Below 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 Sandgate Gardens Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident with cognitive and physical impairments was not provided with the required two-person assistance or bilateral bedrails during incontinent care, resulting in a fall and minor injury. Documentation of the incident was incomplete, and staff interviews confirmed that established safety interventions were not followed.
The facility did not follow the planned menu for a lunch meal, affecting nearly all residents who eat orally. The kitchen staff substituted shredded cheese for the required cheese sauce and used chopped parsley instead of a parsley sprig for both regular and mechanically altered diets. For the pureed diet, the required cheese sauce and pureed bread were not prepared, and powdered parsley was omitted. Dietary staff confirmed these deviations, citing forgetfulness and resident preferences.
The facility did not ensure that meals for residents on pureed and mechanical soft diets were prepared to the required consistency, serving large pieces of meat and gritty pureed meat instead of the specified textures. Both the cook and CDM confirmed the food was not prepared according to dietary requirements, affecting several residents who rely on these specialized diets.
A resident who preferred watching TV in his room was unable to access several major channels, including CBS, NBC, and ABC, despite the facility's documentation stating these should be available. The resident reported the issue multiple times, but staff did not document or address the concern, and the Maintenance Director was unaware of the problem until informed by a surveyor. This resulted in the resident's choices not being respected.
Comprehensive assessments for four residents were not completed within the required 14-day admission or annual timeframes. One assessment was 15 days late, another was four days late, a third was nine days late, and one had not been completed as of the review. Staff interviews confirmed awareness of the required timelines, but no explanation was provided for the delays.
Quarterly assessments for three residents were not completed within the required timeframes, with several assessments finalized well after the regulatory deadlines. The MDS Coordinator and Regional MDS Director confirmed these delays during the survey.
Surveyors identified inaccurate MDS assessments for four residents, including incorrect coding for dialysis, antipsychotic medication, and hospice services. Documentation and interviews revealed that residents were not receiving the treatments or services recorded in their MDS, and staff acknowledged these discrepancies during record reviews.
A resident with limited English proficiency and moderate cognitive impairment did not receive appropriate communication support, such as interpreter services or alternative communication tools, despite documented needs. Staff failed to recognize the language barrier, resulting in the resident's ongoing pain not being properly assessed or addressed.
Three residents with severe cognitive impairment and ADL self-care deficits did not receive proper nail care, as evidenced by repeated observations of long, dirty, and unkempt fingernails. Staff interviews revealed confusion about who was responsible for nail care, with some CNAs believing they could not cut fingernails and others unsure of the policy, despite facility guidelines requiring such care for dependent residents.
Two residents did not receive appropriate care: one with a surgical wound was not provided with a required offloading device despite documented need and staff awareness, and another received antihypertensive medication outside of physician-ordered blood pressure parameters, as confirmed by the DON.
A resident with a UTI had a lab result indicating resistance to Cipro, but the result was not reviewed or acted upon promptly. Cipro was ordered and administered despite the resistance, and there was no documentation of the UTI or antibiotic use in the progress notes. The resident was later hospitalized for sepsis related to the untreated infection and returned with orders for IV antibiotics.
Multiple residents experienced inadequate pain management due to failures in pain identification, lack of medication availability, unclear medication indications, and inconsistent pain assessments. One resident's pain went untreated due to a language barrier and absence of pain medication orders, while another had interruptions in Oxycodone administration because the facility ran out of medication. A third resident received medication not clearly indicated for migraines, leading to confusion among staff, and a fourth resident did not receive consistent pain assessments before and after PRN pain medication.
The facility did not follow pharmacy recommendations for two residents, including not adhering to a recommended nicotine patch tapering schedule for one resident and failing to document the prescriber's rationale for disagreeing with a pharmacist's recommendation regarding Seroquel for another resident. In both cases, required documentation and communication were lacking.
