Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Savannas Park Health And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to assess a resident for self-administration of nebulizer meds. A resident with moderate cognitive impairment, COPD, pleural effusion, and acute/chronic respiratory failure said she wanted to give herself her Pulmicort and PRN albuterol nebulizer treatments like she did at home and had asked staff to leave the meds in her room. An LPN confirmed the resident had not been assessed for self-administration at the facility, despite the resident’s repeated requests.
Incorrect Food Allergy Information Remained on Meal Ticket: A resident with anemia repeatedly reported that her meal ticket incorrectly listed shellfish and shrimp allergies even though she did not have them. She said she had tried multiple times to get the information removed, but it remained in the computer system and on the meal ticket, and the RD confirmed the allergies were documented despite the resident stating she loves shrimp and seafood.
A facility failed to provide a safe, clean, comfortable, and homelike environment in multiple resident rooms and with resident wheelchairs. Surveyors observed cracked tile, stained ceilings and walls, damaged baseboards, broken blinds, rust stains, dirty bathroom flooring, and shower chair cushions with dried debris. Several wheelchairs had nonlocking brakes, torn seats, cracked or torn arm rests, and bald, disintegrating tires. The Administrator could not provide a wheelchair maintenance and cleaning policy.
PRN psychotropic orders were not timely addressed for two residents. One resident with anxiety, mood disorder, and moderate cognitive impairment had PRN Lorazepam orders without a stop date or documented physician rationale to extend use, despite a pharmacy recommendation to limit the order unless a clinical rationale and duration were provided. Another resident under hospice had an indefinite PRN Ativan order, and the pharmacy again recommended limiting PRN psychotropic use unless the prescriber documented justification and duration.
A resident with severe incontinence-related skin issues had multiple overlapping topical treatment orders for a painful rash, but staff did not clarify the orders and documented treatments as completed when they had not been provided. Another resident’s IV antibiotic for an infected heel wound was delayed and missed on scheduled doses, while a resident ordered NPO still had oral medication orders. In addition, a resident with a draining skin cancer site had no current wound care in place when the area was observed uncovered, and an LPN-administered BP medication was repeatedly held or given contrary to the physician’s parameters.
A resident with moderate cognitive impairment and a diagnosis of lack of coordination was on a restorative program for bilateral hand splints and ROM. Surveyors observed the resident in bed on multiple occasions with hands folded inward and no splints in place, while the splints were left on the nightstand during one observation. Records showed the splints were documented as applied only a few times, and staff interviews confirmed the resident was supposed to receive splints three times weekly, with no refusal documentation found.
Feeding tubes were not administered as ordered for two residents. One resident with a feeding tube and NPO status received less than the ordered amount of Osmolite because the tube feeding was stopped early on multiple observations. Another resident with dysphagia and a G-tube had Nepro running at a lower rate than ordered, and later the feeding was found stopped with formula still left in the canister. An LPN/Unit Manager said she was unaware of the decreased rate and could not find a reason for it.
Oxygen orders and equipment cleanliness were not maintained for a resident dependent on supplemental O2. The resident’s chart lacked an O2 order with a rate, yet the resident was observed receiving O2 at 4 L via NC instead of the stated 3 L. The O2 filter was dust laden, and the NC/tubing was found on the floor and later still in use with the same dated tubing.
Medication errors exceeded the allowed rate, with missed and mismatched orders affecting two residents. An LPN administered five meds to one resident but did not give ordered Eliquis or Vitamin D, and the medication was not available in the cart or med room. For another resident, an RN gave Oxycodone while the ordered Folic Acid was unavailable, then found a bottle with the wrong dose, and the MAR times for Oxycodone did not match the physician order.
A resident with diabetes and cancer had an A1C blood test ordered, but the result could not be found in the record and there was no documentation that the test was refused. The DON reviewed the chart and lab book and confirmed she could not locate the result.
