Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. An
observation of the Reflections Activity and Visiting Room on 02/20/23 at 12:14 PM revealed the room was
also utilized for dining. Five residents were observed sitting at a table for restorative dining, while four other
residents were sitting at additional tables in the same room. Staff A, restorative Certified Nursing Assistant
(CNA), and the Speech Therapist (ST) were in the room assisting residents involved in the restorative
program. During this observation, the five residents at the restorative table were served and assisted first,
beginning around noon. The other four residents were served one at a time, between 12:15 PM and 1:15
PM. As per Staff C, CNA, who was noted bringing in a lunch tray to one of the four non-restorative
residents, the restorative trays were delivered first, and then each unit is served, for those that eat in their
rooms. The CNAs on the floor would bring in the trays for the non-restorative residents, from the food cart
being used to serve residents in their rooms. At 1:15 PM, Resident #204 was taken back to her room and
served lunch, after sitting in the Reflections Activity and Visiting Room for over an hour with no interaction.
At times, Resident #204 was noted with her head down on her crossed arms, on the table.
During an observation on 02/22/23 at 12:20 PM, the two restorative aides, Staff A and Staff B, were noted
assisting four residents at the restorative table. The four restorative residents were well into their lunch, and
a couple of them were nearly finished. Resident #92 was sitting at another table, and he was facing the
restorative table, with Resident #47 at the same table but with her back toward the restorative table.
Resident #92 was noted glancing over at the restorative table several times, and then started to leave the
room. Staff A, restorative aide, told the resident his lunch would be coming shortly, so he needed to wait
there. Resident #58 was also in the same room, but at a different table. At 12:35 PM, Residents #47 and
#92 received their lunches. The residents at the restorative table were essentially finished eating, with two
just finishing their desserts. At 12:39 PM, Resident #58 was served his lunch.
During an interview on 02/22/23 at approximately 1:00 PM, Staff D, Licensed Practical Nurse (LPN) on the
Reflections Unit, was asked why the three non-restorative residents were in that particular dining area. The
LPN stated she was fairly new, only having been there 3 or 4 weeks, and was unsure. The LPN did agree
that all the residents in the room should be provided their meals at the same time.
During an interview on 02/22/23 at 1:07 PM, Staff A, restorative aide, explained all the residents in that
dining area needed some cuing and that they used to send two carts about the same time. Staff A did state
they just recently restarted dining in the dining area, and that different residents come into that room at
times. When asked how long it had been since they started reusing the dining area, Staff A would not say.
(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 6
Event ID:
105579
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
105579
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/23/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Savannas Park Health and Rehabilitation Center
1655 SE Walton Road
Port Saint Lucie, FL 34952
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
During an interview on 02/22/23 at 1:11 PM, the Director of Nursing (DON) explained the non-restorative
residents in that dining included whoever is willing to get out of bed who has had weight loss and or needs
additional oversight. When asked why the residents are not receiving their trays at the same time, the DON
stated the kitchen probably doesn't know who is eating in that dining area.
During an interview on 02/22/23 at 1:23 PM, Resident #47 stated it didn't bother her 'too much' that she
had to wait for her lunch while the other ate. During an attempted interview with Resident #92 at 2:40 PM,
the resident was unable to logically answer any questions or hold a conversation.
Based on observation, interviews and record reviews, the facility failed to ensure staff limited the use of cell
phones while on duty and providing care to 9 of 22 sampled residents (Residents #27, #15, #6, #89, #29,
and #300); staff did not communicate in a foreign language while providing care to 9 of 22 sampled
residents (Residents #27, #15, #6, #89, #29, and #300); and four of 22 sampled residents (Resident #204,
#92, #47, #58) were treated in a dignified manner related to dining in 1 of 3 dining rooms (200 unit).
The findings included:
The facility's policy on Dignity (2001, Revised [DATE]) stated, Each resident shall be cared for in a manner
that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of
self-worth and self-esteem.
The facility's Employee Handbook stated: The use of cellular telephones on [the facility's] premises is
permitted only in your parked car in the parking lot or in the event of an emergency. While on duty, cell
phones may be carried on your person in the off position and used for emergency medical aid only.
Employees may use cell phones or walkie-talkies on the course when necessary to perform their duties but
not for personal reasons. It is expressly prohibited to use your phone or any type of electronic device to
record (audio or video) at any time.
1. On 02/22/23 at 1:35 PM, a meeting was held with 5 alert and oriented members of the Resident Council.
Those members included the Resident #27, Resident #15, and 3 additional members (Residents #6, #89,
#29) that were attending each monthly meeting held on the 1st Wednesday of each month.