Medications were found unsecured in two instances: a resident had a cup of pills, including Protonix and Amlodipine, left at their bedside, and a medication cart in Unit B was observed unlocked and unattended on two separate occasions. An LPN confirmed the presence of the pills, and the medication cart was accessible for several minutes without staff supervision.
Surveyors found that the facility did not consistently implement or document Enhanced Barrier Precautions and Contact Precautions for several residents with wounds or MDRO infections. Observations revealed missing PPE, absent precaution signage, and lack of physician orders for required precautions, despite care plans and diagnoses indicating the need for such measures. The Infection Preventionist confirmed these lapses during interviews.
A resident with endocarditis and multiple fractures did not receive IV antibiotics within the facility's required timeframe, as doses were frequently administered several hours late. The resident reported inconsistent timing, and MAR review confirmed repeated late administrations. The DON acknowledged these findings.
A resident with moderate cognitive impairment did not receive the pneumococcal vaccine despite having signed consent, due to conflicting documentation in the medical record and lack of follow-up by the Infection Preventionist to verify vaccination status.
The facility failed to provide timely and appropriate pressure ulcer care for three residents, leading to deficiencies in their treatment and care. A resident with a Stage III pressure ulcer did not receive prescribed wound care for 10 days due to a failure to input orders into the electronic medical record. Another resident did not receive weekly skin assessments, and a third resident had inconsistent documentation of wound care treatments. These issues highlight a pattern of inadequate documentation and follow-through in the facility's wound care practices.
Failure to Provide Required Supervision and Assistive Equipment During Care
Penalty
Summary
A deficiency occurred when a resident with significant cognitive and physical impairments, including hemiplegia, traumatic brain injury, aphasia, and a history of falls, was not provided with adequate supervision and assistive equipment during incontinent care. The resident's care plan and physician orders specified the need for two-person assistance for bed mobility and toileting, as well as the use of bilateral bedrails for safety. However, on the date of the incident, only one staff member assisted the resident, and the bed was not equipped with the required side rails. During care, the resident rolled off the bed and sustained a minor injury, with bleeding noted from the mouth. Documentation related to the incident was incomplete, lacking immediate witness statements and clear identification of the staff involved. Interviews confirmed that the staff member was alone during the incident and that side rails were not in place, contrary to the care plan and physician orders. The Director of Nursing and Administrator were made aware that established interventions for fall prevention and safe care were not followed at the time of the incident.
Failure to Follow Planned Menu for Lunch Meal
Penalty
Summary
The facility failed to follow the planned menu for one of two observed meals, specifically lunch, affecting 96 of 99 residents who consume food orally. Observations revealed that the regular and mechanically altered Philly Beef sandwiches were prepared with shredded cheese instead of the required cheese sauce, and finely chopped parsley was used instead of a parsley sprig. For the pureed diet, the cook did not prepare the required cheese sauce or pureed bread, and powdered parsley was omitted. During interviews, dietary staff acknowledged forgetting to make the pureed bread and stated that the cheese sauce was not prepared because residents did not like the canned version, and no attempt was made to obtain the cheese sauce mix as specified in the menu.
Failure to Provide Properly Prepared Pureed and Mechanical Soft Diets
Penalty
Summary
During a lunch meal observation, the facility failed to provide food in the appropriate form for residents requiring pureed and mechanical soft diets. The main entrée, a Philly Beef Sandwich, was not prepared according to the specified recipes for these diet types. The ground meat for the mechanical soft diet was supposed to be processed to a coarse consistency, but large pieces of meat were observed on the tray line. The pureed meat, intended for residents needing a smooth texture, was not processed to a fine consistency and was found to have a gritty texture upon tasting. Additionally, the sandwiches for both regular and mechanical soft diets were topped with shredded cheese and finely chopped parsley, which was not in accordance with the menu. Interviews with the cook and the Certified Dietary Manager (CDM) confirmed that the meat served did not meet the required consistency for either the mechanical soft or pureed diets. The cook acknowledged preparing the regular meat in a way that was not suitable for the mechanically altered meal, and the CDM agreed that the meat was not coarsely ground as required. Photographic evidence was obtained to support these findings. This deficiency affected multiple residents who required pureed and mechanical soft diets.
