Inspection visit
Inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0623
Level of Harm - Potential for
minimal harm
Residents Affected - Many
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, policy review and interview, the facility failed to ensure the ombudsman was notified of
transfers and discharges for 2 of 2 sampled residents reviewed for hospitalization, Residents #54 and #83.
The census at the time of the survey was 112.
The findings included:
A review of the facility policy, titled, Nursing and Transfer and Discharge Notice, effective March 2015, last
revised in July 2021, revealed, in part, The Nursing Center Transfer and Discharge form must be completed
for all center initiated resident transfers / discharges from the center.
The completed Nursing Center Transfer and Discharge Notice form is to be forwarded to the District
Long-Term Care Ombudsman Council.
A review of the Transfer and Discharge Policy and Procedure, effective March 2015, latest revision July
2021, revealed, in part, The Social Service Director/designee will be responsible for forwarding the Notice
of Discharge/Transfer to the District Ombudsman Council.
1. Record review of Resident #54 revealed the resident was admitted to the facility on [DATE]. During the
resident's stay at the facility he was transferred to a higher level of care for health concerns related to
Diabetes on 11/24/22 and 01/11/23. The resident was readmitted both times on 11/26/22 and 01/25/23.
Further review of the record did not reveal written notifications to the resident / family / representative or to
the Long-term Care Ombudsman for either hospital transfer. The resident was admitted to the hospital due
to critical blood glucose levels on both transfers.
On 05/03/23 at 9:55 AM in an interview with the Social Services Director (SSD), it was revealed that they
stopped doing the notifications to the Ombudsman and family for at least a year ago and possibly 2 years
ago. The SSD stated the previous administrator had informed her that it was no longer a requirement, so
she stopped sending the written notices. The SSD was informed that this remains a requirement.
2. Record review of Resident #83's medical record revealed the resident was admitted to the facility on
[DATE]. During the resident's stay in the facility, the resident was transferred to the hospital on [DATE] for
lethargy and altered mental status. The resident was not readmitted . Further review of the record did not
reveal written notifications to the resident / family / representative or to the Long-term Care Ombudsman for
the hospital transfer.
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 11
Event ID:
105600
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
105600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Port Saint Lucie
1751 SE Hillmoor Drive
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record
review for Resident #30 revealed the resident had a diagnosis of a Urinary Tract Infection (UTI) and was
started on antibiotics for the UTI on 04/24/23. Further review of the record did not reveal a care plan
developed or implemented for the UTIs or interventions to attempt to prevent UTIs. A review of the quarterly
Minimum Data Set (MDS) for 04/30/23 did not document that the resident had a UTI within the last 30 days.
Based on record review, the facility failed to implement care plans for pain and urinary tract infection for 2 of
31 sampled residents' care plans reviewed, Residents #30 and #354.
The findings included:
1. Record review for Resident #354 revealed the resident was prescribed Gabapentin Capsule 400
milligrams (mg) give 1 capsule by mouth three times a day for nerve pain on admission to the facility on
[DATE]. On 05/02/23, the physician prescribed Triamcinolone Acetonide Injection Kit 40 mg/milliliter (ml) for
pain to the right shoulder and right knee. Further review of the record did not reveal a care plan developed
or implemented for pain for the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105600
If continuation sheet
Page 2 of 11
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
105600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Port Saint Lucie
1751 SE Hillmoor Drive
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record
review for Resident #30 revealed an order for barrier cream to the back of the right thigh for redness every
day and evening shift and an order for barrier cream to peri area and buttocks during incontinent care every
shift. A subsequent review of the Treatment Administration Record (TAR) revealed documentation that the
barrier cream was applied as ordered.
Residents Affected - Few
Review of the Minimum Data Set (MDS) dated [DATE], a quarterly review, revealed Resident #30 had a
Brief Interview for Mental Status (BIMS) of 15, indicating the resident is cognitively intact.
On 05/01/23 at approximately 9:00 AM, an interview conducted with Resident #30 revealed the resident
had a rash on her 'backside and between her thighs.' The resident stated that 'sometimes they put cream
on and sometimes they don't, and it takes a long time to get changed after going poop or pee.'
Review of the care plans for Resident #30 revealed a care plan for potential for alteration in skin integrity
and included intervention of a pressure reducing mattress (in place), Protective skin care as ordered, and
skin checks as per facility protocol. Review of the weekly skin assessments from 02/01/23 to present
revealed 7 of 13 skin checks were not completed as per facility protocol. These dates were 02/18, 03/04,
03/11, 04/08, 04/15, 04/22, and 04/29/23. The last skin check documented for this resident was on
04/01/23.
