Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stuart Rehabilitation And Healthcare during CMS and state inspections, most recent first.
The facility did not submit MDS assessment data to the State within the required timeframe for four residents with various medical conditions, including heart disease and stroke. The MDS coordinator acknowledged the late submissions, attributing them to workload and submission scheduling.
A resident in a LTC facility experienced a deficiency in care due to the staff's failure to monitor and document changes in the resident's condition. Despite the resident showing signs of distress and having a care plan that required monitoring for complications, the staff did not document vital signs or follow up on physician's orders. This led to the resident's condition worsening, resulting in an emergency department visit where severe fecal impaction was identified.
A resident in a long-term care facility experienced changes in condition that were not adequately assessed or documented by the staff. Despite having a care plan in place, the staff failed to monitor vital signs and implement physician's orders, leading to an emergency hospital transfer due to severe fecal impaction and abdominal distension.
The facility failed to implement a baseline care plan within 48 hours of admission for two newly admitted residents. The DON confirmed the absence of these care plans during the surveyor's review of the records.
A resident with intact cognition was not invited to participate in care plan meetings, with the facility instead contacting her son for updates. Interviews revealed that staff assumed the resident would not want to attend, but there was no documentation to support this, and the resident expressed a desire to attend the meetings.
The facility failed to provide proper respiratory care for three residents, including not changing oxygen and nebulizer tubing, not remaining with a resident during nebulizer treatment, not completing post-treatment assessments, and using oxygen without a current physician order.
The facility failed to ensure accurate labeling of medications for two residents, leading to discrepancies in administration times. Medications were given earlier than the prescribed bedtime without updating the labels or using change of order stickers.
The facility failed to document when showers or bed baths were provided for three residents, leading to inconsistencies in care. One resident reported receiving fewer showers than scheduled, another had difficulty standing and was unaware of her shower days, and a third resident was unaware of his shower schedule and reported not receiving showers despite asking for them. The documentation system was found to be incorrect, and shower sheets were shredded after review, resulting in a lack of proper records.
Staff failed to wear PPE during direct care for a resident on Enhanced Barrier Precautions and did not perform hand hygiene between residents during meal service. The CNA did not don a gown while providing care to a resident with an indwelling urinary catheter, and the PCA did not wash hands between assisting multiple residents, increasing the risk of cross-contamination.
The facility failed to complete and transmit MDS death assessments within 14 days for three residents who expired in the facility. The MDS Coordinator acknowledged the oversight during an interview, attributing it to human error.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to submit Minimum Data Set (MDS) assessment data to the State within the required 14-day timeframe for four sampled residents. For one resident with diagnoses including Paroxysmal Atrial Fibrillation, Hemiplegia, and Chronic Obstructive Pulmonary Disease, the annual MDS assessment was completed and submitted on day 15. Another resident with Congestive Heart Failure had a quarterly MDS completed and submitted 17 days after completion. A third resident with a history of cerebral infarction had an entry assessment submitted more than 14 days after the Assessment Reference Date. The fourth resident, diagnosed with Atherosclerotic Heart Disease, had a quarterly MDS submitted 22 days after completion. Interviews with the MDS coordinator confirmed that all four MDS submissions were late. The coordinator explained that although she attempts to submit assessments weekly, workload sometimes causes her to submit every two weeks, resulting in delayed submissions. These findings were based on observation, interview, and record review.
Failure to Monitor Resident's Condition Leads to Deficiency
Penalty
Summary
The facility failed to appropriately assess a resident experiencing changes in condition, leading to a deficiency in providing adequate and appropriate health care. The resident, who had been in long-term care at the facility, was assessed as severely impaired in daily decision-making skills and dependent on staff for activities of daily living. The care plan included monitoring for complications such as changes in mental status, distension, and fecal impaction, but these were not adequately observed or reported. The clinical records revealed that the nursing staff did not document or monitor the resident's vital signs after a certain date, despite the resident exhibiting signs of distress, such as not eating and refusing to get out of bed. The nurse communicated with the physician about the resident's condition, but the physician's orders were not documented in the clinical record, and no further attempts were made to complete the prescribed work or initiate fluids. The resident's condition worsened, leading to an emergency department visit where severe fecal impaction and other complications were identified. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed that there were lapses in documentation and monitoring of the resident's condition. The staff did not re-approach the resident to complete necessary assessments and treatments, and there was no evidence of documented vital signs or attempts to follow up on the physician's orders. This lack of assessment and monitoring contributed to the resident's deteriorating condition and the subsequent deficiency finding.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission of agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The resident (Resident #1) was sent to the hospital for evaluation and treatment. The family declined surgical intervention and the resident was placed on Hospice services. A medication error was completed for the omission of the medication ordered on . The nurse completed an online Medication Error Prevention course on . How will you identify other residents having potential to be affected by the same deficient practice? An audit was completed on to ensure that no other residents had an unidentified change in condition. No other residents were identified. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur? Licensed nursing staff were educated on for the need to complete a Change in Condition Observation in the Electronic Medical Record and to continue monitoring the resident for a minimum of 72 hours which will include vital signs, change in condition progress notes each shift, and notification & updates to the physician and family.
