As Indian River Medical Center officials celebrated a unanimous vote to become part of the Cleveland Clinic, Steward Health’s Sebastian River Medical Center has been in the throes of leadership upheaval this month, having to replace a quartet of top executives, endure a nerve-wracking accreditation inspection, and brace itself for the update on last May’s “F” safety grade.

With CEO Kelly Enriquez stepping down unexpectedly, marketing director Donna Jones announced her resignation Oct. 8; she was gone a day-and-a-half later. By then, senior director of operations Matt McGill was also out, apparently with no notice at all.  Another executive, chief of nursing Anna Brooks, had earlier announced she would be retiring in November.

As for that safety report card, the release of the latest Leapfrog Hospital Safety Grades has been delayed until November due to Hurricane Irma. Steward, though, had a chance to preview the grade – and the data that accounted for it – in the weeks before the door slammed behind the departing executives.

On top of all that, there was an unannounced visit from the Joint Commission, a critical hospital accreditation agency. An exhaustive survey of 250 standards wrapped up Sept. 28. The hospital now has 60 days to fix whatever issues the survey found, and complete a plan to resolve them, known as Evidence of Standards Compliance.

Once that’s approved, a decision will be rendered on accreditation. Significant or insignificant, those issues will never be made public.

Neither Steward nor departing executives would comment on the reason for the dismissals of Enriquez and McGill. But the turmoil may trigger some memories, both at Sebastian and Indian River.

Enriquez had been CEO since March 2014, when she stepped in on a moment’s notice – literally – when then-CEO Steve Salyer resigned without notice. Memories of that move are bound to be unpleasant not only for Sebastian but for Indian River Medical Center, which promptly hired Salyer as COO, stepping squarely into a lawsuit.

Enriquez’s replacement at Sebastian River, Kyle Sanders, may be up for the hospital’s latest challenges. Arriving from Jacksonville’s St. Vincent’s Health System, he too has coped with a worst-in-state safety ratings. (Sebastian River’s “F” grade was one of two in Florida.)

In 2014, when Sanders was president of St. Vincent’s Medical Center Southside, that hospital received the highest Medicare penalty in the state for its low scores in patient readmissions within 30 days. The Florida Times-Union quotes Sanders as blaming a joint replacement program that was “growing rapidly” when Medicare began tracking readmissions. He said the rate had “improved as the program matured.”

Sanders also served as system vice president of population health management. Most recently, he was president of St. Vincent’s Health Partners, an accountable care organization, or ACO. That is common ground with Steward executives; before its expansion, Steward Health was known as the largest ACO in New England.

They may also have faith in common, at least historically. St. Vincent’s Healthcare is a subsidiary of Ascension Healthcare, the largest Catholic health system in the world, and the largest nonprofit health system in the nation.

Steward Health had its origins in a small Catholic health system in Massachusetts, Caritas Christi Health System. That system was struggling financially when, in 2010, Steward took over its six hospitals with an investment from the powerful private equity firm Cerberus.

Just seven years later, in May of last year, Steward acquired Sebastian River as part of a bundle of eight hospitals that were part of Community Health Services. Along with Sebastian River and two others in Brevard County, five more CHS hospitals were acquired in Ohio and Pennsylvania. Then, in the same month, Steward swallowed Iasis Healthcare, an operator of 18 hospitals in six states. Overnight, that made Steward the largest private for-profit heath system in the nation.

Capital for that deal came in part from a $1.2 billion investment in 2016 by the healthcare REIT, Medical Properties Trust, in a real estate sale and lease buy-back transaction, plus a $50 million equity investment in Steward.

Since then, Steward has closed one of those acquired CHS hospitals. Northside Regional Hospital in Youngstown, Ohio, shut down in September, leaving 468 people without jobs, according to published reports. Steward cited a 71 percent decline in patient volume over the past decade, while other neighboring hospitals grew.

Youngstown city officials had hoped another health system would take over the Northside hospital, namely Cleveland Clinic. That didn’t happen.