Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Savannas Park Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to store, prepare, and serve foods in a sanitary manner, with issues including improper hand hygiene, damaged equipment, unsafe food storage temperatures, and inadequate knowledge of safe food reheating practices among staff.
The facility failed to follow the approved menu for 'French Dip on a Roll' by not assembling the sandwich as required and not serving 'au jus' in a souffle cup. This deviation potentially affected 113 residents, including those on a puree diet, indicating a systemic issue in meal preparation and adherence to dietary guidelines.
The facility failed to honor residents' preferences for showers and dining room meals. One resident reported receiving only one shower since admission despite being scheduled for twice-weekly showers, with staff failing to document refusals properly. Additionally, the main dining room was closed on weekends and for breakfast and dinner during the week, forcing residents to eat in their rooms, despite their requests to have the dining room open for all meals.
The facility failed to ensure a safe, clean, and comfortable environment for its residents, with issues such as damaged wheelchairs, peeling paint, a clogged sink, and dirty equipment. The preventive maintenance program for wheelchairs was not effectively implemented, leading to the continued use of damaged equipment.
The facility failed to follow its smoking policy, resulting in residents smoking unsupervised and possessing smoking materials outside the designated area. Staff from various departments were assigned to supervise without prior experience, compromising safety.
The facility failed to provide enteral nutrition as ordered for a resident with severe cognitive impairment and a history of CVA and dysphagia. The resident was observed having breakfast and participating in therapy without the tube feeding being restarted, resulting in a lapse in prescribed nutritional care.
The facility failed to post and update nurse staffing information daily, with outdated information found on two units and the staffing data initially missing from the reception desk. Interviews revealed issues with weekend staff updating the information.
The facility failed to conserve the nutritive value of pureed vegetables by reheating cooked vegetables before pureeing them, contrary to their policy and approved recipe. The Food Service Director acknowledged that this practice would significantly diminish the nutritional value of the vegetables.
A resident with severe cognitive impairment and a pork allergy was served pork despite her dietary orders and religious restrictions. The facility's system failed to document her preferences, leading to the oversight.
The facility failed to provide a resident with the necessary assistive eating devices, despite a physician's order for a lip plate with meals. The resident, who had multiple diagnoses including dysphagia, was observed spilling food due to the lack of the prescribed lip plate. The issue was attributed to the order not being entered into the system, resulting in the tray tickets not reflecting the need for the assistive device.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve foods in a sanitary manner in accordance with professional standards for food safety. During an initial kitchen tour, the Food Service Director (FSD) was observed handling open foods without covering facial hair, and a Dietary Aide was seen changing gloves without performing hand hygiene. Personal drink cups were found on a food preparation table, and knives with damaged handles were stored in the preparation area. In the walk-in freezer, an open case of garlic bread was found on the floor, and ice had accumulated on the ceiling over boxes of food. Additionally, a pan of chicken and vegetable mixture was improperly cooled and stored, with the FSD failing to disinfect the thermometer probe before use. The internal temperature of the food was found to be 58 degrees Fahrenheit, indicating improper cooling from the previous day. During a follow-up tour, containers of yogurt were found at an unsafe temperature of 50 degrees Fahrenheit, stored on top of ice-covered milk, shakes, and juices. In the Transitions Unit pantry, a Certified Nursing Assistant (CNA) was observed reheating quiche for a resident without using a thermometer to ensure safe reheating temperatures. The CNA was unable to demonstrate knowledge of safe food reheating practices, and no thermometer was available for staff use. These observations indicate multiple failures in food safety practices, including improper food handling, storage, and temperature control, posing potential risks to resident health and safety.
Failure to Follow Approved Menu for French Dip on a Roll
Penalty
Summary
The facility failed to follow the approved menu for meals, specifically for the 'French Dip on a Roll' that was to be served for lunch. The approved recipe required the sandwich to be assembled with 2.5 ounces of meat placed between a top and bottom roll, and 1 fluid ounce of 'au jus' to be served in a souffle cup on the side. However, during a follow-up kitchen tour, the Food Service Director was observed placing the sliced meat directly on the plate and pouring 'au jus' onto the meat instead of following the approved recipe. This deviation from the menu was also observed in the satellite kitchen on the Oasis Unit, where the sandwich was assembled differently, and the 'au jus' was not portioned in a souffle cup as required by the recipe. These actions potentially affected 113 residents, including those on a puree diet, out of the 117 residents in the facility. The failure to follow the approved menu and recipe was consistent across both the main kitchen and the satellite kitchen, indicating a systemic issue in meal preparation and adherence to dietary guidelines. The observations were confirmed through interviews and record reviews, highlighting a significant lapse in the facility's compliance with nutritional standards and menu adherence.