Failure to Honor Resident TV Channel Preferences
Penalty
Summary
A resident with a history of anxiety disorder and depression, who was cognitively intact and preferred to spend time reading and watching TV in his room, reported that his choice of television channels was not being honored. The resident expressed frustration that several major channels, including CBS, NBC, ABC, and WTCN, were unavailable on the facility's TV system, despite documentation indicating that 49 channels should be accessible. He specifically mentioned missing a desired program and stated that his concerns had not been addressed by staff, even after multiple complaints. Upon investigation, the Maintenance Director confirmed that the channels in question were not functioning and admitted she was previously unaware of the issue. The process for reporting such concerns required staff to document them in the TELLS system, but this had not occurred, resulting in the resident's ongoing dissatisfaction and lack of access to his preferred television programming. The deficiency was identified through observation, interview, and record review, demonstrating a failure to support and facilitate resident choice as required.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments for residents within the required timeframes as specified by the Resident Assessment Instrument (RAI) guidelines. Specifically, four residents did not have their admission or annual comprehensive assessments completed within 14 days of admission or within the annual timeframe. One resident's assessment was completed 15 days late, another's annual assessment was completed four days late, a third resident's assessment was nine days late, and a fourth resident's assessment had not been completed as of the date of review. During interviews, the MDS Director confirmed the required timeframes for assessment completion, and the Regional MDS Director was unable to provide an explanation for the delays. These findings were based on record review and staff interviews, with no additional information provided regarding the residents' medical histories or conditions at the time of the deficiency.
Failure to Complete Timely Quarterly Resident Assessments
Penalty
Summary
The facility failed to complete quarterly assessments for three residents within the required timeframes as specified by the Resident Assessment Instrument (RAI) guidelines. Record reviews showed that multiple quarterly assessments for these residents were not completed within 92 calendar days after the previous assessment, nor within the 14-day window following the Assessment Reference Date (ARD). Specific instances included assessments for one resident with ARDs on 06/10/24, 09/10/24, and 03/11/25, which were completed significantly later than required. Similar delays were found for two other residents, with assessments completed past the regulatory deadlines. During an interview, both the MDS Coordinator and the Regional MDS Director acknowledged and agreed with these findings. No additional information about the residents' medical history or condition at the time of the deficiency was provided in the report.
Inaccurate MDS Assessments for Dialysis, Medication, and Hospice Coding
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for four residents, resulting in multiple instances of incorrect coding. For one resident, the admission MDS assessment inaccurately documented that the resident was receiving dialysis services, despite no evidence in the physician orders, progress notes, or resident interview to support this. Two other residents had MDS assessments that incorrectly indicated the administration of antipsychotic medications during the look-back period, although medication and treatment administration records did not show any such medications were given. In both cases, MDS coordinators acknowledged the discrepancies during side-by-side record reviews. Additionally, another resident's quarterly MDS assessment failed to indicate that hospice services were being provided, even though physician orders and progress notes confirmed hospice care had been initiated and was ongoing. The MDS coordinators also acknowledged this error during a review. These inaccuracies were identified through record reviews and staff interviews, with documentation and resident statements directly contradicting the information recorded in the MDS assessments.