During the meeting, Resident #27 and Resident #15 both complained, Staff use their phone while on duty.
We find them hiding in our bathrooms on their phones. They don't respond when we call for assistance
because they are on their phones 24/7. The staff are speaking in a foreign language to each other when
they are providing care. Resident #27 had voiced these same concerns to a 2nd surveyor during Resident
#27's initial interview conducted on 02/20/23 at 4:05 PM.
The 3 additional Resident Council members (Residents #6, #89, and #29) all confirmed the allegations
made by the Resident #27 and #15, stating that they, too, had witnessed staff on their cell phones while
providing care and hiding out in the bathrooms while talking on their phones. They also confirmed that they
have witnessed staff speaking in a foreign language to each other while providing care to residents.
Review of the Grievance Log and Resident Council Minutes for January 2023 does show grievances filed
regarding staff phone use and the use of foreign language by staff. The resolution noted on the grievance
log was, on-going education.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105579
If continuation sheet
Page 2 of 6
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
105579
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/23/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Savannas Park Health and Rehabilitation Center
1655 SE Walton Road
Port Saint Lucie, FL 34952
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
2. On 02/20/23 at 10:43 AM, Resident #300 was interviewed about any concerns he had while living at the
facility. The Resident's Minimum Data Set (MDS) assessment was completed on 01/23/23. The assessment
documented the resident's Brief Interview for Mental Status (BIMS) was a 15 which indicated the resident is
cognitively intact.
During the interview, Resident #300 stated the Certified Nursing Assistants (CNA's) will come into the room
to assist him and they will be talking on their phones during his care. He stated they also speak in a foreign
language to each other while they are in his room, and he does not appreciate it. He stated it has been
discussed at the Resident Council Meetings; however, it continues to happen.
During an interview on 02/23/23 at 11:42 AM with a 2nd surveyor, Resident #300 added to his concerns.
He stated the CNAs talk on their phones, using the ear buds, while they are assisting him with care. The
resident stated the staff also go into his bathroom to talk on their phones. The resident explained that some
are speaking English, but when they are talking in another language on their phones, it makes him feel
uncomfortable, further stating, I don't know if they are laughing about me or something else. Resident #300
stated he was never allowed to talk on the phone when he worked, and they should not be allowed either.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105579
If continuation sheet
Page 3 of 6
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
105579
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/23/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Savannas Park Health and Rehabilitation Center
1655 SE Walton Road
Port Saint Lucie, FL 34952
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 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, record review and policy review, the facility failed to ensure reasonable
accommodation of needs for 2 of 21 sampled residents, as evidenced by: Resident #24 lacked a call bell
system that she could physically utilize to get staff assistance; and Resident #80 lacked an appropriately
sized bed.
Residents Affected - Few
The findings included:
Review of the policy, Equipment - General Use for All Residents, revised August 2026, documented, Our
facility shall provide routine equipment for the general use of the resident population. 3. Request or the
need for special equipment should be referred to the Social Services Department.
1. On 02/22/23 at 8:37 AM, while in a resident room speaking with Resident #75, the roommate on the
other side of a drawn curtain, Resident #24 called out nurse nurse please help me . help me with my elbow.
The surveyor explained she was unable to assist, but asked the resident to push her call bell for assistance.
Resident #24 stated, I can't . it's not here.
Observation revealed the call bell hanging from the bottom of the side rail with the call button nearly on the
floor. Photographic Evidence Obtained. When the call bell was placed in the resident's hands, it was noted
that her fingers were somewhat disfigured (arthritic). Resident #24 attempted to push the call light and
didn't have the strength or ability in her finger to engage the call button. The surveyor engaged the light.
Staff E, Certified Nursing Assistant (CNA) entered the room and said she was going to assist the resident
with breakfast. The CNA was not paying attention to the resident, so the surveyor explained the resident
had a request and needed other assistance.
During an interview on 02/22/23 at 9:02 AM, Staff E confirmed Resident #24 could make her needs known
and does use the call bell and volunteered, but sometimes has difficulty pushing the button. When asked if
the facility uses other types of call bells, like the gray soft one (pneumatic), the CNA was unsure. The CNA
had not told the nurse or a manager that the resident had difficulty with the current call bell, but agreed the
resident had a right to be able to call for assist.
During a supplemental observation on 02/22/23 at 12:15 PM, Resident #24 now had a soft pneumatic type
call button. Staff E was in the room at the time and pointed out the new call button and stated the resident
was able to use that one.