Infection control standards were not followed for multiple residents with infectious conditions and wound care needs. A resident with loose stools had delayed contact precautions after C-diff was identified, another resident had a delayed stool specimen despite repeated loose/diarrhea stools and an order to rule out C-diff, staff failed to follow contact precautions and hand hygiene during a medication pass for a resident on ESBL precautions, and two staff members provided wound care for a resident with necrotizing fasciitis without wearing gowns despite EBP orders.
The facility failed to store, prepare, and serve foods in a sanitary manner, with issues including improper hand hygiene, damaged equipment, unsafe food storage temperatures, and inadequate knowledge of safe food reheating practices among staff.
The facility failed to follow the approved menu for 'French Dip on a Roll' by not assembling the sandwich as required and not serving 'au jus' in a souffle cup. This deviation potentially affected 113 residents, including those on a puree diet, indicating a systemic issue in meal preparation and adherence to dietary guidelines.
The facility failed to honor residents' preferences for showers and dining room meals. One resident reported receiving only one shower since admission despite being scheduled for twice-weekly showers, with staff failing to document refusals properly. Additionally, the main dining room was closed on weekends and for breakfast and dinner during the week, forcing residents to eat in their rooms, despite their requests to have the dining room open for all meals.
The facility failed to ensure a safe, clean, and comfortable environment for its residents, with issues such as damaged wheelchairs, peeling paint, a clogged sink, and dirty equipment. The preventive maintenance program for wheelchairs was not effectively implemented, leading to the continued use of damaged equipment.
The facility failed to follow its smoking policy, resulting in residents smoking unsupervised and possessing smoking materials outside the designated area. Staff from various departments were assigned to supervise without prior experience, compromising safety.
The facility failed to provide enteral nutrition as ordered for a resident with severe cognitive impairment and a history of CVA and dysphagia. The resident was observed having breakfast and participating in therapy without the tube feeding being restarted, resulting in a lapse in prescribed nutritional care.
The facility failed to post and update nurse staffing information daily, with outdated information found on two units and the staffing data initially missing from the reception desk. Interviews revealed issues with weekend staff updating the information.
The facility failed to conserve the nutritive value of pureed vegetables by reheating cooked vegetables before pureeing them, contrary to their policy and approved recipe. The Food Service Director acknowledged that this practice would significantly diminish the nutritional value of the vegetables.
A resident with severe cognitive impairment and a pork allergy was served pork despite her dietary orders and religious restrictions. The facility's system failed to document her preferences, leading to the oversight.
The facility failed to provide a resident with the necessary assistive eating devices, despite a physician's order for a lip plate with meals. The resident, who had multiple diagnoses including dysphagia, was observed spilling food due to the lack of the prescribed lip plate. The issue was attributed to the order not being entered into the system, resulting in the tray tickets not reflecting the need for the assistive device.
Failure to Assess Self-Administration of Nebulizer Medications
Penalty
Summary
The facility failed to ensure resident rights for 1 of 3 sampled residents by not assessing a resident for self-administration of medications. The resident was admitted with a recent readmission and had a current MDS BIMS score of 12, indicating moderate cognitive impairment. Her diagnoses included pleural effusion, COPD, and acute and chronic respiratory failure with hypoxia. Physician orders included Pulmicort inhalation suspension twice daily via nebulizer for shortness of breath and Albuterol sulfate nebulization solution every 4 hours as needed for shortness of breath. During interviews, the resident stated that she received nebulizer treatments daily and as needed throughout the day and night and wanted to administer them herself as she had done at home. She also stated that she had repeatedly told nursing staff she wanted to give herself the nebulizer treatments and had asked for the medication to be left in her room, but staff told her they were not allowed to leave it there. An LPN stated she knew the resident had self-administered nebulizer treatments at another nursing home, but was not sure whether the resident had been assessed at this facility and then confirmed that the resident had not been assessed to self-administer the nebulizer medications. Record review after the interview showed that a Self-Administration of Medication Evaluation was initiated for the resident.
