Lehigh Acres Healthcare & Rehab Center

Location & what’s nearby

Open in Google Maps ↗ · Directions ↗ · Larger map ↗

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

63.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 199 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 58.9% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 168 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 128 beds and averages 122.0 residents a day — about 95% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.50 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.53 hrs/resident/day on weekends vs 4.30 on weekdays — 18% thinner on weekends. RN hours go from 0.76 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 16 most serious are shown; the remaining 13 are one tap away and print in full.

• Immediate jeopardy · Kcited before2025-06-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review, residents and staff interviews, the facility failed to implement ongoing training, competencies and supervision of staff to ensure the safe use of manual and mechanical lifts to prevent avoidable accidents for 1 (Resident #48) of 29 residents care planned for manual or mechanical lift transfer. Resident #48's diagnoses included obesity, history of multiple strokes and functional limitation in range of motion of upper and lower extremities on one side. On 5/2/25 the nurse on duty documented the resident was crying and in a lot of pain. Her ankle was swollen with purple bruising. Resident #48 reported she sustained the injury to her foot the previous night when the lift was used wrong. Resident #48 was diagnosed with a fracture of the left heel bone. The facility had no documentation staff using manual and mechanical lifts to transfer Residents were trained and competent to safely use the lifts. This lack of knowledge and ability placed all 29 residents care planned for manual and mechanical lift transfers at a likelihood of serious harm, and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-06-21 · tag F0726 — failed to have competent, trained nursing staff — pattern
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record reviews, residents and staff interviews, the facility failed to ensure nursing staff had the appropriate training and competencies to prevent avoidable accidents during residents' transfer with manual and/or mechanical lifts for 1 (Resident #48) of 29 residents care planned for transfers with manual or mechanical lifts. Resident #48 diagnoses included a history of multiple strokes, obesity and unilateral functional limitation in range of motion of upper and lower extremities. Resident #48 was care planned for the use of a (brand name) manual sit-to-stand lift for transfers. On 5/2/25 the nurse on duty documented the resident was crying and in a lot of pain. Her ankle was swollen with purple bruising. Resident #48 reported she sustained the injury to her foot the previous night when the lift was used wrong. On 5/3/25, Resident #48 was diagnosed with a fracture of the left heel bone. Resident #48 suffered serious injury from the improper use of the manual sit-to-stand lift. The facility had no documentation staff using manual and mechanical lifts to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2025-06-21 · tag F0835 — failed to run the facility competently — pattern
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review, residents and staff interviews, the facility's Administration failed to utilize its resources effectively to maintain oversight and ensure staff were trained and competent in the safe use of manual and mechanical lifts to transfer residents and appropriately respond to residents' incidents for 1 (Resident #48) of 29 residents care planned for manual or mechanical lifts for transfers. Resident #48 diagnoses included a history of multiple strokes, obesity and unilateral functional limitation in range of motion of upper and lower extremities. Resident #48 was care planned for the use of a manual sit-to-stand lift for transfers. On 5/2/25 the nurse on duty documented the resident was crying and in a lot of pain. Her ankle was swollen with purple bruising. Resident #48 reported she sustained the injury to her foot the previous night when the lift was used wrong. On 5/3/25, Resident #48 was diagnosed with a fracture of the left heel bone. Resident #48 suffered serious injury from the improper use of the manual sit-to-stand lift. The facility…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-08-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policies and procedures, resident representative and staff interviews, the facility failed to protect the residents' right to be free from neglect. The facility failed to re-evaluate the risk for elopement and implement adequate supervision to prevent unsafe wandering and elopement for 1 (Resident #1) of 3 sampled residents reviewed with severe cognitive impairment, confusion, and decreased safety awareness. Resident #1 was a vulnerable adult admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, cognitive communication deficit, and generalized muscle weakness. On 8/16/24, documentation in the nursing progress notes indicated Resident #1 was confused, wandering and said he wanted to go down the street to his house. The facility neglected to re-evaluate the risk for elopement and adequately supervise Resident #1. On 8/16/24 at approximately 7:30 p.m., Resident #1 was sitting in the front lobby with a bag of clothes on his shoulder. The…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-08-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility's policies and procedures, resident representative and staff interviews the facility failed to recognize risk factors for elopement and adequately supervise 1 (Resident #1) of 3 sampled residents with severe cognitive impairment, confusion, wandering behavior and poor safety awareness who expressed desire to leave the facility. On 8/16/24 at approximately 7:30 p.m., Resident #1 who was confused, wandered, and voiced desire to leave the facility sat in the front lobby with a bag of clothes. The receptionist unlocked the door to the front lobby and allowed the resident to leave the facility without verifying his identity. The facility staff were not aware of the resident's exit until 8/16/24 at approximately 8:45 p.m. Resident #1 walked approximately 75 feet to a busy six lane road, got on a bus to Fort [NAME] located approximately 16 miles from the facility. Resident #1 was at a bar, complained of chest pain and was transported to a local emergency room