On 05/04/23 at 9:10 AM, an interview with the Director of Nursing (DON) stated that this resident refused
her skin checks. The DON could not provide documentation by the nursing staff of the resident refusing the
skin checks that are missing in the record.
Further review of the record did not reveal care plans of the resident refusing care apart from them using
the Hoyer lift, which she stated earlier in the survey that she did not like the staff to get her up with the lift
and elects to remain in bed.
On 05/04/23 at 9:55 AM, an interview with Resident #30 revealed the staff had just come in and asked her
if they could check her skin and she agreed. The resident said she was informed by the nursing staff that
she had no further redness on her backside and that her skin was clear. The surveyor asked the resident if
she had ever refused a skin check where they look over her entire body for any skin concerns. The resident
stated No, I do not refuse any care regarding my health. I just do not like them to use the lift to get me out of
bed, but that when they check her skin, the nurses turn her side to side to look and she is okay with that.
Based on observation, interviews, record review and policy review, the facility failed to do skin assessments
per facility policy for 2 of 4 sampled residents reviewed for skin assessments, Residents #81 and #30.
The finding included:
The facility policy, titled, Skin Care and Wound Management, effective date 10/14 and revision date 07/17,
documented, in part: The weekly skin sweep will be used by the licensed nurse to conduct a skin inspection
at the time of admission, upon hospital return and no less than every 7 days.
1. Record review revealed Resident #81 was admitted to the facility on [DATE], with diagnoses, in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105600
If continuation sheet
Page 3 of 11
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
105600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Port Saint Lucie
1751 SE Hillmoor Drive
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 0684
Level of Harm - Minimal harm
or potential for actual harm
part, of Parkinson's Disease, Adult Failure to Thrive and Major Depressive Disease. The resident has a
Brief Interview for Mental Status (BIMS) score of a 10, indicating moderate impaired cognition.
Review of the record for Resident #81 revealed the last weekly skin inspection was documented as
03/30/23.
Residents Affected - Few
On 05/04/23 at approximately 9:15 AM, an interview was conducted with the Director of Nurses, (DON).
She stated sometimes the resident refuses care. Review of the record contains no documentation of the
resident's refusal of skin assessments.
On 05/04/23 at 9:50 AM, an interview was conducted with Resident #81. It was reviewed with the resident
what a total body skin assessment would involve, to ensure his understanding. The resident was asked if he
has ever refused to allow anyone at the facility to inspect his skin. He stated he has never ever refused a
skin inspection (assessment).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105600
If continuation sheet
Page 4 of 11
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
105600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Port Saint Lucie
1751 SE Hillmoor Drive
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 0692
Provide enough food/fluids to maintain a resident's health.
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 obtain weights per policy for 4 of
7 sampled residents reviewed for nutrition, Residents #94, #352, #353 and #354.
Residents Affected - Few
The findings included:
The facility's policy, titled, Obtaining Weights revised March 2016, revised March 2018, revised September
2018, revealed On Admission, the height and weight of each resident will be obtained by the nursing staff
and entered in POC [plan of care]. Residents will be weighed weekly x two weeks to monitor adequacy of
intake and identify immediate issues with nutrition and hydration.
1. Resident #94 was admitted to the facility on [DATE] post hospitalization. Resident #53 had a Brief
Interview for Mental Status (BIMS) score of 15 per the admission Minimum Data Set (MDS) with an
assessment reference date (ARD) of 03/20/23, indicating the resident was cognitively intact.
Review of the weight tab in the electronic health record (EHR) revealed the first weight recorded was a
hospital weight of 110 pounds (#). The second recorded weight was on 03/19/23 at 110 pounds. The third
recorded weight was on 03/27/23 at 109.2 pounds. The fourth recorded weight was on 04/02/23 at 111.4
pounds. The resident was discharged home on [DATE].
A nutrition note dated 03/14/23 revealed, Therapeutic diet appropriate per dx. [diagnosis] Appetite good,
consuming 76-100% of meals. BMI [basal metabolic index] indicates WNL [within normal limits] for age
utilizing hospital weight, obtain actual weight.
2. Resident #352 was admitted to the facility on [DATE] post hospitalization. On 05/02/23 at 8:26 AM, record
review for Resident #352 revealed the first weight recorded on 04/28/23 was a hospital weight of 240.5
pounds. There were no other weights for Resident #352 in the resident's record.
A nutrition progress note dated 05/01/23 revealed, Appetite good, consuming mainly 76-100% of meals.
BMI indicates obese, class 1, utilizing hospital weight. Weight reduction may be beneficial. Obtain actual
weight.