Incorrect Food Allergy Information Remained on Meal Ticket
Penalty
Summary
The facility failed to respond to a resident's request to remove incorrect food allergy information from the meal ticket, affecting Resident #34. The resident was admitted with a diagnosis of anemia, and her care plan, revised on 07/29/25, identified her as at risk for altered nutrition and lab values. During an interview on 08/25/25, she stated that her meal ticket listed allergies to shellfish and shrimp even though she did not have those allergies, and she said she had repeatedly tried to get the information corrected without success. On 08/27/25, the resident again stated that she did not have shellfish or shrimp allergies and reported that she had been complaining to staff who entered her room about removing the allergy information from the meal ticket. She said she believed dietary staff may have entered another resident's allergy information into her records and expressed frustration that she had missed shrimp salads served at the facility. On 08/28/25, the Registered Dietitian reviewed the computer system and was surprised the allergies were recorded; she confirmed they were on the meal ticket, stated the resident had no shellfish or shrimp allergies, and acknowledged that the allergies had been removed from the meal tracker but remained in the computer system.
Unsafe and Poorly Maintained Resident Rooms and Wheelchairs
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in 3 of 4 units based on observations, record review, and interviews. During a tour with the Maintenance Director and Director of Housekeeping, multiple environmental concerns were observed, including white caulking patches on a wall, cracked bathroom tile, a moved metal bar above a toilet with screw holes and rust stains left unrepaired, dirty bathroom flooring with black stains and black caulking, and door trim that had come off the wall. Additional room observations included water stains on ceiling tiles, broken blinds, wall patches without paint, stains dripping down a wall, torn vinyl baseboard, damaged wall corners, and shower chair cushions with hard dried dark brown material attached. Resident equipment concerns were also observed in several rooms. One resident told the surveyor and Maintenance Director that the left brake on the wheelchair did not lock. Other wheelchairs had torn seats, cracked or torn arm rests, and tires that were bald and disintegrating or rotting away from the wheel. The surveyor requested a policy on wheelchair maintenance and cleaning multiple times, but the Administrator stated he was unable to find one and the surveyor was not provided a policy. The Director of Rehabilitation stated she completed monthly wheelchair audits and showed documentation and a checklist for wheelchair inspection, including brakes, arm rests, seats, cushions, wheels, and alignment.
PRN Psychotropic Orders Lacked Required Duration or Rationale
Penalty
Summary
The facility failed to ensure PRN psychotropic medication orders were addressed in a timely manner for 2 of 7 sampled residents. Resident #96 had a history of anxiety disorder and mood disorder, and the annual comprehensive assessment documented a Brief Interview for Mental Status score of 10, indicating moderate cognitive impairment. The record showed an order for Lorazepam 0.5 mg every four hours as needed for anxiety with no discontinue date or documented physician rationale to extend the order, along with a prior order for Lorazepam 0.5 mg every 8 hours for anxiety. The care plan identified the resident as at risk for complications related to psychotropic drug use, and the consultant pharmacist recommended that PRN psychotropic orders be limited to 14 days unless the prescriber provided a clinical rationale and duration. The APRN responded that the resident was under hospice care, but the medication was not discontinued and no appropriate rationale was documented. Resident #85 was admitted under hospice care and had an order for Ativan 0.5 mg every four hours as needed for anxiety that lacked a duration or stop date, with the order details listing the duration as indefinite. The consultant pharmacist noted that the resident had been on PRN Ativan since the order date and recommended that PRN psychotropic orders be limited to 14 days unless the prescriber deemed continuation appropriate and provided a duration of use. The APRN documented disagreement with the recommendation and stated that the patient was under the care of hospice.
