the OT department.
Failure to Document Vital Signs as Ordered
Penalty
Summary
The facility failed to ensure that vital signs were documented as ordered for a resident with multiple diagnoses, including Cerebral Atherosclerosis, Hypertension, Anxiety, Edema, palliative care, and Hyperlipidemia. The physician's orders required vital signs to be obtained every shift, specifically during the day and evening shifts. However, a review of the Medication Administration Record (MAR) showed that while the vital signs were signed off as completed, there was no documentation of the actual vital signs. Additionally, the vital signs record did not show any documentation after a specific date, except for the day the resident was transferred to the hospital via emergency medical services. The nursing progress notes also lacked any documentation regarding the resident's vital signs. The Director of Nursing confirmed that all available nursing documentation for the resident was provided, indicating a lapse in maintaining accurate medical records as per professional standards.
Infection Control Breach During Pericare
Penalty
Summary
The facility failed to adhere to its infection control process during pericare for two residents diagnosed with urinary tract infections (UTIs) caused by Extended Spectrum Beta-Lactamase (ESBL) producing bacteria. The facility's policy on infection prevention and control, as well as transmission-based precautions, requires the use of personal protective equipment (PPE) such as gowns and gloves during interactions that may involve contact with the resident or potentially contaminated areas. However, these protocols were not followed during the care of Residents #37 and #46. For Resident #37, who was severely cognitively impaired and required substantial assistance with personal hygiene, the CNA, Staff B, was observed performing pericare without changing gloves after touching potentially contaminated surfaces such as the curtain, bed remote, and bed linens. Additionally, Staff B failed to perform hand hygiene between glove changes, which is a critical step in preventing the spread of infection. This oversight occurred despite the resident's positive test for ESBL in the urine and the ongoing treatment with intravenous antibiotics. In the case of Resident #46, who was moderately cognitively impaired and always incontinent with bladder, the CNA, Staff A, did not wear any PPE while providing pericare, allowing her uniform to come into contact with the bed. This was a direct violation of the contact precautions in place due to the resident's ESBL-positive UTI. The lack of signage at the door to alert staff of the necessary precautions further contributed to the breach in infection control practices. The Director of Nursing was informed of these deficiencies, highlighting the need for strict adherence to infection control protocols.
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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 Port Saint Lucie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tiffany Hall Nursing And Rehab Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Port Saint Lucie | 0.9 mi | ★★★★★ | 15 | 0 |
| Savannas Park Health And Rehabilitation Center | 1.1 mi | ★★★★★ | 21 | 0 |
| Port St Lucie Rehabilitation And Healthcare | 4.5 mi | ★★★★★ | 0 | 0 |
| Waters Edge Health And Rehabilitation | 7 mi | ★★★★★ | 0 | 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.