Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Port St Lucie Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Unsanitary kitchen equipment and inadequate dishwashing sanitation: The dish machine was running below the required sanitizing temperature while staff continued washing dishes, and the CDM stated the temperature had been below standard since she started. A sanitizing bucket tested low and contained more than one towel, the ice machine had black buildup with no cleaning log, the kitchen hand sink had no hot water due to hot water heater issues, and a unit pantry ice cooler had pink residue inside.
Staff failed to maintain resident dignity and respect when they argued loudly about resident assignments where residents could hear, spoke in another language in resident areas, and yelled at a resident after the call light was used for assistance. Two residents with ADL assistance needs and documented grievances about long call light response times reported hearing staff comments, delayed care, and communication they could not understand.
Unsanitary resident room and bathroom conditions were observed across multiple units, including bubbled and damaged wall surfaces, missing baseboards, corroded toilet fixtures, dirty floor mats, rust-like residue on bed components, peeled wheelchair and table coverings, dust on AC grates, and a missing ceiling tile. The Plant Operations Director agreed with the findings during the survey.
A resident with HTN, A-fib, heart disease, high lipid levels, and a pacemaker had an order for PRN Clonidine 0.2 mg for BP above ordered parameters, but multiple elevated BP readings over several months were documented without evidence the PRN medication was given. During record review, the RN/Unit Manager stated the PRN Clonidine should have been administered when the BP exceeded the physician's parameters and agreed with the findings.
Two residents with severe cognitive impairment were not provided fluids within reach and were not assisted with drinking as needed. One resident was observed with a dry mouth, asked for water, and later could not open a milk container until a student CNA helped after the resident repeated the request in English. Another resident had water placed out of reach and unopened milk left out of reach in the room, with a relative reporting similar issues with milk left from the prior day.
Unsanitary Garbage Area: The side of the garbage compactor was observed filled with random items, including a plastic bin with yellow liquid, a red bucket, a broom, an orange towel, a Brillo pad, and other small items. The CDM stated these items should not have been there.
Medical records were incomplete and inaccurate for three residents. One resident receiving Seroquel had no signed consent in the chart despite staff confirming the medication had been started and increased. Another resident with severe cognitive impairment still had active seizure precaution and padded side rail orders even though the DON stated those precautions had been discontinued after a hospital EEG showed no seizure activity. A third resident had duplicate PRN albuterol orders in the EMR, and staff confirmed the duplicate order was present.
Failure to follow EBP and maintain sanitary conditions: A CNA provided hygiene and Foley catheter care to a resident on EBP without wearing a gown, despite an order for EBP related to a Foley catheter and wound. In another room, PPE was present but no EBP sign was posted for a resident with ESBL, MRSA, VRE, a Foley catheter, and wounds, and staff had to review the chart to confirm precautions. The laundry area also had stained and rust-like contaminated equipment, residue, and dust-covered vents.
A resident rights deficiency occurred when the facility’s Voluntary Arbitration Agreement contained conflicting rescission language, stating in bold above the signature line that the resident could rescind within 10 business days while another section stated 30 days. Three residents or their representatives signed the form with the incorrect 10-business-day statement, and the Admissions Coordinator acknowledged the form was inconsistent and that the rescission language should reflect 30 days.
The facility's kitchen operations were found deficient in maintaining sanitary conditions. Issues included improper chlorine levels in the ware washing machine, mold in the ice machine, and damaged equipment. Staff were observed handling food without gloves and lacking proper beard restraints. Personal items were stored with disposable wares, indicating a failure to meet food safety standards.
A resident with chronic pain was not provided with timely pain management due to prescription issues, leading to unmanaged severe pain and a hospital visit. The facility's policy required a new prescription for Norco, which was delayed due to the primary physician's absence and a prescription error. Staff confirmed the medication was unavailable, and the resident's pain care plan was not effectively followed, resulting in inadequate pain management.
