Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cedarbrook Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with chronic back pain experienced severe pain due to the facility's failure to provide timely administration of prescribed pain medications. Despite having physician orders for Morphine and Roxicodone, the medications were not in stock, leading to a significant delay in pain relief. The resident reported a high pain level and was unable to start therapy. Staff communication issues contributed to the delay, as the DON was not informed of the resident's needs promptly.
The facility failed to maintain a clean and comfortable environment, with issues such as a strong odor of urine, insects, and unsanitary conditions in resident rooms. Residents reported a lack of clean linen, and the laundry room had broken equipment. The Maintenance Director and Housekeeping Supervisor acknowledged these issues, with no maintenance book or PAR system in place.
The facility failed to provide adequate personal hygiene care for several residents, including those with dementia and other health conditions. Observations and interviews revealed missed showers, unshaven residents, and inconsistent documentation of care. Residents and their families reported dissatisfaction with the care provided, highlighting issues with staff responsiveness and adherence to care plans.
A facility failed to provide sufficient staffing, leading to delayed responses to call lights and inadequate personal care for residents. Observations and interviews revealed long wait times for assistance, unmet hygiene needs, and insufficient documentation of care activities. Family members expressed concerns about staffing levels, particularly in the memory care unit.
A resident's representative was not informed of a dose reduction and discontinuation of Seroquel, an antipsychotic medication, despite the resident's significant other being responsible for healthcare decisions. The resident, with severe cognitive impairment, experienced behavioral changes after the medication was discontinued. Interviews confirmed the lack of documentation and notification, although a discussion occurred during a care plan meeting.
The facility failed to ensure accurate comprehensive assessments of activity preferences for two residents with severe cognitive impairments. Both residents' MDS assessments inaccurately marked all activity preferences as 'very important,' despite their inability to provide accurate responses. The administrator acknowledged issues with the previous Activity Director's documentation.
The facility failed to provide a meaningful, resident-centered activity program for two residents with cognitive impairments. One resident with dementia was often left sitting alone without engagement, despite a care plan outlining various activities. Another resident with Parkinson's and dementia was observed with minimal activity participation, and their significant other noted a lack of staff assistance to activities. The Activity Director, new to the position, acknowledged challenges in providing individualized activities, and the Administrator noted issues with previous staff not completing assessments.
A resident with an indwelling urinary catheter experienced improper catheter care as the drainage bag was repeatedly found on the floor, contrary to facility policy. Despite staff awareness of proper procedures, a lack of supplies led to the use of a makeshift paper clip hook to keep the bag off the floor, resulting in unsanitary conditions.
Two residents in the facility experienced deficiencies in IV therapy management. One resident had a PICC line with an undated dressing and unlabeled IV solution, with no documented care orders. Another resident had an IV catheter in place without current treatment orders, and staff were unaware of the necessary care instructions. Both cases lacked adherence to facility policy and professional standards for IV care.
The facility did not maintain nebulizer machines in a sanitary manner for two residents. Observations revealed uncovered and undated nebulizer masks on nightstands. The facility's policy requires masks to be stored in plastic bags and dated. A Unit Manager confirmed the responsibility lies with the unit nurse.
A resident with Type II Diabetes, Celiac Disease, and malnutrition was not provided with a diet that met her gluten and lactose dietary restrictions. She reported being served oatmeal and grits, which she could not eat. Observations revealed she was served 2% milk, cereal, and non-gluten-free bread, contrary to her dietary needs. The Dietary Manager confirmed these errors.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident with chronic back pain due to spinal stenosis, resulting in the resident experiencing severe pain. Upon admission, the resident had physician orders for Morphine Sulfate and Roxicodone to manage chronic pain. However, the facility did not have the prescribed medications in stock, and the resident did not receive the first dose of Roxicodone until the following day, and the first dose of Morphine was delayed even further. The resident reported waiting 20 hours for pain relief, experiencing a pain level of 7 out of 10, and was unable to start therapy due to the pain. Interviews with staff revealed that the prescription for Morphine was faxed to the pharmacy but was not available at the facility. The resident was offered Tylenol instead, which was not sufficient for her pain level. Communication issues were evident as the Director of Nursing (DON) was not aware of the prescription being available and had not been informed of the resident's needs on the day of admission. The DON began educating staff on the issue only after becoming aware of the situation, indicating a lack of immediate response to the resident's pain management needs.