An interview with Resident #352 on 05/04/23 at 7:30 AM during breakfast revealed he was weighed
yesterday (after surveyor intervention).
3. Record review revealed Resident #353 was admitted to the facility on [DATE] post hospitalization. His
BIMS score per the admission MDS with ARD of 04/30/23 was 13, indicating the resident was cognitively
intact. Record review was conducted on 05/02/23 at 8:53 AM of the weights for Resident #353. The only
weight in the EHR was 186.56 pounds, a hospital weight, dated 04/28/23.
On 04/28/23, a nutritional progress note stated, Appetite fair/good, consuming 51-100% of meals. BMI
indicates overweight utilizing hospital weight. Skin impaired, not pressure related .
4. On 05/02/23 at 9:05 AM, record review for Resident #354 noted the resident was admitted to the facility
post hospitalization on 04/26/23. The resident had a BIMS score of 15, per admission MDS assessment
with an ARD of 05/01/23, indicating she was cognitively intact.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105600
If continuation sheet
Page 5 of 11
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
105600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Port Saint Lucie
1751 SE Hillmoor Drive
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 0692
Review of the weights for the resident revealed she had one weight in the EHR of 129 pounds.
Level of Harm - Minimal harm
or potential for actual harm
A review of the nutritional progress note dated 04/28/23 revealed, BMI indicates underweight. Skin intact.
No labs to evaluate VPS. No edema noted. Will add fortified cereal .
Residents Affected - Few
An interview was conducted on 05/03/23 at 11:35 AM with the facility's dietician who has been working in
the facility for 6 years. She comes to this facility 2 days a week. The dietician stated the Unit Manager (UM)
on the second floor, Staff A, is in charge of giving the Certified Nursing Assistants (CNAs) the weights that
need to be done. She does not know why the weights are not timely per policy. She stated she forwards the
sheet of weights to the Director of Nurses (DON), Executive Director (ED), Unit Managers, Risk Manager,
Therapy department and MDS nurse. She stated within the past year, there has been a change in the way
the weights are taken. They used to have restorative CNAs take the weights, now Staff A is in charge of the
weights.
An interview was conducted with Staff A, UM, on 05/03/23 at 12:07 PM. She stated that she gets the list
from the dietician on Tuesday or Wednesday of the residents that are of concern. For all new admissions,
there is a weekly weight times 3 weeks and if it is stable, it is a monthly weight after that or if not stable,
weekly weights continue.
Staff A further stated the first weekend of the month, they weigh everyone on the first floor. She is not sure
how long that takes because she does not work on the weekend. The second weekend of the month, they
weigh residents on the second floor and anyone that is new downstairs and anyone that they are
concerned with. The list comes back to her, she will put out another list to be done Monday or Tuesday.
Staff A stated residents who are new admissions are sometimes done the next morning, especially when
they come in late in the evening. She continued to state that on the admission paperwork, a weight is
required so the nurses put in the hospital weight so they can close the assessment. The surveyor asked
Staff A why it is taking 5 days to get the actual weight. The UM replied that sometimes the residents refuse.
The DON chooses what CNA will do the weights. There has been a CNA lately that regularly does the
weights with another CNA.
Interview conducted with the DON on 05/03/23 at 12:18 PM, revealed the weights are being done. This
surveyor asked her to produce the weights for the above residents. As of 05/03/23 at 2:54 PM, she had not
provided the weights.
An additional interview was conducted with the dietician on 05/03/23 at 3:34 PM. This surveyor asked her if
there was another place that the weights would be recorded besides the EHR. She stated Staff A keeps
track of the people who are weighed. She stated she had not yet received a list of residents weighed on the
weekend of 04/30/23.
On 05/03/23 at 3:44 PM, an interview with Staff A revealed the weights from 04/30/23 were found in the
dietary box and she does not know who put them there or who they were meant to go to.
Interview with the dietician on 05/03/23 at 3:50 PM revealed she was not aware that she had a box where
weights would be put.
Interview with administrator on 05/03/23 at 3:57 PM revealed she was not aware that weights were being
done on the weekend.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105600
If continuation sheet
Page 6 of 11
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
105600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Port Saint Lucie
1751 SE Hillmoor Drive
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 0692
An interview was conducted with Staff B, CNA, on 05/3/23 at 4:00 PM, who stated she is the one who put
the weight papers in the mailbox because 'they' told her to put them there.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105600
If continuation sheet
Page 7 of 11
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
105600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Port Saint Lucie
1751 SE Hillmoor Drive
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 0697
Provide safe, appropriate pain management for a resident who requires such services.
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 provide pain management for 2
of 2 sampled residents reviewed for pain management, Residents #352 and #354.