Unsanitary kitchen equipment and inadequate dishwashing sanitation
Penalty
Summary
The facility failed to provide proper sanitation of dishes and sanitizing towels in the main kitchen. During observation, the chemical sanitizing low-temperature dishwashing machine was operating at 70 degrees and did not reach the 120 degrees required for sanitizing per the manufacturer’s recommendations, yet staff continued washing dishes in the machine. The Certified Dietary Manager acknowledged that the dishwasher temperature had been below the recommended level since she started on 02/04/26 and stated that disposable paper goods or single-use items should have been used instead of dishes. Review of the Dish Machine Log for February and March 2026 showed daily temperatures below the manufacturer’s recommended 120-140 degrees Fahrenheit for both wash and rinse cycles, and the log stated that if temperature or chemical concentration did not meet parameters, washing should stop and a manager should be alerted. The facility also failed to maintain sanitary conditions in other kitchen areas. A stationary sanitizing bucket used for wiping towels tested at 100 ppm instead of the expected 200 ppm, and the bucket contained more than one towel even though the CDM stated only one towel should be in the bucket. The ice machine had black buildup in the inside door closing mechanism and on the white shield, and there was no cleaning schedule or cleaning log for it. On a later tour, the kitchen hand-washing sink had no hot water because the entire kitchen lacked hot water due to issues with the hot water heaters, and the CDM stated pots and pans were being cleaned by using boiling water from the stove to fill the three-compartment sink. In Unit C’s pantry, the ice cooler had pink residue around the interior aspect of the cooler.
Dignity and Respect Concerns During Care and Communication
Penalty
Summary
The facility failed to maintain residents’ dignity and respect by allowing staff to argue loudly about resident assignments in areas where residents could hear, by speaking in a language residents could not understand while in resident areas, and by raising their voices at a resident when the call light was used to request care. Resident #32 was admitted with diagnoses including fracture and depression, had a BIMS score of 11 indicating moderate cognitive impairment, and required assistance with toileting hygiene, bathing, dressing, footwear, and personal hygiene. The resident’s care plan identified a self-care deficit and need for assistance with activities of daily living. The resident reported hearing staff argue loudly about assignments near the nursing station, including statements that they did not want certain residents, and said the arguing could be heard from her room. Resident #32 also reported waiting approximately 3 to 4 hours for care and had previously filed a grievance about long call light response times. Resident #94 was admitted with diagnoses including Parkinson’s disease and depression, had a BIMS score of 15, and required assistance with oral hygiene, toileting hygiene, bathing, dressing, footwear, and personal hygiene. The resident reported that when she used the call light for assistance, staff sometimes entered the room and yelled at her for using it, and that staff frequently spoke in another language in her room or while on the phone and did not pay attention to her. During the survey, staff were observed speaking loudly to each other in another language in the hallway near resident areas, and the resident’s grievance log also documented concerns about long call light response times.
Unsanitary resident room and bathroom conditions
Penalty
Summary
The facility failed to ensure a clean and sanitary environment on 4 of 6 units, affecting 8 of 32 sampled residents. During the initial pool process, surveyors observed multiple environmental and equipment concerns in resident rooms and bathrooms, including bubbled wall material and a gap between the wall and baseboard in one bathroom, green corrosive-type residue on toilet piping, and white residue on a bathroom door. In another room, the metal base of a bed was corroded with a rust-like surface and the floor beneath it was scarred with the same substance. Surveyors also observed dirty floor fall mats with white spots, gray stains, and smudge marks, along with a brown coffee-like stain on a dresser. Additional observations included a bathroom wall covered with a thin paper-like material that was sparsely screwed into place with gaps, missing baseboards near and behind the toilet and under the sink, and toilet anchors and piping covered with rust-like and green corrosive-type residue. A toilet paper holder was also covered in a corroded rust-like substance. In another room, the over-the-bed table had rubber edging peeled off and hanging to the floor, and the wheelchair armrest covering was peeled in spots. Surveyors further noted dust on the grates of an air conditioning unit, a spackled and unpainted wall area behind a bed, and a missing corner of a ceiling tile in one resident room. The Plant Operations Director agreed with these findings during the survey process.
PRN antihypertensive order not followed for elevated blood pressure readings
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident with hypertension, atrial fibrillation, heart disease, high lipid levels, and a pacemaker. The resident had an order, effective 10/03/25, for Clonidine 0.2 mg twice daily as needed when systolic blood pressure was greater than 160 or diastolic blood pressure was greater than 100, but the record showed multiple elevated blood pressure readings in October, November, and December 2025 without documentation that the ordered PRN Clonidine was administered. The blood pressure readings included 161/99, 164/90, 164/95, 162/90, 163/100, 164/101, 161/97, 161/106, 158/102, 155/102, 155/102, 161/99, and 168/63. During a side-by-side record review and interview on 03/04/26, the RN/Unit Manager stated the resident was on a routine blood pressure medication and that the PRN Clonidine should have been given when the resident's blood pressure was over the physician-ordered parameters. The RN reviewed the readings and agreed with the findings.