Facility Fails to Maintain Sanitary Environment and Adequate Linen Supply
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by multiple observations and interviews. Upon entrance, a strong odor of urine was detected, and a large brown insect was found crawling in the dining room. Maintenance staff confirmed the presence of the insect, which was alive. Additionally, a resident's indwelling catheter drainage bag was observed on the floor, and the wall in one room had unpainted patches. Another room had a toilet plunger stored in a wash basin, urine in the toilet, black grout, and peeling tiles, with a strong odor of urine reported by a resident's spouse. Several residents reported unsanitary conditions, including sticky floors with crumbs, feces on the bathroom floor, and clogged sinks. One resident's bathroom had a buildup of dirt around the toilet, and another had missing laminate from the sink and brown particles behind the toilet. The Maintenance Director stated that pest control visits weekly, but there was no maintenance book for staff to report issues, relying instead on maintenance rounds. The facility also failed to provide adequate linens, with residents and staff reporting a lack of clean towels and sheets for several months. The laundry room was found to have broken equipment, with one dryer and one washer out of service since August. The laundry aide reported insufficient linen supplies and a broken air-conditioner in the laundry room. The Housekeeping Supervisor confirmed the lack of a PAR system for linen distribution and stated that linen was distributed based on immediate need. Despite purchase orders for linen, the facility's linen closets were inadequately stocked, and the Administrator admitted there was no policy for laundry services.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for several residents, as observed and documented in the report. Resident #8, who has dementia and requires supervision for showers, was found with a strong body odor of urine and unshaven for several days. His wife reported that she often had to shave him herself and that staff were unresponsive to her requests for assistance. Documentation showed missed showers and inconsistent personal hygiene care. Resident #51, who requires substantial assistance with showers, reported infrequent showers despite being scheduled for them multiple times a week. He expressed dissatisfaction with the care provided and had communicated his concerns to various staff members, including the Director of Nursing and the Administrator. Documentation revealed multiple instances where scheduled showers were not provided or documented. Resident #89, who is dependent on assistance for personal hygiene, was observed with unshaven facial hair, long fingernails, and soiled bed sheets. The resident reported long wait times for assistance and inadequate care. Staff interviews indicated a lack of consistent documentation and follow-up on residents' refusals of care. Similar issues were noted for Residents #317 and #95, who also experienced lapses in scheduled showers and personal hygiene care, with inadequate documentation and staff awareness of their care needs.
Inadequate Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, resulting in delayed responses to call lights and inadequate personal care. Observations and interviews revealed that residents experienced long wait times, often over 30 minutes, for assistance after activating their call lights. Some residents reported that staff would turn off the call lights without providing the needed help, particularly during the evening and night shifts. This lack of timely response was compounded by reports of staff being seen watching television instead of attending to residents' needs. Several residents were observed to have unmet personal care needs, such as being unshaven, having long fingernails, and emitting strong odors of urine, indicating a lack of regular hygiene care. Documentation reviews showed that scheduled showers and personal hygiene tasks were frequently marked as not applicable or not documented at all, suggesting that these care activities were not consistently provided. Family members of residents also expressed concerns about insufficient staffing, particularly in the memory care unit, where incidents of resident falls and wandering were reported. The facility's failure to provide adequate staffing and timely care resulted in residents not receiving necessary assistance with activities of daily living, such as bathing, shaving, and toileting. This deficiency was evident across multiple shifts and affected numerous residents, as corroborated by both resident and family member testimonies and the lack of documentation for care activities. The observations and interviews conducted by surveyors highlighted a systemic issue of inadequate staffing and care provision within the facility.
Failure to Notify Resident's Representative of Medication Changes
Penalty
Summary
The facility failed to notify the representative of a resident about changes in the medication regimen, specifically the dose reduction and discontinuation of an antipsychotic medication, Seroquel. The resident, a male with diagnoses including Parkinson's disease, Dementia, and Depression, was admitted from an acute care hospital with a prescription for Seroquel 50 mg twice daily. On 10/15/24, the physician reduced the dosage to once daily, and on 10/21/24, the medication was discontinued. However, there was no documentation in the clinical record indicating that the resident's representative was informed of these changes. The resident's significant other, who was responsible for making healthcare decisions, was unaware of the medication changes until 11/1/24, when she noticed behavioral changes in the resident and inquired about the medication. Interviews with the Director of Nursing and the MDS Coordinator confirmed the lack of documentation and notification to the resident's representative. The MDS Coordinator mentioned discussing the medication change with the spouse during a care plan meeting on 10/24/24, but this discussion was not documented.
Inaccurate Activity Preference Assessments for Residents
Penalty
Summary
The facility failed to ensure that comprehensive assessments accurately reflected the activity preferences of two residents. Resident #83, who was admitted with diagnoses including Cerebral Vascular Accident, Dementia, and Parkinson's Disease, had a severely impaired cognition as indicated by a Brief Interview for Mental Status score of 00. Despite this, the Minimum Data Set (MDS) assessment recorded that all eight questions related to daily and activity preferences were marked as 'very important,' suggesting inaccuracies in the assessment process. Similarly, Resident #95, admitted with Parkinson's disease, Dementia, and Depression, also had a severely impaired cognition with a Brief Interview for Mental Status score of 03. The resident was unable to correctly report the year, month, or day, and could not recall specific words. Yet, the MDS assessment similarly noted that all questions regarding daily and activity preferences were marked as 'very important.' The facility's administrator acknowledged issues with the previous Activity Director's completion and documentation of activity assessments, which contributed to these inaccuracies.