Failure to follow physician orders for treatments, medications, and wound care
Penalty
Summary
The facility failed to ensure timely and appropriate treatment for Resident #8, who was cognitively intact, totally dependent on staff for toileting, and had a care plan addressing incontinence-related skin issues. The resident reported that her butt hurt from lying in urine too long and said she could not sit in her chair for more than a couple of hours without her bottom hurting. During observation, staff noted she was very red during perineal care, and a bright red rash was seen extending from the groin and buttocks down to the mid-thighs. Multiple active physician orders were in place for treatment to the coccyx, buttocks, groin, perineal area, and thighs, including Triad cream, ketoconazole cream, ketoconazole powder, and an external paste, but the orders were not clarified despite overlapping treatments. Staff also signed off treatments as completed even though they stated the treatments had not actually been provided that day. Resident #96 had a wound culture collected for a left heel wound infection, and the culture results were reviewed by facility staff. The physician later ordered Cefepime 2 grams IV every eight hours for the infected wound. The record showed the antibiotic was not started as ordered on multiple occasions, including entries indicating it was not given because vitals were outside parameters even though no such parameters were documented for the antibiotic. The antibiotic was ultimately initiated six days after the wound culture results were received, and another scheduled dose was left blank on the MAR. The DON acknowledged the antibiotic delay during interview. Resident #3 had a feeding tube and was ordered to remain NPO, with the care plan stating the resident was not allowed anything by mouth. Despite this, active physician orders included oral medications such as glycopyrrolate, methenamine hippurate, and PRN Tylenol by mouth. Resident #61 had a draining skin cancer area on the right jaw that was observed uncovered with clear red drainage on the gown and later on a cloth napkin on the chest. Staff stated the resident had previously had wound care to the area but did not have current orders at the time of observation, and the area had been draining for days before staff addressed it. Resident #6 had a hydralazine order with specific hold parameters, but the MAR showed multiple doses were withheld when blood pressure and heart rate were within the ordered parameters and multiple doses were given when the medication should have been held based on the physician’s parameters.
Failure to Apply Ordered Hand Splints
Penalty
Summary
The facility failed to provide care and services to prevent further decrease in range of motion for one resident who was on the restorative nursing program for bilateral hand splints. The resident had a BIMS score of 10, indicating moderate cognitive impairment, and a documented diagnosis of unspecified lack of coordination. The care plan directed restorative nursing to assist with bilateral lower extremity active ROM and bilateral upper extremity passive ROM, then apply splints to both upper extremities to maintain hand ROM. The physician order required bilateral hand splints to be worn up to five hours per day, three times per week. Survey observations on multiple days found the resident lying in bed with hands folded inward and no splints on the hands, while the splints were seen on the nightstand during one observation. Record review showed the splints were documented as applied only on four dates, with no documentation that the resident refused them. Interviews with the restorative RN and a CNA showed the staff understood the resident was on a splint program three times per week and that documentation should be entered in the task record, but the restorative weekly binder did not identify which aides were assigned to residents on restorative. The RN also confirmed there was no refusal documentation in the task record.
Feeding Tubes Not Administered as Ordered
Penalty
Summary
The facility failed to follow physician orders for enteral nutrition for 2 of 2 sampled residents with feeding tubes. A review of the policy on Care and Treatment of Feeding Tubes stated that feeding tubes are to be used according to physician orders, including the type of feeding, volume, duration, administration method, and flush frequency, and that staff are to ensure enteral nutrition is consistent with practitioner orders. Resident #3 had a feeding tube, was documented as nothing by mouth, and had an order for Osmolite 1.5 at 50 mL per hour for 20 hours or until 1000 mL was administered, starting at 2 PM and stopping at 10 AM. Survey observations found the feeding was stopped early on two occasions, with about 300 mL left in the canister on one day and about 150 mL left on another, meaning the resident received about 700 mL and 850 mL instead of the prescribed 1000 mL. Resident #5, who had dysphagia and a G-tube and was also documented as not to eat by mouth, had an order for Nepro at 50 mL per hour for 20 hours or until 1000 mL was administered, starting at 2 PM and stopping at 10 AM. Survey observations found the feeding running at 30 mL per hour and later found the feeding had been stopped with about 100 mL left in the canister. The LPN/Unit Manager stated she had not been aware of the decreased feeding and could not find a reason for it, and agreed with the findings.