Failure to Provide Fluids Within Reach and Assist With Drinking
Penalty
Summary
The facility failed to ensure fluids were available to and provided for two sampled residents who showed signs of or complained of thirst. Resident #2 had severe cognitive impairment with a BIMS score of 5 and required supervision for eating. During an observation, the resident was in bed with a very dry mouth and lips sticking together while speaking, stated in Spanish that she needed water, and had no water within reach. During a later breakfast observation, she was holding a closed screw-top milk container, stated in Spanish that she could not open her milk, and continued trying to open it while staff in the room did not understand her request until a student CNA later opened it after the resident repeated the request in English. Resident #104 also had severe cognitive impairment with a BIMS score of 5 and needed supervision with eating. The care plan directed staff to provide fluids of choice within the diet order, yet an observation found a full cup of water placed out of reach on the over-the-bed table at the foot of the bed. The resident's relative later found milk in the room still cool to touch, unopened, and out of reach, and stated that milk from the previous day had also been found in the room warm and unopened. A CNA stated staff only needed to place food or fluids in front of the resident and was unaware the milk had been out of reach.
Unsanitary Garbage Area
Penalty
Summary
The facility failed to maintain sanitary conditions in the garbage area. During an outside tour, the side of the garbage compactor machine was observed to be filled with random items, including a plastic bin with yellow liquid in the bottom, a red bucket, a broom, an orange towel, a Brillo pad, and other small items. The Certified Dietary Manager stated that these items should not have been there.
Incomplete and inaccurate resident medical records
Penalty
Summary
Complete and accurate medical records were not maintained for 3 of 32 sampled residents. For one resident with severe cognitive impairment and an antipsychotic order for Seroquel, the medical record did not contain a signed consent for the medication. The unit manager confirmed the medication had been started and increased, but could not locate written consent in the record. The DON later provided an email from the resident’s son stating he was aware of and agreed to the Seroquel use, but the signed consent was still absent from the record. For another resident with diagnoses including encephalitis, diabetes, cerebral atherosclerosis, CVA, and hemiplegia, the record contained physician orders for seizure precautions and padded side rails. The resident’s MDS documented severe cognitive impairment. Observations showed the resident in bed with upper side rails in place but no side rail pads observed. Staff confirmed the seizure precaution order and padded side rail order remained active even though the DON stated the resident’s hospital EEG showed no seizure activity and the doctors had decided to discontinue seizure precautions when the resident returned to the facility. The care plan still reflected seizure precautions based on the diagnosis and orders. For a third resident with anemia and shortness of breath, the physician orders included two active PRN orders for albuterol sulfate HFA inhaler, both for shortness of breath. The resident’s MDS showed moderate cognitive impairment. Staff reviewing the EMR confirmed there were duplicate albuterol orders, and the unit manager acknowledged the duplicate order was present in the record. The duplicate PRN medication orders remained active until one was later discontinued.
Failure to Follow EBP and Maintain Sanitary Laundry Conditions
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions (EBP) for Resident #7. The resident was admitted with diagnoses including neurogenic bladder, UTI, right hip fracture, and non-Alzheimer’s dementia, and the MDS documented severe cognitive impairment with dependence on staff for toileting, dressing, and hygiene. Physician orders dated 01/28/26 indicated EBP for the presence of a Foley catheter and a wound, and a later order dated 02/07/26 directed catheter care each shift. The care plan also documented the resident’s Foley catheter and EBP status, and a urine analysis on 03/05/26 showed yeast and bacteria. During observation on 03/04/26, a CNA performed the resident’s hygiene and Foley catheter care without wearing a gown. When asked about EBP, the CNA read the sign at the door and stated that she forgot to put on a gown. During record review and interview on 03/05/26, the DON and Infection Preventionist confirmed the resident had been placed on EBP for a Foley catheter and a wound, but the wound had healed since 01/30/26 while the EBP order related to the wound remained in place. The facility also failed to maintain sanitary conditions in the laundry area and failed to post EBP signage for Resident #95. During the laundry tour, commercial dryers and washing machines were observed with rust-like stains, dried brown and opaque liquid stains, separating panels, residue in crevices, rust-like stains on laundry bins, and dust-covered ceiling vents. For Resident #95, physician orders and the care plan documented EBP related to ESBL in urine, MRSA, VRE, a Foley catheter, and wounds. When the surveyor attempted to enter the room, a PPE kit was on the door but no precaution sign was posted, and the nurse was unsure what precautions were required until reviewing the record and confirming EBP and wound care orders.