Deficiency in Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing, meaningful, resident-centered activity program to support the interests and meet the physical, mental, and psychological well-being of two residents. Resident #8, who has dementia with mood disturbance and anxiety, was observed multiple times seated in his wheelchair in the lounge area with the television on but no individualized activities in progress. Despite having a care plan that included various interventions to engage the resident in activities, the resident's spouse reported that her husband was rarely taken to activities and often left sitting alone. The Activity Director, who had recently started, acknowledged the lack of activities on individual units and stated that activities were conducted in the main dining room, making it challenging to provide individualized attention. Resident #95, diagnosed with Parkinson's disease, dementia, and depression, was also observed sitting alone in front of the TV or at a table with minimal engagement in activities. The resident's significant other noted that staff did not often assist the resident to activities. The activity calendar in the resident's room showed no activities listed past 3:30 p.m., and records indicated that the resident had attended activities only a few times in the past 30 days. The Administrator acknowledged issues with the previous Activities Director not completing assessments and documentation, and noted that the current activity staff were new. The facility's activity program was found lacking in providing individualized and meaningful engagement for residents, particularly those with cognitive impairments. The Activity Director confirmed the absence of activities on individual units and the challenges in conducting one-on-one activities for all residents. The Administrator mentioned a separate activity schedule for the memory care unit but could not provide documentation of Resident #95 attending activities there. The lack of a facility policy for the activities program was also noted.
Improper Catheter Care and Sanitation
Penalty
Summary
The facility failed to maintain urinary catheters in a safe and sanitary manner for a resident with an indwelling urinary catheter. The facility's policy on catheter care, revised in January 2024, mandates that infection control guidelines be followed to minimize catheter-associated infections. This includes ensuring that the drainage spigot does not touch the floor, the tubing is free of kinks, and the catheter is kept at an appropriate level to promote urine flow. However, during observations, it was noted that the resident's catheter drainage bag was found on the floor on multiple occasions. On one occasion, a registered nurse confirmed the drainage bag was on the floor and acknowledged it should not be there. The following day, the drainage bag was again observed on the floor, and the nurse admitted to using a makeshift paper clip hook due to a lack of supplies. Interviews with certified nursing assistants revealed that catheter drainage bags should be hung from the bed or wheelchair to prevent them from touching the floor. Despite this knowledge, the facility failed to provide adequate supplies to ensure proper catheter care, leading to the observed deficiency.
Deficiencies in IV Therapy Management for Two Residents
Penalty
Summary
The facility failed to ensure proper care and management of intravenous (IV) therapy for two residents, leading to deficiencies in the administration and maintenance of IV lines. Resident #67, who was admitted with Alzheimer's disease, dementia, and other conditions, was observed with a peripherally inserted central catheter (PICC) in the left forearm. The dressing on the insertion site was undated, and the IV solution bag was unlabeled and undated. There were no documented orders for the care of the catheter, including dressing changes and flushing, as required by the facility's policy and professional standards. Resident #89, who had been readmitted with multiple diagnoses including venous insufficiency and chronic heart failure, had an IV catheter in place without any current orders for its care or removal. The resident reported that the IV had been in place since hospital discharge and was not being used for any current treatment. The facility staff, including registered nurses, were unaware of the orders for the care and flushing of the IV catheter. The medication administration record indicated that the antibiotic therapy was completed earlier, yet the IV remained in place without proper documentation or care instructions.
Failure to Maintain Sanitary Nebulizer Machines
Penalty
Summary
The facility failed to maintain nebulizer machines in a sanitary manner for two residents who required respiratory care. The facility's policy, revised in December 2023, mandates that nebulizer and tubing should be stored hygienically, with the tubing bag labeled with the date it was changed. During an observation, a nebulizer mask was found uncovered and undated on a nightstand in one resident's room. In another resident's room, a nebulizer mask was observed hanging down the side of the nightstand. The Unit Manager, a Registered Nurse, confirmed that nebulizer masks should be covered in a plastic bag and dated when not in use, and that the nurse on the unit is responsible for the care of the nebulizer.
Failure to Accommodate Dietary Restrictions
Penalty
Summary
The facility failed to provide a diet that accommodated the documented gluten and lactose dietary restrictions for a resident with Type II Diabetes, Celiac Disease, and malnutrition. The resident reported being served oatmeal and grits, which she could not eat due to her Celiac Disease. During an observation, the resident's breakfast included a carton of 2% milk and cereal, despite her meal ticket indicating allergies to gluten and lactose. Additionally, the resident was served a slice of bread at lunch, which was not gluten-free. The Dietary Manager confirmed that the resident should not have been served cereal, 2% milk, or non-gluten-free bread.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Myers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Page Rehabilitation And Healthcare Center | 0.6 mi | ★★★★★ | 8 | 0 |
| Fort Myers Rehabilitation And Nursing Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Aspire At Evans | 1.7 mi | ★★★★★ | 4 | 0 |
| Lee Memorial Hospital Skilled Nursing Unit | 2.6 mi | ★★★★★ | 0 | 0 |
| Ambassador Healthcare At College Park | 2.8 mi | ★★★★★ | 11 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.