Failure to Monitor and Document Resident's Condition
Penalty
Summary
The facility failed to appropriately assess and monitor a resident experiencing changes in condition, leading to a deficiency in quality of care. The resident, who had been in the facility long-term, was dependent on staff for activities of daily living and had active diagnoses that required careful monitoring. Despite the care plan outlining specific interventions for monitoring complications, the staff did not adequately observe or report the resident's symptoms, such as changes in mental status, abdominal distension, and other signs of obstruction. The clinical records revealed that the nursing staff did not document vital signs or the resident's condition adequately, particularly during a period when the resident exhibited significant changes, such as refusing to eat and remaining in bed. Although the nurse communicated with the physician and received orders for medication, these were not properly documented or followed up in the clinical record. Additionally, there was a lack of documentation regarding the resident's refusal of vital signs and laboratory studies, and no further attempts were made to complete these assessments. The investigation highlighted that the nursing staff failed to assess the resident's condition thoroughly and did not implement the physician's orders effectively. The resident's symptoms, including abdominal distension and fecal impaction, were not adequately addressed, leading to an emergency transfer to the hospital. The facility's documentation was insufficient, and the staff did not re-approach the resident to complete necessary testing and treatment, resulting in a significant oversight in the resident's care.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The resident (Resident #1) was sent to the hospital for evaluation and treatment. The family declined surgical intervention and the resident was placed on Hospice services. A medication error was completed for the omission of the medication ordered on . The nurse completed an online Medication Error Prevention course on . How will you identify other residents having potential to be affected by the same deficient practice? An audit was completed on to ensure that no other residents had an unidentified change in condition. No other residents were identified. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur? Licensed nursing staff were educated on the need to complete a Change in Condition Observation in the Electronic Medical Record and to continue monitoring the resident for a minimum of 72 hours which will include vital signs, change in condition, progress notes each shift, and notification & updates to the physician and family. Nurses have also been educated that they must notify the physician by phone when they initiate a Change in Condition Observation. The Nurses have been re-educated that all physician orders must be entered into the electronic medical record under Orders upon receipt of a new physician's order. How will the corrective action(s) be monitored to ensure the deficient practice will not recur, and what quality assurance program will be put into place? The DON or designee will monitor the Change of Condition Observations initiated by a notification in the Messages tab of the Electronic Medical Record on a daily basis. The DON or designee will schedule a change of condition progress note for every shift for the next 72 hours after the initial Change of Condition Observation has been completed. The DON or designee will audit all Change of Condition Observations twice a week for completion and follow up. Findings will be reported monthly to the QAPI committee for a period of 3 months and or until substantial compliance is achieved.
Failure to Implement Baseline Care Plans
Penalty
Summary
The facility failed to implement a baseline care plan within 48 hours of admission for two newly admitted residents. Resident #71, admitted with diagnoses including Parkinsonism, Obstructive and Reflux Uropathy, Alzheimer's Disease, and Dementia, had no evidence of a Baseline Care Plan in their electronic health record (EHR). Similarly, Resident #202, admitted with diagnoses including Dementia, Frontotemporal Neurocognitive Disorder, and Anxiety, also lacked a Baseline Care Plan in their EHR. The Director of Nursing (DON) confirmed the absence of these care plans during the surveyor's review of the records.
Resident Not Invited to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident was invited to participate in care plan meetings. Resident #61, who has an intact cognition as indicated by a BIMS score of 15, was not aware of her care plan meetings and had only attended one meeting since her admission. The facility's records showed that the resident's son attended the meetings via telephone, but there was no documentation explaining why the resident herself did not attend the meetings on multiple occasions. Interviews with the Director of Social Service and the DON revealed that it was an established practice to call the resident's son for updates, and they assumed the resident would not want to attend the meetings. However, there was no documentation to support that the resident was ever invited or that she declined to attend. When asked, the resident expressed a desire to attend the care plan meetings, contradicting the staff's assumptions.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care and services for three residents. For Resident #36, staff did not store and change oxygen and nebulizer tubing as required, did not remain with the resident during nebulizer treatment, and failed to complete a post-treatment assessment. Observations revealed that the oxygen tubing was not changed weekly as ordered, and the nebulizer mask was soiled and improperly stored. Additionally, the resident's nasal cannula was often misplaced, and no assessments were documented before or after treatments as per policy. For Resident #306, staff did not assess lung sounds before and after administering a nebulizer treatment. During an observation, the resident experienced desaturation after the treatment, and although the staff stayed with the resident until her oxygen levels improved, they failed to listen to her lung sounds post-treatment. The staff later acknowledged that they should have followed the policy, which requires lung sound assessments before and after nebulizer treatments. Resident #9 was found to be using oxygen without a current physician order. The resident had a history of COPD and other significant health issues. Upon review, it was discovered that the oxygen order was discontinued when the resident was sent to the hospital and was not reinstated upon return. The staff used the oxygen as needed without a formal order, and the resident's oxygen saturation was checked only after the surveyor's inquiry, revealing that the resident did not need the oxygen at that time.