Residents Affected - Few
The findings included:
The facility's policy, titled, Pain assessment and management, effective 01/01/20, revealed, in part: If pain
has not been adequately controlled, it may be necessary to reconsider the current approaches and revise
or supplement them as indicated .
1. Resident #352 was admitted to the facility on [DATE] post hospitalization with diagnoses that included
Spinal Stenosis, Low back pain, and unspecified Osteoarthritis. On 05/04/23 at 8:00 AM, at the time of the
record review, the resident did not have a Brief Interview for Mental Status (BIMS) score recorded.
On 05/01/23 at 8:41 AM, the resident was interviewed as part of the initial pool process. The resident stated
he felt he needed a stronger pain medication and is supposed to see a pain doctor. He stated the pain
medication that he receives was helping initially but doesn't last long enough.
On 05/04/23 at 7:30 AM, Resident #352 stated he had a pain level of 8 of 10 (10 being the worse). He did
not think he saw the pain doctor because the doctor he saw said she does not take care of pain
management; and he is still looking for a medication that will help his pain.
On 05/04/23 at 7:35 AM, record review conducted on Resident #352 revealed there were no notes from a
pain specialist. Review of the medications for the resident revealed upon admission, he had orders for
Meloxicam 15 milligrams (mg) daily for arthritis pain, Norco Oral Tablet 10-325 mg 1 tablet every 8 hours as
needed for pain, and Tylenol 325 mg 2 tabs every 4 hours as needed for mild to moderate pain. The record
documented that from 05/02/23-05/04/23, his pain level was between 7-8/10, when the Norco was
administered.
Immediately after doing the record review on 05/04/23 at 7:35 AM, the surveyor spoke with Staff C, Unit
Manager (UM) of the first floor. Staff C stated the resident was seen by a pain doctor on 05/01/23 but she
does not put the notes in their electronic health record (EHR). The surveyor asked for the doctor's notes to
review and asked Staff C if she realized Resident #352 was a pain level of 8 this morning. She responded
that she would speak with the resident now.
On 05/04/23 at 12:15 PM, an additional interview was conducted with Staff C. She stated the physician, a
Physiatrist, face-timed the resident this morning and changed the timing of the Norco to every 6 hours as
needed and added Zohydro which is a long acting pain medication given routinely two times a day. The
physician's notes from a visit on 05/01/23 and 05/04/23 were produced at this time.
2. Resident #354 was admitted to the facility post hospitalization with diagnoses that included Vertigo, Type
2 Diabetes Mellitus with Diabetic Neuropathy and muscle weakness. Resident had a Brief Interview for
mental Status (BIMS) of 15 per admission assessment with an assessment reference date of 05/01/23
indicating the resident was cognitively intact.
The resident had physician ordered: Lidocaine patch for lower back pain, Tylenol 325 mg 2 tablets
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105600
If continuation sheet
Page 8 of 11
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
105600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Port Saint Lucie
1751 SE Hillmoor Drive
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 0697
by mouth for pain three times a day, and Tramadol 50 mg 1 every 8 hours as needed for pain.
Level of Harm - Minimal harm
or potential for actual harm
On 05/01/23 at 11:30 AM, Resident #354 was interviewed during the initial pool process. The resident
stated both of her hips are painful.
Residents Affected - Few
Review of medical record did not reveal any physician visits for pain management.
On 05/04/23 at 7:15 AM, the resident was observed sleeping in bed before the breakfast tray came. At 7:30
AM, observation showed the resident's tray on the bedside table and the resident was awake. Resident
#354 stated she has a lot of pain in her left hip and doesn't know if she can eat. She stated she told her
daughter she had pain. This surveyor asked her if she got anything for pain and she replied that she got
Tylenol.
Review of medical record revealed an order for Oxycodone 2.5 mg dated 05/01/23 and put into the
computer on 05/04/23 at 7:00 AM. Interview with Staff C at this time, regarding why was the order not in the
computer until 05/04/23, revealed she stated the order was missed and she found the order today. Staff C
stated the pain management doctor comes in on Monday and Friday, but she does not put her notes in the
computer since she has her own computer program. The surveyor asked to see the notes for the visit.
On 05/04/23 at 8:52 AM, the surveyor placed a telephone call to the pharmacy regarding the order for
Oxycodone. The pharmacist stated the order, via fax, came in at 8:38 AM this morning (05/04/23) and the
pharmacist called the facility at 8:40 AM to say they will not be filling it due to a codeine allergy.
