Complaint Investigation

Sandgate Gardens Rehab And Nursing Center

November 3, 2025 · Fort Pierce, FL · 703 S 29th St

Citations 1

CMS Rating 2/5

Beds 107

Provider ID 105382

Healthcare Facility

Sandgate Gardens Rehab And Nursing Center

Fort Pierce, FL · View full profile →

Inspection Summary

SANDGATE GARDENS REHAB AND NURSING CENTER in FORT PIERCE, FL — inspection on November 3, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0689

Quality of Life and Care Deficiencies

Potential for More Than Minimal Harm

During an observation on 11/03/25 at 1:50 PM, Resident #1's bed was not observed with bilateral side rails.

During an interview on 11/03/25 at 2:00 PM, the DON and Administrator were made aware of the interventions that were not followed relating to the resident's fall on 10/22/25, to provide 2-people to assist with incontinent which was already care planned as an intervention since 2024; and that the resident had a physician's order for bilateral side rails which the resident didn't have at the time of the fall.

The DON responded, She does? I do realize that there is an issue with doing a thorough investigation.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FORT PIERCE, FL, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SANDGATE GARDENS REHAB AND NURSING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

Sandgate Gardens Rehab And Nursing Center

Inspection Findings

Frequently Asked Questions

More Reports