via…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-08-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, review of facility's policy and procedure, staff and resident interview the facility failed to follow safety precautions during transportation to doctor's appointments to prevent avoidable accident and injury to 1 (Resident #900) of 2 residents reviewed. The findings included:Review of the facility's policy and procedure for Securing Residents in Wheelchairs for Van Transport (no effective date) revealed, It is the policy of this facility to ensure the safe and secure transport of all residents traveling in wheelchairs. All residents must be properly secured suing approved wheelchair tie-downs in compliance with Americans with Disabilities Act (ADA) and National Highway Traffic Safety Administration (NHTSA) guidelines. Staff must follow the outlined procedures at all times to prevent accidents or injuries. Securing the wheelchair. Attach two front tie-downs to solid frame points on the wheelchair (not on the footrests or detachable parts). Attach two rear tie-downs to the rear frame of the wheelchair. Tighten all straps to remove slack and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-06-21 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  On 6/17/25 at 10:15 a.m., the Wound Care Nurse was observed cleaning Resident #60's open areas to the buttocks and sacrum. The Wound Care Nurse donned gloves and filled a wash basin with tap water. He added soap to the water from the wall mounted soap dispenser in the resident's shower. The Wound Care Nurse used a washcloth and the soapy water in the wash basin to clean the resident's open areas to the buttocks and sacrum. The Wound Care Nurse took the wash basin to the shared bathroom and rinsed it in the sink. He placed the wet, uncovered wash basin on the grab bar of the shared shower to dry. An uncovered, unlabeled urinal was observed hanging from the grab bar behind the toilet. On 6/17/25 at 10:40 a.m., the DON verified the observation of the unlabeled and uncovered wash basin stored on the grab bar of the shared shower and the uncovered, unlabeled urinal stored on the grab bar behind the shared toilet. The DON said the improper storage of the washbasin and urinal were an infection control concern. Based on observation and resident and staff interviews, the facility failed to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure 2 (Residents #111 and #62) of 3 dependent residents reviewed for Activities of Daily Living received the necessary assistance for shaving per their preferences. The findings included: Review of the facility policy for Shaving the Resident revised February 2018, revealed the purpose of the procedure was to promote cleanliness and provide skin care. The following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure. 4. Any problems or complaints made by the resident related to the procedure. 5. If the resident refused the treatment, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the procedure. 2. Report other information…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-06-21 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review, resident and staff interviews, the facility failed to provide care and services to prevent the development and worsening of a pressure ulcer for 1 (Resident #60) of 2 residents reviewed who developed a pressure ulcer at the facility. The findings included: On 6/15/25 at 10:45 a.m., Resident #60 was observed in bed. Resident #60 was able to answer interview questions. Resident #60 said he uses a lift for transfers but they do not always have the staff to get him out of bed. He said he had a wound on his buttocks and the Certified Nursing Assistants (CNAs) did not apply the ordered Zinc Oxide to his buttocks. Review of the clinical record for Resident #60 revealed an admission date of 3/8/24. Diagnoses included Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, moderate protein calorie malnutrition, muscle weakness and peripheral vascular disease. Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 5/8/25 revealed Resident #60 scored 15 on the Brief Interview for Mental Status, indicating the resident's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review and interview, the facility failed to ensure 1 (Resident #76) of 3 residents reviewed for nutrition and weight loss received the prescribed diet for 2 of 3 meals observed, failed to ensure accurate documentation of resident's risk factors and interventions to prevent weight loss, and failed to ensure timely coordination when the resident experienced difficulty with chewing and swallowing food. The findings included: Review of the clinical record for Resident #76 revealed an admission date of 2/26/25. Diagnoses included Parkinson's disease, anemia, unspecified protein calorie malnutrition, muscle weakness and need for assistance with personal care. Review of the admission Minimum Data Set (MDS) assessment with a target date of 3/2/25 revealed Resident #76 required partial/moderate assistance for eating (Ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented). Review of the care plan initiated on 3/10/25 revealed Resident #76 was at risk for malnutrition, alteration in nutrition and/or hydration…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, resident and staff interview and observations the facility failed to deliver the prescribed oxygen amount for 1 (Resident #60) of 6 residents sampled. The findings included: Review of the clinical record for Resident #60 revealed a physician's order dated 1/23/25 for oxygen to be delivered at 3 liters per minute via nasal cannula with humidifier for a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). On 6/15/25 at 10:30 a.m., in an interview, Resident #60 stated that his oxygen was to be set at 3 liters per minute. He said he was unable to get up and check the oxygen himself so he counted on the staff to make sure the concentrator was set at 3 Liters. Observation of the oxygen concentrator during the interview revealed it was set at 4 Liters (L) and had no humidifier. Photographic evidence obtained On 6/16/25 at 10:15 a.m., and 6/17/25 at 12:15 p.m., Resident #60 was observed in bed in his room. Resident #60 was receiving oxygen via nasal cannula. Observation of the oxygen concentrator revealed the oxygen was set at 4 liters per minute. No…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-08-24 · tag F0843 — widespread
  Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
  What the surveyor found here — the official record, unedited, may be distressing

