Sandgate Gardens Rehab And Nursing Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
(CNA) providing care to Resident #1 on 10/22/25, was asked when the resident fell out of the bed, Staff A stated, Yes, I was changing her brief, I turned her on her right side and she rolled off of the right side of the bed. I was on the left side. When asked were the side rails up, she stated, She doesn't have side rails.
When asked if she was the only one assisting the resident at the time of the fall, she stated, Yes, after the resident fell I went to the door and called the nurse. Me and two nurses assisted her back in bed. The nurse said that the resident was on hospice she needed to call them and then do a follow up and send her out to
the hospital. When asked when the incident happen, she stated, Early in the morning. I was getting ready to go off shift. I work the 11AM to 7AM shift. When asked if she noticed if the resident had any injuries, she stated, No, nothing new. She had injuries from the previous fall, the forehead on the right side was swollen and her right eye was purple. When asked how Resident #1 is normally when providing care, Staff A stated,
She is normally calm. 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.
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SANDGATE GARDENS REHAB AND NURSING CENTER in FORT PIERCE, FL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.