F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
administrative and clinical record review and staff interview, the facility failed to ensure the clinical records
accurately documented physicians orders for residents' treatment and services; and failed to accurately
document the performance and administration of medications, treatment and services. This failure affected
2 of 3 sampled residents' clinical records reviewed, Residents #1 and #4.
The findings included:
1. Review of the clinical record for Resident #1 revealed the resident was admitted to the facility on [DATE]
with diagnoses that included Chronic Systolic Congested Heart Failure and Ischemic Cardiomyopathy.
Further review of the clinical record revealed that the staff failed to consistently document that they
administered the prescribed medication by placing their initials in the appropriate boxes and failed to
ensure they had a physician prescription for administered treatments and transfers as follows:
a. Review of the physician orders revealed that the physician prescribed for the resident to receive:
Digoxin Tablet 250 mcg give 1 tablet by mouth one time a day for heart failure;
Furosemide Tablet 40 mg give 1 tablet by mouth one time daily;
Metopolol Tartrate 25 mg give tablet by mouth one time a day for HTN (Hypertension);
Spironolactone 25 mg one tablet one time a day for diuretic;
Trelegy Elipta Inhalation Aerosol Powder Breath Activated 200-62.5-25 mcg/ACT one puff inhale orally one
time a day for breathing aid;
Topiramate Oral 50 mg give 1 tablet two times a day for Migraine;
Midodrine HCL tablet 5 mg Give 1 tablet by mouth three times daily (1:00 PM);
Potassium Chloride ER Tablet Extended Release 20 Meq Give 1 tablet by mouth three times a day for
hypokalemia;
Combivent Aerosol 18-103 MCG/ACT 2 puffs inhale orally four times a day for shortness of breath.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
105382
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105382
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/31/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sandgate Gardens Rehab and Nursing Center
703 S 29th St
Fort Pierce, FL 34947
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the Medication Administration Record (MAR) revealed the nursing staff failed to document and
placed their initials in the appropriate boxes to indicate they had administered various doses of the above
medications on July 30, 2023 and August 4, 2023.
b. Further review of the clinical record revealed the nurses documented Resident #1 wore oxygen via nasal
cannula, even though oxygen saturations were being monitored for the resident. Despite the nurses'
documentation and interviews during the survey that the resident was using oxygen via nasal cannula,
there was no physician's prescription / order prescribing the oxygen.
An interview conducted on 08/31/23 beginning at 11:50 AM with Staff A, Registered Nurse, revealed the
resident wore oxygen via nasal cannula continuously but would frequently remove his oxygen. The resident
would then become short of breath. Even though the nurses were aware of the resident wearing oxygen
and the challenges associated with the resident's failure to continuously use the oxygen, the nurses did not
obtain a physician order or prescription for the oxygen.
The record documented Resident #1 was transferred to the hospital on [DATE]. The clinical record failed to
provide documentation of physician prescribing / ordering for the resident to be transferred to the hospital.
2. Review of the clinical record for Resident #4 revealed the resident was originally admitted to the facility
on [DATE] and had a recent readmission date of 07/03/23. The resident had diagnoses that included
Chronic Obstructive Pulmonary Disease, Unspecified sequelae of Cerebral Infarction, Pneumonia,
unspecified organism, and Chronic Kidney Disease.
Observation of the resident on 08/28/23 at approximately 2:30 PM revealed the resident was wearing
oxygen. Further review of Resident #4 clinical record failed to provide evidence of the resident having a
physician order or prescription prescribing for the resident to receive oxygen.
An interview was conducted with the Director of Nursing on 08/30/23 in the afternoon, who stated they
would complete a search to ensure that all residents on oxygen have a corresponding order.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105382
If continuation sheet
Page 2 of 2