Review of the record verified Resident #24 was alert and oriented with diagnoses to include multiple
contractures of hands and other joints.
2. An observation on 02/21/23 at 2:18 PM revealed Resident #80 as being quite tall and large, lying in a
regular facility bed. During an interview at this time, the resident stated she was able to physically assist by
rolling to one side or the other for personal care, but the bed was quite small. Resident #80 also stated she
was 6' 1 (6 foot, 1 inch), and the bed was too short. An observation at that time revealed her feet were right
at the end of the bed. Resident #80 stated she had asked for a longer bed and was told they didn't have
one.
Review of the record revealed Resident #80 was admitted to the facility on [DATE], and moved to her
current room as of 06/21/22. Further review of the record revealed an admission weight of 272.8 pounds,
and a current weight 341.8 pounds.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105579
If continuation sheet
Page 4 of 6
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
105579
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/23/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Savannas Park Health and Rehabilitation Center
1655 SE Walton Road
Port Saint Lucie, FL 34952
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 0558
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 02/23/23 at 2:44 PM, the Unit Manager was asked about the provision of a larger
bed for Resident #80. The Unit Manager agreed she should have been offered a larger bed. The Director of
Nursing (DON) was nearby and agreed with the need, further stating the resident had gained weight since
her admission. During an interview on 02/23/23 at 3:44 PM, the Unit Manager informed the surveyor the
larger bed had been ordered.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105579
If continuation sheet
Page 5 of 6
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
105579
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/23/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Savannas Park Health and Rehabilitation Center
1655 SE Walton Road
Port Saint Lucie, FL 34952
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 0561
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to and the facility must promote and facilitate resident self-determination through
support of resident choice.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to provide requested beautician services to 1 of
1 sampled resident (Resident #7).
The findings included:
During an interview on 02/20/23 at 10:26 AM, Resident #7 stated she would like a haircut, as she pulled
her long pony-tail up to show the surveyor. When asked if she had requested a haircut with the facility's
beautician, the resident stated she had asked but they say nothing.
Review of the record revealed Resident #7 was admitted to the facility on [DATE], and had transferred to
her current room on 02/22/21. Review of the current Minimum Data Set (MDS) assessment dated [DATE],
documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scale,
indicating she was alert and oriented with minimal confusion. This same MDS documented the resident
needed extensive to total assistance for all Activities of Daily Living (ADLs) except for eating.
During an interview on 02/23/23 at 10:44 AM, the facility beautician stated she works Thursday and Friday
mornings at that facility. When asked about Resident #7, the beautician stated she had gone to her several
times to offer services, and more often than not the resident was in bed and stated, not today . maybe
tomorrow. The beautician explained she had encouraged the resident to have the CNAs (Certified Nursing
Assistants) get her up, but then when she returned to the room, the resident was still in bed. The beautician
stated a list was kept with the receptionist for each week's service. Resident #7 was not on that week's list
for beautician services.
During an interview 02/23/23 at 10:48 AM, the Administrative Assistant / Receptionist explained when the
resident or family requested beauty salon services, she would put the resident's name on the list. The
receptionist provided a binder with previous weeks of beauty salon requests. The receptionist explained the
resident would initial or sign the appointment sheet upon receipt of services. When asked what happened if
a resident did not receive services for some reason, and the receptionist stated the beautician would
normally add the resident to the next week's list.
Review of the appointments revealed the most current appointment was scheduled for 02/09/23 and
02/10/23. Next to this appointment, the resident was in bed and refused. Resident #7 had not been added
to the list for 02/16/23. Further review of the appointments revealed Resident #7 was scheduled on 02/02 02/03/23, 08/30/22, and 08/24 - 08/25/22. All of these dates documented the residents name on the
schedule, but lacked any resident initials, signature, or rationale for the lack of services.
During an interview on 02/23/23 at 1:56 PM, the Reflections Unit Manager stated she was unaware
Resident #7 had been on the appointment schedule, further explaining she did not have a list of the beauty
salon appointment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105579
If continuation sheet
Page 6 of 6
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F561 - Self-determination
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
FAQ · About this visit
Common questions about this visit
What happened during the February 23, 2023 survey of SAVANNAS PARK HEALTH AND REHABILITATION CENTER?
This was a inspection survey of SAVANNAS PARK HEALTH AND REHABILITATION CENTER on February 23, 2023. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SAVANNAS PARK HEALTH AND REHABILITATION CENTER on February 23, 2023?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.