Failure to Honor Resident Preferences for Showers and Dining Room Meals
Penalty
Summary
The facility failed to honor the residents' right to self-determination and choice, specifically in providing showers and meal services as per the residents' preferences. Resident #56, who was admitted with a BIMS score indicating intact cognition, reported only receiving one shower since admission despite being scheduled for showers twice a week. The CNA responsible for Resident #56 admitted to not documenting refusals properly, and the Unit Nurse Manager confirmed that if it isn't documented, it wasn't done. The resident expressed dissatisfaction with the shower chair and the staff's reluctance to provide showers, citing staffing issues and the resident's size as reasons for not adhering to the shower schedule. Additionally, the facility failed to provide meal services in the dining room as requested by the residents. Observations revealed that the main dining room was closed on weekends and for breakfast and dinner during the week, forcing residents to eat in their rooms. Resident #78, who is cognitively intact, expressed a desire to have the dining room open for all meals, stating that eating in the room was tiresome. The Dietary Manager and other staff confirmed the dining room's closure due to staffing issues, although the DON mentioned it was more about figuring out who would work there rather than a lack of staff. Interviews with the residents and staff highlighted the residents' dissatisfaction with the current meal arrangements and the lack of communication and proper documentation regarding shower refusals. The Administrator acknowledged the residents' requests but admitted to not making efforts to reopen the dining room recently, citing poor interest in the past. This failure to accommodate residents' preferences for showers and dining room meals constitutes a deficiency in promoting and facilitating resident self-determination and choice.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable homelike environment for its residents. During an initial and secondary tour of the facility, several deficiencies were observed and acknowledged by the Maintenance Director and the Housekeeping Manager. These included damaged and dirty equipment, such as wheelchairs with cracked or torn armrests, and a sit-to-stand lift that was dirty. Additionally, there were issues with the physical environment, such as exposed wiring on a resident's call bell, peeling paint, scuffed doorways, and a clogged sink in one of the bathrooms. The presence of brown splatter on the walls in a hallway further indicated a lack of cleanliness and maintenance in the facility. The facility's preventive maintenance program for wheelchairs, which was supposed to ensure that wheelchairs are maintained in a safe and operable manner, was not effectively implemented. The program required that wheelchairs in need of repair be taken out of service until repairs were completed, but this was not adhered to, as evidenced by the continued use of damaged wheelchairs. The Maintenance Director was responsible for developing and maintaining a schedule of preventive maintenance services, but the observed conditions indicated a failure to follow through on these responsibilities. The deficiencies were documented with photographic evidence, highlighting the extent of the issues present in the facility.
Failure to Ensure Safe Smoking Environment
Penalty
Summary
The facility failed to follow its policies and procedures to ensure a safe smoking environment for residents. Specifically, three residents were observed smoking without supervision on multiple occasions. The facility's smoking policy mandates that all residents who choose to smoke must be supervised, and all smoking materials must be kept in a lock box at the adjacent nurse's station. However, residents were found smoking unsupervised, and some residents had smoking materials in their possession outside the designated smoking area. Resident #60, who was cognitively intact with a BIMS score of 15, was observed smoking without supervision. Similarly, Resident #110, also cognitively intact with a BIMS score of 15, was found smoking unsupervised and admitted to keeping smoking materials in their wheelchair. Resident #112, with a BIMS score of 15, confirmed that staff had recently removed smoking paraphernalia from their room, indicating previous non-compliance with the policy. Staff interviews revealed that the facility had recently liberalized the smoking schedule due to residents' non-compliance with the previous schedule. However, the new schedule was not effectively implemented, as evidenced by the lack of consistent supervision. Staff members from various departments, including dietary and housekeeping, were assigned to supervise the smoking area without prior experience or training, further compromising the safety of the smoking environment.