  Based on record review and staff interview, the facility failed to have a written transfer agreement in effect with one or more hospitals approved for participation under the Medicaid and Medicare programs. The findings included: Review of the facility's assessment tool showed the facility had an agreement with multiple entities to allow for a smooth operation. The agreements did not include a transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. On 8/24/24 at 3:47 p.m., in an interview the Assistant Director of Nursing said the facility did not have an existing transfer agreement with a hospital. On 8/24/24 at 4:49 p.m., in an interview the administrator verified the facility did not have an existing transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-24 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, review of facility's policies and procedures, and staff interviews, the facility failed to ensure an allegation of neglect was reported to the State Survey Agency within the prescribed timeframe for 1 (Resident #1) of 3 residents reviewed. The findings included: Review of the facility's Standards and Guidelines for Abuse, Neglect and Exploitation investigations with a revised date of 11/1/2017 noted, All allegations of . neglect . are to be reported immediately to the Administrator and according to Federal and State Regulations . The facility will . file the Federal Immediate Report to the State Agency (if applicable). A 5 Day Follow-up Federal Report must be submitted within 5 days of the event occurring or when the Facility was made aware of the allegation . Review of the facility's incident investigations showed on 8/16/24 at around 7:30 p.m., Resident #1 with a diagnosis of Alzheimer's disease and mild cognitive impairment eloped from the facility. The preliminary report was submitted to the State Survey Agency on 8/20/24, four days after the facility…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-10-26 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, and review of job descriptions the facility failed to designate a licensed nurse to serve as a charge nurse on each tour of duty as required. The findings included: Review of facility Job description for Nurse Supervisor which states: Purpose of your job position: The primary purpose of your position is to supervise the day-to-day nursing activities of the Facility during your tour of duty. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility, and as may be required by the Director of Nursing Services (DON), to ensure that he highest degree of quality care is maintained at all times. Delegation of Authority: As Nurse Supervisor you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. On 10/25/23 12:51 p.m., during an interview the DON confirmed the facility has day shift managers, an evening supervisor, but no designated charge nurse or supervisor from 11:00 p.m., until 7:00 a.m. She said, No one is…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-10-26 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review, the facility failed to have a system in place to ensure an accurate inventory of controlled medications returned for disposition. The findings included: Review of the Policy Number 5.9 Medication Dispensing: Controlled Substances revised 3/2016 page 1 of 4: Controlled dangerous substances are handled by the facility in a manner that promotes proper storage, security, and compliance with applicable State and Federal regulations. On 10/24/23 at 11:42 a.m. Licensed Practical Nurse (LPN) Staff N said the Director of Nursing (DON) collects unused narcotics (controlled medications) from the medication carts each Friday and locks them in her office. 10/26/23 at 11:49 a.m., in an interview the DON confirmed she collects the controlled substances from each medication cart on Fridays. She signs the log verifying she removed the controlled substance packages. The log does not specify which medication and the remaining quantity removed. She said she brings them to her office and places them inside the double-locked file cabinet. Observation of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-10-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and medical record review, the facility failed to ensure the accurate nursing skin evaluation and coordination of care between dietary and physician services for nutritional supplements for 1 (Resident #45) of 3 residents reviewed for pressure wounds. The findings included: Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 had 2 unhealed stage 3 pressure ulcers and was receiving pressure ulcer care at the facility. Review of the admission and discharge record for Resident #45 revealed the resident was discharged from the facility on 10/5/23 and readmitted on [DATE]. Review of the progress note dated 10/5/23 at 5:32 p.m. revealed Resident #45 was sent to the hospital. Review of the progress note dated 10/17/23 at 5:20 a.m. revealed the resident returned to the facility. Review of the admission Nursing Comprehensive Evaluation for Skin completed on 10/17/23 revealed Resident #45's skin was intact and did not include the 2 unhealed stage 3…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$149,609 in federal fines across 3 penalties.

• $16,720 — penalty dated 2025-08-25
• $71,435 — penalty dated 2025-06-21
• $61,454 — penalty dated 2024-08-24

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to GOLD FL TRUST II — 36 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in FL