Conflicting Arbitration Agreement Rescission Language
Penalty
Summary
The facility failed to ensure resident rights were clearly communicated for 3 of 55 sampled residents when its Voluntary Arbitration Agreement contained conflicting language about the resident’s right to rescind the agreement. The form included a bold, underlined statement above the signature area saying the resident may rescind the agreement within 10 business days of execution, while another sentence in the body of the agreement stated the correct 30-day rescission period. Residents #5, #8, and #71, or their representatives, signed the agreement with the incorrect 10-business-day statement. During interview, the Admission Coordinator initially stated residents or their representatives had 48 hours to change their mind, then corrected herself and said it was 10 business days, pointing to the bolded statement on the form. She later acknowledged that another sentence in the agreement stated the correct 30-day requirement and confirmed the form contained conflicting information. The report states that the incorrect wording may have affected the residents’ right to change their mind about signing the Arbitration Agreement.
Sanitation and Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an initial tour. The mechanical ware washing machine's chlorine concentration was below the required 50 parts per million, and the wash, rinse, and sanitizing cycles did not reach the necessary 120 degrees Fahrenheit. Mold was found in the ice machine basin, and the wall behind the coffee stations was damaged. Residue accumulated on the range and convection oven handles, and a sanitizer bucket was improperly stored over the oven and flat top range. Foam containers and small bowls were not stored properly to prevent contamination, and there was ice accumulation on the walk-in freezer curtains. The exterior of the walk-in cooler and freezer was dirty and rusted, with unsecured floor tiles. Aluminum foil was used inappropriately to line shelving in a food preparation area. During a follow-up visit, further deficiencies were noted. A dietary aide was observed handling lettuce with bare hands, and several staff members were preparing to serve meals without proper beard restraints. A damaged wire whisk handle was found, making it uncleanable. Another dietary aide handled silverware with bare hands, directly contacting food surfaces. Personal items were improperly stored with single-use wares. These observations indicate a failure to adhere to professional standards for food safety and sanitation, as acknowledged by the Certified Dietary Manager.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident #51, who was experiencing severe pain. The resident, who had a history of chronic pain syndrome, osteoarthritis, and anxiety disorder, reported not receiving her prescribed pain medication, Norco, for two days. This led to her seeking emergency care due to unmanaged pain. The facility's policy required a new prescription to be sent to the pharmacy to obtain the medication, but due to the primary physician being on vacation and a prescription error at the hospital, the medication was not available. The resident's pain care plan indicated that medications should be administered as ordered and the medical doctor notified if interventions were unsuccessful. Despite this, the resident's pain was not managed effectively, as evidenced by her complaints of severe pain and the lack of Norco availability. Nursing notes documented the resident's ongoing pain and the inability to obtain a new prescription, which resulted in the resident being sent to the hospital for pain management. Interviews with staff, including an LPN and the Director of Nursing, confirmed the medication was unavailable due to prescription issues. The consultant pharmacist explained that Norco could not be dispensed from the emergency kit without a current prescription. The resident eventually received Norco from the emergency kit after the necessary prescription was obtained, but this was after the resident had already experienced significant pain and required hospital intervention.
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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) |
|---|---|---|---|---|
| Savannas Park Health And Rehabilitation Center | 4.3 mi | ★★★★★ | 0 | 0 |
| Palm Garden Of Port Saint Lucie | 4.5 mi | ★★★★★ | 7 | 0 |
| Tiffany Hall Nursing And Rehab Center | 4.7 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Port Saint Lucie | 5.3 mi | ★★★★★ | 12 | 0 |
| Aviata At Saint Lucie | 6.8 mi | ★★★★★ | 8 | 0 |
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