Sandgate Gardens: Resident Fell Alone During Brief Change - FL
The nursing assistant, identified in the inspection report as Staff A, described what happened when federal inspectors interviewed her during a November 3 complaint inspection. She was on the left side of the bed. She turned the resident, identified as Resident 1, onto her right side. The resident rolled off.
"I was changing her brief, I turned her on her right side and she rolled off of the right side of the bed," Staff A told inspectors. "I was on the left side."
There were no side rails. When inspectors asked about them, Staff A said simply: "She doesn't have side rails."
After the resident hit the floor, Staff A walked to the door and called for a nurse. Two nurses came and together the three of them lifted the resident back into bed. One of the nurses told Staff A that the resident was on hospice and that she needed to call the hospice provider and arrange a hospital transfer.
Staff A told inspectors she was near the end of her overnight shift when it happened. She works 11 p.m. to 7 a.m. She also told them that when she looked the resident over, she didn't see any new injuries. What she did see were injuries from a previous fall: swelling on the right side of the resident's forehead, and a bruised right eye that had turned purple.
The resident was, by Staff A's account, normally calm during care.
When inspectors returned to Resident 1's room that afternoon at 1:50 p.m., the bed still had no bilateral side rails. The physician's order requiring them remained unfilled, nearly two weeks after the fall.
At 2 p.m., inspectors sat down with the Director of Nursing and the facility administrator and laid out what they had found: a resident on hospice, care-planned since 2024 to receive two-person assistance for incontinence care, who had been left with a single aide. A physician's order for side rails that had never been acted on. A fall. An investigation that inspectors described as not thorough.
The Director of Nursing's response, as recorded in the inspection report: "She does? I do realize that there is an issue with doing a thorough investigation."
That response captures something beyond a single missed order. The director of nursing, the person responsible for overseeing the clinical care of every resident in the building, did not know that this resident had a physician's order for bilateral side rails. She learned it from a federal inspector, eleven days after the resident had fallen out of a bed that should have had them.
The care plan requiring two people to assist with incontinence had been in place since 2024. It wasn't a new instruction written in response to a deteriorating condition. It was an existing, documented protection that someone decided, on the morning of October 22, not to follow. Whether that decision was a staffing shortage, a lapse in communication, or something else, the inspection report does not say. What it records is the outcome: one aide, one resident, no rails, and a fall.
Resident 1 was on hospice at the time, meaning she had already been assessed as having a terminal condition. Hospice residents in nursing facilities are among the most physically fragile. They are placed on hospice precisely because their bodies are no longer able to withstand the ordinary demands of illness and treatment. A fall for such a resident is not a minor event.
The inspection was classified as a complaint investigation. The level of harm was recorded as minimal harm or potential for actual harm. The violations fell under F0689, the federal tag covering accident prevention and supervision.
When Staff A looked at Resident 1 after the fall and saw the swollen forehead and the purple eye from a previous incident, she told inspectors those were not new. That accounting, offered almost as reassurance, is its own kind of detail: this was not the first time this resident had been hurt.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sandgate Gardens Rehab and Nursing Center from 2025-11-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
SANDGATE GARDENS REHAB AND NURSING CENTER in FORT PIERCE, FL was cited for violations during a health inspection on November 3, 2025.
She was on the left side of the bed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.