Failure to Ensure Accurate Medication Labeling
Penalty
Summary
The facility failed to ensure accurate labeling of medications for two residents, leading to discrepancies in the administration times. For Resident #5, the medication Atorvastatin was originally ordered to be given at bedtime but was administered at 5:00 PM daily in April and May 2024 without updating the medication label or using a change of order sticker. The nursing staff did not discontinue the previous order or send the new order to the pharmacy for the updated administration time. Similarly, for Resident #9, the medication amitriptyline was ordered to be administered at bedtime but was given at 5:00 PM starting from May 11, 2024, without updating the medication label or using a change of order sticker. The Director of Nursing confirmed that the labels indicated bedtime administration, yet the medications were given earlier in the evening. The change was made based on the resident's choice, but the proper procedures for updating the medication labels were not followed.
Failure to Document Showers and Bed Baths
Penalty
Summary
The facility failed to document when showers or bed baths were provided for three sampled residents, which has the potential to affect all residents. Resident #61, who has multiple diagnoses including Type 2 Diabetes Mellitus and Chronic Obstructive Pulmonary Disease, reported not receiving showers as per her schedule. Despite the physician's order for showers three times a week, the resident stated she only received showers once a week and had not communicated this to the staff. The staff was unable to provide evidence of the showers due to being flustered by the state surveyors' presence, and the resident was unsure of when her last shower was. Resident #49, diagnosed with conditions such as Rheumatoid Arthritis and Mild Cognitive Impairment, also reported not receiving showers as scheduled. The resident's physician's order indicated showers three times a week, but the Point Care History showed an outdated schedule. The resident expressed difficulty standing and was unaware of her shower days. During an observation, the resident was found in a hospital gown and had been asking for a shower since the morning. A CNA promised to give her a shower after attending to another resident, which was eventually done. Resident #252, with diagnoses including Cardiomyopathy and Epilepsy, reported not receiving showers despite asking for them. The resident was unaware of his shower schedule, which was three times a week according to the physician's order. A CNA explained that the Point of Care documentation system did not have a section for bed baths, and the DON acknowledged that the documentation was incorrect. The facility's process involved filling out shower sheets, which were reviewed by the nurse and wound care nurse, but these sheets were ultimately shredded, leading to a lack of documentation for bed baths versus showers.
Failure to Follow PPE and Hand Hygiene Protocols
Penalty
Summary
Staff failed to wear Personal Protective Equipment (PPE) during direct care for a resident on Enhanced Barrier Precautions (EBPs). The resident had an indwelling urinary catheter, and the Certified Nursing Assistant (CNA) providing care did not don a gown as required. The CNA was observed assisting the resident with bathing and catheter care without wearing the necessary PPE. When questioned, the CNA did not understand the purpose of EBPs and admitted that the practice was new to her, indicating a lack of proper training or awareness regarding the facility's infection control policies. Additionally, staff failed to perform hand hygiene between residents during meal service on two separate occasions. A Personal Care Assistant (PCA) was observed delivering meal trays and assisting multiple residents without washing hands between tasks. The PCA touched various surfaces and residents' personal items, including beds, pillows, and clothing, without performing hand hygiene. This failure to follow proper hand hygiene protocols during meal service affected multiple residents and increased the risk of cross-contamination and infection spread within the unit.
Failure to Complete and Transmit MDS Death Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) death assessments were completed and transmitted within 14 days after completion for three residents. Record reviews revealed that Resident #27, #37, and #59 were admitted to the facility and subsequently expired there. However, their death/discharge MDS assessments were not completed. The MDS Coordinator acknowledged during an interview that she had missed completing the death assessments for these residents, attributing the oversight to human error.
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Illustrative
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.
Illustrative
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Illustrative
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Nursing homes near Stuart
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Solaris Healthcare Parkway | 0.6 mi | ★★★★★ | 8 | 0 |
| Waters Edge Health And Rehabilitation | 2.5 mi | ★★★★★ | 0 | 0 |
| Palm City Nursing & Rehab Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Seabranch Health And Rehabilitation Center | 4.3 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Port Saint Lucie | 7.1 mi | ★★★★★ | 15 | 0 |
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