Oxygen Orders and Equipment Cleanliness Not Maintained
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for Resident #5, who was admitted with diagnoses including respiratory failure and dependence upon supplemental oxygen. The current MDS documented a BIMS score of 14 and that the resident was receiving supplemental oxygen. However, the current physician orders lacked any order for oxygen administration with an ordered rate, although the care plan stated the resident was dependent upon oxygen and oxygen was to be administered per physician order. An order to clean the oxygen filter every night shift on Sundays was present. Observations showed the resident receiving oxygen via nasal cannula at 4 liters on multiple occasions, while the resident stated she used oxygen at 3 liters via nasal cannula. The oxygen filter was observed to be dust laden. The oxygen tubing and nasal cannula were later observed lying directly on the floor near the head of the bed, and the same tubing was still being used the following day with the date 08/24 and an unidentifiable name on tape. During record review and interview, the Unit Manager identified that an oxygen order for 2 liters per nasal cannula had been entered later, and when shown the observations and photographs of the oxygen set at 4 liters and the tubing on the floor, had no response until asked to have the tubing changed.
Medication Errors and MAR Order Mismatch
Penalty
Summary
Medication errors exceeded the acceptable threshold, with a reported error rate of 14.81% based on 27 opportunities. During a medication pass observation, an LPN prepared and administered five medications to Resident #22, including Acetaminophen 325 mg, Vitamin C 500 mg, Atorvastatin 40 mg, and Methocarbamol 500 mg, but the resident’s physician orders also included Vitamin D 50 mcg in the evening and Eliquis 5 mg twice daily at 9:00 AM and 5:00 PM. When the MAR was reviewed, neither Vitamin D nor Eliquis had been signed off, and the LPN stated she had not administered Eliquis because she did not have it and would need to look for it in the Pyxis. A later review found the Eliquis had last been ordered on 08/12/25, and staff could not locate it in the cart or med room. For Resident #86, an RN prepared and administered Oxycodone 15 mg while stating the resident was supposed to receive Folic Acid but she could not find it. After giving the Oxycodone, she checked the medication room, found a bottle of folic acid, and stated it was not the right dose but that she was going to give it. Review of the physician order showed Oxycodone HCL 15 mg immediate release was ordered three times daily at 6:00 AM, 1:00 PM, and 10:00 PM, but the August 2025 MAR listed administration times of 12:00 AM, 12:00 PM, and 6:00 PM. The DON was informed that the MAR times did not coincide with the physician order, and the prescription on file confirmed the ordered times differed from the MAR schedule.
Ordered A1C Lab Test Not Found in Record
Penalty
Summary
The facility failed to ensure that a laboratory test was completed as ordered for Resident #5. Resident #5 was re-admitted with diagnoses including diabetes and cancer, and the care plan revised on 08/04/25 identified the resident as at risk for nutritional problems due to type 2 diabetes, altered nutrition-related lab values, dysphagia, and dependence on enteral nutrition, with an intervention to review labs as indicated. Physician orders dated 08/22/25 included an A1C blood test, but there was no evidence in the record that the test was completed, no result could be found, and there was no documentation that the test was refused. During interview on 08/28/25, the DON reviewed the records, stated she did not see the result in the computer system, and then confirmed she could not locate the test result in the lab book either.