Failure to Provide Communication Support for Non-English Speaking Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure effective communication with a resident who was unable to speak English. The facility's policy required providing appropriate support and assistance for communication, including the use of qualified interpreters and alternative communication tools for residents with language barriers. Despite documentation in the resident's care plan and admission records indicating a preference for Spanish and a need for an interpreter, staff did not provide these services. The resident, who had a history of COPD, was moderately cognitively impaired and was receiving hemodialysis. She had an active order for pain monitoring and a documented history of a right heel wound. Pain assessments recorded a pain level of zero, but during interviews conducted in Spanish, the resident reported severe, ongoing pain in her right heel and stated that she had repeatedly informed staff about her pain without any action being taken. She also reported that staff did not understand her due to the language barrier and that she was not offered a translator or communication tools, making it difficult to communicate her needs. Staff interviews revealed a lack of awareness regarding the resident's language needs, with both the DON and a CNA incorrectly believing the resident spoke English. No communication tools or language line services were used, despite their availability. The resident's representative also confirmed the absence of Spanish-speaking staff and expressed that having a translator would be beneficial. The facility's failure to provide appropriate communication support resulted in the resident's pain not being properly assessed or addressed.
Failure to Provide Nail Care for Residents Unable to Perform ADLs
Penalty
Summary
The facility failed to provide adequate nail care for three residents who were unable to perform activities of daily living (ADLs) independently, as observed and documented over several days. All three residents were severely cognitively impaired, with conditions such as dysphagia, aphasia, dementia, and senile degeneration of the brain, and had documented ADL self-care deficits in their care plans. Despite these documented needs, repeated observations revealed that each resident consistently had long, dirty, and unkempt fingernails. One resident also had chipped nail polish that was not addressed. Interviews with residents and their representatives indicated that nail care was often neglected unless specifically requested by family members. Staff interviews revealed confusion and inconsistency regarding responsibility for nail care. Certified Nursing Assistants (CNAs) reported being unsure whether they were permitted to cut fingernails, with some believing only a podiatrist could do so, while others stated they were only allowed to clean nails. The Unit Manager and an LPN clarified that CNAs were trained and expected to cut fingernails, with the exception of toenails, but acknowledged the confusion among staff. The facility's policy required appropriate ADL care, including nail care, for residents unable to perform these tasks independently, but this was not consistently implemented for the sampled residents.
Failure to Provide Offloading Device and Adhere to Antihypertensive Parameters
Penalty
Summary
The facility failed to provide appropriate care and services for two residents. For one resident with a surgical wound, documentation indicated the need for offloading the affected area using standard facility practices, such as a foam boot, to minimize pressure. Despite the resident's report of unintentionally rolling onto the wound during sleep and the nurse practitioner's verbal acknowledgment of a solution, no foam boot was provided, and staff were unaware of any such device being ordered or available. Observations confirmed the absence of the offloading device in the resident's room, and the wound care nurse stated that no order for the boot had been entered. For another resident with a history of orthostatic hypotension and multiple falls, the physician's order specified that Midodrine should be held if the resident's blood pressure exceeded 130. However, medication administration records showed that the antihypertensive was given on two occasions when the resident's blood pressure was above the prescribed threshold. The DON confirmed that the medication should have been withheld according to the order.