On 05/04/23 at 9:13 AM, the surveyor placed a telephone call to the resident's daughter asking if she had
notified the facility about her mother's pain. She stated she called this morning at 6:00 AM and spoke to the
nurse and stated her mother had pain in the right knee, right hip, and right shoulder. the daughter stated
her mother had been asking her to call the facility for 2 days but she did not have a chance to call until this
morning. She stated she reminded the nurse to offer her the pain medication because her mother does not
understand what 'prn' (as needed) means even though she is alert. The daughter stated she told
admissions staff that her mother has chronic pain.
On 05/04/23 at 12:15 PM, the surveyor spoke with Staff C. Staff C stated the physician face-timed the
resident this morning and wrote new orders. Review of the physician (Physiatrist) notes revealed on
05/01/23, the physician saw the resident and ordered Oxycodone and Kenalog injections to the right knee
and right shoulder to be given on 05/05/23 for inflammation. The Oxycodone order was discontinued due to
codeine allergy. On the 05/04/23, review of the physician notes revealed the physician reported the
resident's pain level was 9/10 and changed the Tramadol order to 50 mg 2 tablets every 6 hours as needed
for pain.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105600
If continuation sheet
Page 9 of 11
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
105600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Port Saint Lucie
1751 SE Hillmoor Drive
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 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review and policy review, the facility failed to ensure Dialysis communication forms were
completed as per facility policy for 1 of 1 sampled resident, Resident #78, reviewed for dialysis.
Residents Affected - Few
The findings included:
Review of the facility policy, titled, Care of the Resident Receiving Dialysis effective October 2014, revision
date April 2017, revealed in part:
Pre-dialysis care
a. Nurse will complete the top section of the Dialysis Communication Form and sign/date.
b. The dialysis communication form will be sent with the resident to the dialysis clinic.
Post-dialysis care
a. Nurse will evaluate resident's condition upon return from the dialysis clinic.
b. Document evaluation by completing bottom section of the Dialysis Communication form. Sign/date the
form. File the completed form in the resident's medical record.
Review of Resident #78's medical record revealed the resident is scheduled to go out of the facility for
dialysis every Monday, Wednesday, and Friday. Review of the Dialysis Communication forms dating back to
02/24/23 from present revealed 7 of the Dialysis Communication forms were lacking documentation.
They lack of documentation included the following related to Resident #78:
a. 02/24/23: The section labeled PG Center Nurse to complete upon return from dialysis was not filled out
or signed by the receiving nurse as having assessed the resident upon their return. This section included
return time, post weight from dialysis center, blood pressure, pulse, respirations, pain, bruit present, thrill
present, access site/shunt assessment (including bleeding, redness, edema), signature and date.
b. 03/03/24: The section labeled PG Center Nurse to complete upon return from dialysis was not filled out
or signed by the receiving nurse as having assessed the resident upon their return. This section includes
return time, post weight from dialysis center, blood pressure, pulse, respirations, pain, bruit present, thrill
present, access site/shunt assessment (including bleeding, redness, edema), signature and date.
c. 03/13/23: There is no patient identifier on the form.
d. 03/24/23: In the pre-dialysis section, the medications administered, if any, are not documented and it
lackseda signature.
In the section labeled PG Center Nurse to be completed upon return from dialysis, it was not filled
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105600
If continuation sheet
Page 10 of 11
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
105600
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/04/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Palm Garden of Port Saint Lucie
1751 SE Hillmoor Drive
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 0698
Level of Harm - Minimal harm
or potential for actual harm
out or signed by the receiving nurse as having assessed the resident upon their return. This section
included return time, post weight from dialysis center, blood pressure, pulse, respirations, pain, bruit
present (an audible vascular sound associated with turbulent blood flow), thrill present (a vibration felt upon
palpation of a blood vessel caused by blood flowing through the fistula), access site / shunt assessment
(including bleeding, redness, edema), signature and date.
Residents Affected - Few
e. 03/31/23: The post-dialysis assessment is not signed by the nurse that completed the assessment.
f. 04/07/23: The post-dialysis is incomplete. There was no documentation of assessing the dialysis
site/shunt for the presence of bruit and thrill.
g. On 3/31/23, 04/03/23, and 04/07/23, a different form was found in the record and they did not include an
area for the pre-dialysis nurse to sign and date as required by facility policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105600
If continuation sheet
Page 11 of 11
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
8 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.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
FAQ · About this visit
Common questions about this visit
What happened during the May 4, 2023 survey of PALM GARDEN OF PORT SAINT LUCIE?
This was a inspection survey of PALM GARDEN OF PORT SAINT LUCIE on May 4, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PALM GARDEN OF PORT SAINT LUCIE on May 4, 2023?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Inspect, test, and maintain automatic sprinkler systems."
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.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.