Failure to Provide Enteral Nutrition as Ordered
Penalty
Summary
The facility failed to provide nutrition via enteral means as ordered by physicians for Resident #108, who had severe cognitive impairment and a history of cerebrovascular accident (CVA) and dysphagia. The resident's dietary orders included a controlled carbohydrate diet and enteral feeding with Glucerna 1.5 at 40 milliliters per hour from 10 AM to 2 PM. However, on the morning of 04/30/24, Resident #108 was observed having breakfast in the Main dining room and later participating in therapy, without the tube feeding being restarted as per the physician's orders. Staff N, an LPN, confirmed during an interview that the tube feeding was not restarted until the next scheduled time at 2:00 PM, despite the resident being disconnected from the feeding tube before the start of Staff N's shift. This lapse in care resulted in the resident not receiving the prescribed enteral nutrition for a significant portion of the day, contrary to the care plan that aimed to ensure the resident's nutritional needs were met through tube feeding.
Failure to Post and Update Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information daily and did not update the nursing staff information, including the names of staff providing care to the residents and the residents' census on two of three units. Upon entering the facility, the survey team could not locate the nurse staffing hours. During a tour, the staffing data was again not found until later in the morning when it was placed on the reception desk in the Main Lobby. Additionally, on the Reflections Unit and the Oasis Unit, the whiteboards listing the names of the nursing staff were outdated by one and two days, respectively. Interviews with the Administrator and a Registered Nurse/Unit Manager revealed that the Unit Managers were responsible for ensuring the staffing information was posted and updated, but there were issues with staff updating the information on weekends.
Failure to Conserve Nutritive Value of Pureed Vegetables
Penalty
Summary
The facility failed to prepare and provide meals in a manner that conserved the nutritive value of pureed vegetables. During an initial kitchen tour, a dietary aide was observed handling containers of sliced carrots and broccoli intended for use in pureed vegetables later in the week. The vegetables, which had already been cooked, would need to be reheated before being pureed and served. The Food Service Director acknowledged that reheating the vegetables would significantly diminish their nutritional value. The facility's policy and approved recipe for pureed vegetables emphasized the importance of conserving maximum nutritive value and specified that leftovers should not be used for pureed food. However, the observed practice of reheating cooked vegetables before pureeing them was inconsistent with these guidelines.
Failure to Accommodate Resident's Religious Dietary Preferences
Penalty
Summary
The facility failed to provide food according to a resident's religious preferences, specifically for a resident with severe cognitive impairment who was allergic to pork. The resident, who had a Controlled Carbohydrate diet with mechanical soft texture, was served pork despite her dietary orders and religious restrictions. During an interview, the resident expressed dissatisfaction with the food, stating that she did not eat pork due to her religion. An observation confirmed that the resident was served ground pork for breakfast, and the tray ticket did not document her preference against pork. Further investigation revealed that the Food Service Director and the Registered Dietitian acknowledged that the resident's allergies and dislikes were not included in the system, which resulted in the omission on the tray ticket. An inspection of the facility's walk-in freezer confirmed that all sausage products served were pork-based. This oversight led to the resident being served food that did not align with her dietary restrictions and religious preferences.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide assistive devices to enable Resident #267 to improve or maintain their ability to eat or drink independently. Resident #267, who was cognitively intact with a BIMS score of 13, had multiple diagnoses including arthritis, malnutrition, and dysphagia. The resident had a physician's order for a No Added Salt (NAS) diet with a regular texture, thin consistency, and a lip plate with meals. However, during observations of lunch and breakfast being served, it was noted that the resident was given meals on a traditional plate without an elevated or extended lip, causing the resident to spill food on themselves. The tray tickets accompanying the meals did not include the order for the lip plate. During an interview with the Food Service Director and the Registered Dietitian, it was revealed that if the order for the lip plate was not entered into the system, it would not appear on the tray ticket. It was also observed that there was a tub with unused lip plates in the main kitchen, indicating that the necessary assistive devices were available but not utilized for Resident #267's meals.
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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.
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Nursing homes near Port Saint Lucie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palm Garden Of Port Saint Lucie | 1.1 mi | — | 0 | 0 |
| Tiffany Hall Nursing And Rehab Center | 1.1 mi | — | 0 | 0 |
| Life Care Center Of Port Saint Lucie | 1.4 mi | — | 15 | 0 |
| Port St Lucie Rehabilitation And Healthcare | 4.3 mi | — | 0 | 0 |
| Waters Edge Health And Rehabilitation | 7.7 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.