Failure to Timely Review Lab Results and Administer Appropriate Antibiotic for UTI
Penalty
Summary
A resident was admitted to the facility and had a urine sample collected for urinalysis, which later tested positive for a urinary tract infection (UTI). The urinalysis report, which indicated the presence of bacteria resistant to Cipro, was not signed off as reviewed by staff. Despite the resistance noted in the report, Cipro was ordered and administered to the resident five days after the urinalysis results were available. There was no documentation in the progress notes regarding the UTI diagnosis or the use of Cipro during this period. Subsequently, the resident developed a fever and decreased intake, leading to hospital admission where they were diagnosed with sepsis secondary to the UTI. Upon return to the facility, the resident had a care plan for sepsis with ESBL and E. coli bacteremia and was prescribed intravenous Ertapenem. Interviews with the Unit Manager and DON confirmed the urinalysis was not reviewed in a timely manner and that the antibiotic administered was not appropriate for the identified bacteria.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for four residents, as evidenced by multiple deficiencies in pain identification, medication availability, and assessment practices. One resident with a history of chronic obstructive pulmonary disease, arthritis, and a recent right heel wound reported severe pain for approximately two months, which was not addressed by staff due to a language barrier and lack of pain medication orders. Despite care plan interventions to monitor and manage pain, the resident's complaints were not understood or acted upon, and no pain assessments were conducted by nursing staff. Another resident with a right leg fracture experienced interruptions in pain medication administration due to the facility running out of Oxycodone on multiple occasions. The medication was not available for several scheduled doses, and delays in prescription refills and access to the emergency medication supply were documented. The nurse practitioner and DON were unaware of the medication availability issues until after the fact, and pharmacy communication lapses contributed to the delay in pain management. A third resident with moderate cognitive impairment and a history of neck and shoulder pain was prescribed Tizanidine for neck pain and muscle spasms, but the medication was not clearly indicated for migraine headaches, which the resident also experienced. Staff were unclear about which medication to administer for migraine complaints, leading to confusion and inadequate pain management. Additionally, a fourth resident with multiple fractures and endocarditis did not consistently receive pre- and post-administration pain assessments for PRN Oxycodone, and reported that staff were not always available to provide pain medication as needed. Documentation of pain assessments was lacking, and the resident stated that reassessment of pain after medication administration was rare.
Failure to Ensure Proper Drug Regimen Review and Documentation
Penalty
Summary
The facility failed to ensure appropriate drug regimen reviews for two residents. For one resident, the pharmacy recommended a specific tapering schedule for a nicotine patch, including a six-week period on a 14 mg dose before tapering to 7 mg, with clear stop dates. However, the resident was switched from 14 mg to 7 mg after only five days, rather than the recommended six weeks. The resident was not informed of this change, and the B-Unit Manager confirmed that nurse practitioners entered new orders after pharmacy recommendations, but she did not have access to the recommendations themselves. For another resident, the pharmacist recommended that the prescriber address the ongoing need for Seroquel, as there was no recent documentation of its necessity or the ability to taper the dose. The prescriber disagreed with the recommendation but did not provide a rationale on the Medication Regimen Review (MRR) form or in the medical record. The A-Unit Manager acknowledged that after discussing the case with the prescriber, she failed to document the reason for disagreement on the MRR form, despite signing it after the conversation.
Unsecured Medications and Unattended Medication Cart
Penalty
Summary
Surveyors observed that medications were not properly secured in the facility, resulting in two specific deficiencies. On one occasion, a cup containing two pills—identified as Protonix and Amlodipine—was found at the bedside of a resident, rather than being administered directly or stored securely. The resident had a history of gastroesophageal reflux disease and hypertension, as indicated by the medications present. A Licensed Practical Nurse confirmed the presence and identification of the pills. Additionally, on two separate occasions, a medication cart in Unit B was found unlocked and unattended in a hallway, with the drawers facing outward and accessible. The cart remained unattended for several minutes, and the responsible nurse was not present at the time of observation. These incidents demonstrate a failure to ensure that drugs and biologicals were stored in locked compartments and not left unsecured or accessible to residents.
Failure to Implement and Document Required Infection Control Precautions
Penalty
Summary
The facility failed to follow established infection prevention and control practices for residents requiring Enhanced Barrier Precautions (EBP) and Contact Precautions. For one resident with a wound, there was no EBP signage or Personal Protective Equipment (PPE) available in or outside the room during multiple observations, despite the resident having an active wound infection and orders for wound care. The Infection Preventionist confirmed that EBP orders and PPE should have been in place, but follow-up observations showed continued non-compliance. Additionally, three residents with documented infections requiring Contact Precautions did not have appropriate physician orders in place. One resident with an ESBL-positive wound had a Contact Precaution sign posted but lacked a corresponding order. Two other residents with ESBL E. coli bacteremia and MRSA infections had care plans indicating the need for transmission-based precautions, but no active Contact Precaution orders were found in their records. In one case, only an EBP sign was present when Contact Precautions were required. Interviews with the Infection Preventionist confirmed that the necessary orders and precautions were not implemented as required by facility policy. The deficiencies were identified through record reviews, direct observations, and staff interviews, highlighting lapses in the execution of infection control protocols for residents with wounds and multidrug-resistant organism (MDRO) infections.