Infection Control Failures During C-diff Management, Contact Precautions, and EBP
Penalty
Summary
The facility failed to ensure infection control standards for multiple residents with infectious conditions and wound care needs. Resident #33 had frequent loose stools and a stool specimen was collected for C-diff testing, with positive results later reported to the facility; however, contact precautions were not initiated until two days after loose stools were identified. The record also showed the positive result was reviewed by facility staff after it had already been reported. Resident #51 had a physician order to collect a stool sample to rule out C-diff, but the specimen was not collected for 18 days after the order. CNA documentation showed repeated loose or diarrhea stools on multiple shifts over several days, yet the stool specimen was not obtained during those shifts. During interview, the LPN/Unit Manager stated she believed the resident did not have an appropriate specimen and agreed with the findings when informed of the CNA documentation. During a medication pass observation, Resident #51 was on contact precautions for ESBL in the urine, but staff entered the room without hand hygiene, gown, or gloves, placed items directly on the bedside table, used a blood pressure cuff on the resident and then placed it on the medication cart without cleaning it, and another nurse used the same cuff on a different resident without cleaning it. For Resident #129, who had necrotizing fasciitis and a surgical wound on the right calf with EBP ordered and included in the care plan, two staff members provided wound care without wearing gowns while the resident’s door was open.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve foods in a sanitary manner in accordance with professional standards for food safety. During an initial kitchen tour, the Food Service Director (FSD) was observed handling open foods without covering facial hair, and a Dietary Aide was seen changing gloves without performing hand hygiene. Personal drink cups were found on a food preparation table, and knives with damaged handles were stored in the preparation area. In the walk-in freezer, an open case of garlic bread was found on the floor, and ice had accumulated on the ceiling over boxes of food. Additionally, a pan of chicken and vegetable mixture was improperly cooled and stored, with the FSD failing to disinfect the thermometer probe before use. The internal temperature of the food was found to be 58 degrees Fahrenheit, indicating improper cooling from the previous day. During a follow-up tour, containers of yogurt were found at an unsafe temperature of 50 degrees Fahrenheit, stored on top of ice-covered milk, shakes, and juices. In the Transitions Unit pantry, a Certified Nursing Assistant (CNA) was observed reheating quiche for a resident without using a thermometer to ensure safe reheating temperatures. The CNA was unable to demonstrate knowledge of safe food reheating practices, and no thermometer was available for staff use. These observations indicate multiple failures in food safety practices, including improper food handling, storage, and temperature control, posing potential risks to resident health and safety.
Failure to Follow Approved Menu for French Dip on a Roll
Penalty
Summary
The facility failed to follow the approved menu for meals, specifically for the 'French Dip on a Roll' that was to be served for lunch. The approved recipe required the sandwich to be assembled with 2.5 ounces of meat placed between a top and bottom roll, and 1 fluid ounce of 'au jus' to be served in a souffle cup on the side. However, during a follow-up kitchen tour, the Food Service Director was observed placing the sliced meat directly on the plate and pouring 'au jus' onto the meat instead of following the approved recipe. This deviation from the menu was also observed in the satellite kitchen on the Oasis Unit, where the sandwich was assembled differently, and the 'au jus' was not portioned in a souffle cup as required by the recipe. These actions potentially affected 113 residents, including those on a puree diet, out of the 117 residents in the facility. The failure to follow the approved menu and recipe was consistent across both the main kitchen and the satellite kitchen, indicating a systemic issue in meal preparation and adherence to dietary guidelines. The observations were confirmed through interviews and record reviews, highlighting a significant lapse in the facility's compliance with nutritional standards and menu adherence.
