Palm Garden of Port Saint Lucie

In the surveyor’s words

From the most serious findings on record at Palm Garden of Port Saint Lucie, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 22, 2026

  Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses. This had the potential to affect approximately 105 residents who ate food by mouth. The census at the time of survey was 107. The findings included:A tour of the kitchen was conducted with Staff E, the Assistant Director of Culinary Services, on 01/19/26 at 8:55 AM. The following was observed:A 1-gallon bottle of liquid margarine and a small pot of melted liquid margarine was on the counter next to the stove. When the cook, Staff G, was asked what she used this margarine for, she said she added it to oatmeal, grits, and fried eggs. […]

• No harm, potential for more than minimal, patternF563Jan 21, 2022

  Based on observation, interview, record review and policy review, the facility failed to ensure indoor visitation as per resident's choice for 4 of 4 sampled residents, as evidenced by 3 residents who were not receiving Hospice and or palliative services, Residents #16, #148, and #149; and 1 resident who was receiving hospice services, Resident #33. This had the potential to affect any resident in the facility who wished to have visitation with family or friends. The facility census at the time of survey was 83. […]

• No harm, potential for more than minimal, patternF725Jan 21, 2022

  Based on observation, interview, record review, and job description review, the facility failed to ensure there was sufficient nursing staff to provide nursing services to residents on the 100 unit. This failure was evidenced by the failure to ensure there was a nurse for 1 of 4 facility units (100A-unit) on 01/19/22, and as evidenced by staff failure to ensure weekly weights were done for 1 of 3 sampled residents, Resident #11; failed to provide restorative services for 1 of 1 sampled resident, Resident #21; and a sampled resident who voiced concern of lack of staff, Resident #23. The findings included: 1. […]

• No harm, potential for more than minimal, isolatedF561Jan 22, 2026

  Based on record review and interview, the facility failed to ensure showers as per residents' preference for 1 of 6 sampled residents reviewed for choices, Resident #62. The findings included:The findings included:Review of Resident #62 medical records revealed the resident was admitted [DATE] with a diagnosis to include Acquired Absence of Right Leg Above the Knee, Muscle Weakness, Type II Diabetes, History of Falling and Major Depressive Disorder. His quarterly MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview Mental Status) score of 13, indicating intact cognition. Section GG documents he is dependent on staff for showers. Review of his Care Plan documents that his bathing preference is showers and or bed baths. […]

• No harm, potential for more than minimal, isolatedF757Jan 22, 2026

  Based on record review and interview, the facility failed to ensure appropriate behavior monitoring and duration of use for PRN (as needed) psychotropic medications for 1 of 5 sampled residents, Resident #4, who was prescribed PRN clonazepam, an antianxiety medication.The findings included:Review of the record revealed Resident #4 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment documented the resident had a diagnosis of anxiety disorder and was taking an antianxiety medication. Review of the current physician orders documented as of 12/29/25 the use of Clonazepam 0.5 milligrams every 12 hours as needed for anxiety. […]