Failure to Administer IV Antibiotics Timely
Penalty
Summary
The facility failed to administer intravenous (IV) antibiotics in a timely manner for a resident who was admitted with endocarditis and multiple fractures. According to the facility's policy, medications are to be administered within one hour before or after their prescribed time unless otherwise specified. The resident was prescribed ceftriaxone 2 grams IV every 12 hours for 38 days. Record review showed that the administration times for both morning and evening doses of ceftriaxone frequently fell outside the required one-hour window, with some doses being administered several hours late. The resident, who was cognitively intact, reported that the IV antibiotic was not given consistently every 12 hours and that the timing varied by several hours. Review of the Medication Administration Record (MAR) for the month revealed multiple instances where the 8 AM and 8 PM doses were administered late, sometimes by more than four hours. During an interview, the Director of Nursing acknowledged and agreed with these findings.
Failure to Administer Pneumococcal Vaccine Despite Signed Consent
Penalty
Summary
A deficiency occurred when the facility failed to provide the pneumococcal immunization to a resident who had signed consent for the vaccine. The facility's policy required assessment of vaccination status within five working days of admission and administration of the vaccine within thirty days unless medically contraindicated, already given, or refused. In this case, the resident had a re-entry admission and a documented moderate cognitive impairment, with a BIMS score of 12. The electronic medical record indicated that the resident refused the pneumococcal vaccine, but there was also an uploaded, signed informed consent for the vaccine dated the same day as admission. During interviews, the Infection Preventionist was unable to explain the discrepancy between the documented refusal and the signed consent. The Infection Preventionist later confirmed that the resident still wanted the vaccine but was unable to verify if the vaccine had been administered, citing lack of access to the Florida Shot Finders website. No follow-up was provided to the surveyor regarding the resident's vaccination status, resulting in a failure to ensure the resident received the pneumococcal immunization as per facility policy.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide timely and appropriate pressure ulcer care for three residents, leading to deficiencies in their treatment and care. Resident #1 was admitted with a Stage III pressure ulcer, but did not receive the prescribed wound care until 10 days after admission. The Wound Care Nurse failed to input the physician's orders into the electronic medical record, resulting in a delay in treatment. Additionally, weekly skin assessments were not consistently documented, with only one assessment noted after admission. Resident #2, who had multiple wounds on her left lower extremity, did not receive weekly skin assessments as required. The last documented assessment was on 11/28/24, and subsequent assessments were not completed. An observation revealed multiple bruises and a blood blister on the resident's right arm, which were not addressed in a timely manner. The nurse responsible for the resident confirmed the lack of completed assessments and attributed it to the resident's room location. Resident #3 had physician orders for wound care that were not consistently documented as completed. The Treatment Administration Record (TAR) showed missing initials for several dates, indicating that the prescribed treatments may not have been performed. The Wound Care Nurse admitted to sometimes failing to check the electronic medical record before performing treatments, leading to potential lapses in care. These deficiencies highlight a pattern of inadequate documentation and follow-through in the facility's wound care practices.
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Illustrative
What surveyors actually found near you
We read the 81 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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Nursing homes near Fort Pierce
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vivo Healthcare Fort Pierce | 0 mi | ★★★★★ | 1 | 0 |
| Aviata At Saint Lucie | 1 mi | ★★★★★ | 8 | 0 |
| Port St Lucie Rehabilitation And Healthcare | 6.9 mi | ★★★★★ | 0 | 0 |
| Savannas Park Health And Rehabilitation Center | 10.8 mi | ★★★★★ | 21 | 0 |
| Palm Garden Of Port Saint Lucie | 11.2 mi | ★★★★★ | 0 | 0 |
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