Failure to Honor Resident Preferences for Showers and Dining Room Meals
Penalty
Summary
The facility failed to honor the residents' right to self-determination and choice, specifically in providing showers and meal services as per the residents' preferences. Resident #56, who was admitted with a BIMS score indicating intact cognition, reported only receiving one shower since admission despite being scheduled for showers twice a week. The CNA responsible for Resident #56 admitted to not documenting refusals properly, and the Unit Nurse Manager confirmed that if it isn't documented, it wasn't done. The resident expressed dissatisfaction with the shower chair and the staff's reluctance to provide showers, citing staffing issues and the resident's size as reasons for not adhering to the shower schedule. Additionally, the facility failed to provide meal services in the dining room as requested by the residents. Observations revealed that the main dining room was closed on weekends and for breakfast and dinner during the week, forcing residents to eat in their rooms. Resident #78, who is cognitively intact, expressed a desire to have the dining room open for all meals, stating that eating in the room was tiresome. The Dietary Manager and other staff confirmed the dining room's closure due to staffing issues, although the DON mentioned it was more about figuring out who would work there rather than a lack of staff. Interviews with the residents and staff highlighted the residents' dissatisfaction with the current meal arrangements and the lack of communication and proper documentation regarding shower refusals. The Administrator acknowledged the residents' requests but admitted to not making efforts to reopen the dining room recently, citing poor interest in the past. This failure to accommodate residents' preferences for showers and dining room meals constitutes a deficiency in promoting and facilitating resident self-determination and choice.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable homelike environment for its residents. During an initial and secondary tour of the facility, several deficiencies were observed and acknowledged by the Maintenance Director and the Housekeeping Manager. These included damaged and dirty equipment, such as wheelchairs with cracked or torn armrests, and a sit-to-stand lift that was dirty. Additionally, there were issues with the physical environment, such as exposed wiring on a resident's call bell, peeling paint, scuffed doorways, and a clogged sink in one of the bathrooms. The presence of brown splatter on the walls in a hallway further indicated a lack of cleanliness and maintenance in the facility. The facility's preventive maintenance program for wheelchairs, which was supposed to ensure that wheelchairs are maintained in a safe and operable manner, was not effectively implemented. The program required that wheelchairs in need of repair be taken out of service until repairs were completed, but this was not adhered to, as evidenced by the continued use of damaged wheelchairs. The Maintenance Director was responsible for developing and maintaining a schedule of preventive maintenance services, but the observed conditions indicated a failure to follow through on these responsibilities. The deficiencies were documented with photographic evidence, highlighting the extent of the issues present in the facility.
Failure to Ensure Safe Smoking Environment
Penalty
Summary
The facility failed to follow its policies and procedures to ensure a safe smoking environment for residents. Specifically, three residents were observed smoking without supervision on multiple occasions. The facility's smoking policy mandates that all residents who choose to smoke must be supervised, and all smoking materials must be kept in a lock box at the adjacent nurse's station. However, residents were found smoking unsupervised, and some residents had smoking materials in their possession outside the designated smoking area. Resident #60, who was cognitively intact with a BIMS score of 15, was observed smoking without supervision. Similarly, Resident #110, also cognitively intact with a BIMS score of 15, was found smoking unsupervised and admitted to keeping smoking materials in their wheelchair. Resident #112, with a BIMS score of 15, confirmed that staff had recently removed smoking paraphernalia from their room, indicating previous non-compliance with the policy. Staff interviews revealed that the facility had recently liberalized the smoking schedule due to residents' non-compliance with the previous schedule. However, the new schedule was not effectively implemented, as evidenced by the lack of consistent supervision. Staff members from various departments, including dietary and housekeeping, were assigned to supervise the smoking area without prior experience or training, further compromising the safety of the smoking environment.
Failure to Provide Enteral Nutrition as Ordered
Penalty
Summary
The facility failed to provide nutrition via enteral means as ordered by physicians for Resident #108, who had severe cognitive impairment and a history of cerebrovascular accident (CVA) and dysphagia. The resident's dietary orders included a controlled carbohydrate diet and enteral feeding with Glucerna 1.5 at 40 milliliters per hour from 10 AM to 2 PM. However, on the morning of 04/30/24, Resident #108 was observed having breakfast in the Main dining room and later participating in therapy, without the tube feeding being restarted as per the physician's orders. Staff N, an LPN, confirmed during an interview that the tube feeding was not restarted until the next scheduled time at 2:00 PM, despite the resident being disconnected from the feeding tube before the start of Staff N's shift. This lapse in care resulted in the resident not receiving the prescribed enteral nutrition for a significant portion of the day, contrary to the care plan that aimed to ensure the resident's nutritional needs were met through tube feeding.
Failure to Post and Update Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information daily and did not update the nursing staff information, including the names of staff providing care to the residents and the residents' census on two of three units. Upon entering the facility, the survey team could not locate the nurse staffing hours. During a tour, the staffing data was again not found until later in the morning when it was placed on the reception desk in the Main Lobby. Additionally, on the Reflections Unit and the Oasis Unit, the whiteboards listing the names of the nursing staff were outdated by one and two days, respectively. Interviews with the Administrator and a Registered Nurse/Unit Manager revealed that the Unit Managers were responsible for ensuring the staffing information was posted and updated, but there were issues with staff updating the information on weekends.
Failure to Conserve Nutritive Value of Pureed Vegetables
Penalty
Summary
The facility failed to prepare and provide meals in a manner that conserved the nutritive value of pureed vegetables. During an initial kitchen tour, a dietary aide was observed handling containers of sliced carrots and broccoli intended for use in pureed vegetables later in the week. The vegetables, which had already been cooked, would need to be reheated before being pureed and served. The Food Service Director acknowledged that reheating the vegetables would significantly diminish their nutritional value. The facility's policy and approved recipe for pureed vegetables emphasized the importance of conserving maximum nutritive value and specified that leftovers should not be used for pureed food. However, the observed practice of reheating cooked vegetables before pureeing them was inconsistent with these guidelines.
Failure to Accommodate Resident's Religious Dietary Preferences
Penalty
Summary
The facility failed to provide food according to a resident's religious preferences, specifically for a resident with severe cognitive impairment who was allergic to pork. The resident, who had a Controlled Carbohydrate diet with mechanical soft texture, was served pork despite her dietary orders and religious restrictions. During an interview, the resident expressed dissatisfaction with the food, stating that she did not eat pork due to her religion. An observation confirmed that the resident was served ground pork for breakfast, and the tray ticket did not document her preference against pork. Further investigation revealed that the Food Service Director and the Registered Dietitian acknowledged that the resident's allergies and dislikes were not included in the system, which resulted in the omission on the tray ticket. An inspection of the facility's walk-in freezer confirmed that all sausage products served were pork-based. This oversight led to the resident being served food that did not align with her dietary restrictions and religious preferences.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide assistive devices to enable Resident #267 to improve or maintain their ability to eat or drink independently. Resident #267, who was cognitively intact with a BIMS score of 13, had multiple diagnoses including arthritis, malnutrition, and dysphagia. The resident had a physician's order for a No Added Salt (NAS) diet with a regular texture, thin consistency, and a lip plate with meals. However, during observations of lunch and breakfast being served, it was noted that the resident was given meals on a traditional plate without an elevated or extended lip, causing the resident to spill food on themselves. The tray tickets accompanying the meals did not include the order for the lip plate. During an interview with the Food Service Director and the Registered Dietitian, it was revealed that if the order for the lip plate was not entered into the system, it would not appear on the tray ticket. It was also observed that there was a tub with unused lip plates in the main kitchen, indicating that the necessary assistive devices were available but not utilized for Resident #267's meals.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 57 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Palm Garden Of Port Saint Lucie | 1.1 mi | ★★★★★ | 0 | 0 |
| Tiffany Hall Nursing And Rehab Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Port Saint Lucie | 1.4 mi | ★★★★★ | 15 | 0 |
| Port St Lucie Rehabilitation And Healthcare | 4.3 mi | ★★★★★ | 0 | 0 |
| Waters Edge Health And Rehabilitation | 7.7 mi | ★★★★★ | 0 | 0 |
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