Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Eagleridge Health And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents experienced inappropriate and poorly managed discharges. One resident with acute PE, acute respiratory failure, DM2, affective disorder, and Parkinson’s disease was discharged to an ALF with transportation arranged through an outside company, but the transport request was later canceled and not confirmed by staff. After being moved from her room to an activities area and repeatedly told her ride was coming, she left the building in her wheelchair without staff awareness and was later found on the roadside and taken to the ED. Another resident with degenerative disc disease, DM2 due to other mental disorder, and adjustment disorder was transferred to another nursing home without a documented medical reason, without a 30‑day written notice, and with a discharge order lacking reason, level of care, or assistance needs. He reported being told he would be evicted if he did not choose a facility, refused to sign the transfer notice, and ultimately was sent to a different nursing home than the one he chose, later having to arrange and pay for his own transportation after the receiving facility would not take him back.
A resident who had prepaid for services was discharged with a credit balance of $7,582.31 due back after copays were applied, but the facility did not refund the full amount within the required 30 days. The business office confirmed the resident had prepaid $11,067.31 and acknowledged that the facility’s refund turnaround time was about 30–60 days. Documentation showed two partial refund checks totaling $5,123.31 were sent, leaving $2,459.00 still owed to the resident beyond the 30-day timeframe, contrary to federal requirements and the facility’s own policy.
A resident with chronic kidney disease, recent digestive surgery aftercare, and a nephrostomy tube, who required maximal assist for transfers and used a wheelchair, was being transported by a CNA-driver for follow-up care and subsequent ER evaluation. Instead of proceeding directly to the ER, the CNA-driver diverted to a personal dental appointment, parked the facility van in an unshaded area, turned the engine off, and left the resident strapped in the wheelchair in the back of the van without supervision. The van’s doors and windows were largely closed, it became very hot inside, and the resident, who remained cognitively intact, called 911 reporting she was locked in and getting warm. Police and Fire Department responders found the non-running van with only a slightly open door and one window down, noted the resident was visibly sweating, and removed her from the vehicle. The facility’s own policies prohibited leaving residents unattended in vehicles and required continuous supervision during transport, but these were not followed, resulting in a finding of neglect and Immediate Jeopardy.
Two residents with intact cognition experienced unsafe and inappropriate discharges when the facility failed to confirm and document transportation, ensure supervision until departure, provide proper notice, and accurately document reasons and destinations for transfer. One resident with multiple serious medical conditions waited for hours for a ride that had been canceled by the transport company, then left the building in a wheelchair without staff awareness and was later found on the roadside and taken to the ER by EMS before being sent to an ALF. Another resident with diabetes, spinal disc degeneration, insomnia, and depressive disorders was told he had to choose a new facility or be evicted, was not given a 30‑day written notice, refused to sign the transfer form, and was discharged without a documented medical reason to a different nursing home than the one he reported choosing, later incurring personal costs and housing instability after the receiving facility would not readmit him post‑hospitalization.
A cognitively intact LTC resident with multiple medical and mental health diagnoses was discharged to another nursing home without receiving the required 30‑day written notice for a non-emergency transfer. The physician’s discharge order lacked a documented reason, level of care, or assistance needs, and the transfer notice stated the resident’s health had improved so facility services were no longer needed, which the resident refused to sign. The resident reported being told he would be evicted if he did not choose among three placement options and that his room was needed for a different type of care, and he was ultimately sent to a different facility than the one he selected. Facility staff acknowledged that only an undocumented verbal notice of about three weeks was given, that there was no medical reason for the transfer, and that the move was related to the facility’s transition to more short-term beds, with the receiving facility not offering higher-level services.
The facility did not follow its own policy requiring that any credit balance on a private account be refunded within 30 days once all payers are settled. A resident who had prepaid for services was discharged with a substantial credit balance due back. The Business Office Manager confirmed the prepaid amount and the total overpayment owed, and stated that the facility’s refund turnaround time is about 30–60 days. Records showed that only partial refunds were issued over several months, and a significant portion of the refund remained unpaid well beyond the required timeframe, resulting in the resident not receiving the full amount owed in a timely manner.
Housekeeping and maintenance services were not provided to keep several resident rooms clean and orderly. Surveyors observed black substance on AC vents in multiple rooms, along with missing and cracked floor tiles, discolored and cracked caulking, peeling wallpaper, water damage, stained bathroom tiles, and embedded dirt in the Memory Care unit. The DSES said he was responsible for cleaning the vents, stated they should not look like that, and acknowledged awareness of the environmental concerns.
A resident had a significant, documented weight loss over several months, with dietary notes showing reduced intake, no supplements, and medications that could contribute to weight change. Although dietary staff noted the resident needed MD review, the record did not show the physician was notified, and provider notes continued to state the resident’s weight was stable and ROS was negative for weight loss.
A resident with muscle wasting and atrophy, Type II DM, and pulmonary disease had the admission MDS completed 21 days after admission instead of within the required 14-day timeframe. RN and an LPN verified the delay, and the LPN stated the assessment should have been completed by the deadline but was not.
A resident with severe cognitive impairment and a history of falls experienced multiple falls and significant injuries due to inadequate supervision and unclear implementation of a fall prevention plan. Despite having a care plan, the resident continued to fall, resulting in a right hip fracture and a right humerus fracture. The facility's documentation and staff interviews revealed gaps in supervision, with no clear definition of frequent rounds, contributing to the resident's repeated falls.
Failure to Ensure Safe and Properly Planned Discharges for Two Cognitively Intact Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate, and properly planned discharges for two cognitively intact residents, resulting in noncompliance with federal requirements for transfer, discharge, and discharge planning. For the first resident, who had diagnoses including acute pulmonary embolism, acute respiratory failure, type 2 diabetes, unspecified affective disorder, and Parkinson’s disease without dyskinesia, the facility arranged same-day transportation through an outside transport company to return the resident to an assisted living facility (ALF). The Social Services Director documented that transportation was scheduled for late afternoon, but the clinical record did not contain documentation of the actual pickup date and time. The transport company later reported that the request was canceled because it did not meet their required notice time. The resident was removed from her room and placed in the activities room to wait, and staff repeatedly told her that transportation was on the way. As the day progressed, key administrative staff left the building while the resident continued to wait. The ADON reported that when he left around early evening, the resident was at the nurse’s station asking about her ride, and he told her that the ALF was coming to pick her up. He later received text messages from an RN indicating that the resident was upset and wanted to leave, followed by another message that she had left. The NHA stated that staff assumed the resident had left with her ride, even though no one actually saw her get into a vehicle. The resident reported that she had been waiting for transportation for several hours, that “the big wigs left,” and that the night nurses did not know what to do with her. She stated she eventually pushed open the door and left the facility in her wheelchair without staff awareness. She described self-propelling in the road, not knowing the route to her ALF, and being found on the side of the street by passersby who called 911. An ER physician note documented that she reported waiting all day, becoming tired of waiting, leaving, and being found on the side of the street in her wheelchair before being transported to the ER. For the second resident, who had diagnoses including degenerative disc disease, type 2 diabetes due to other mental disorder, and adjustment disorder with mixed anxiety and depressed mood, the facility discharged him to another nursing home in a different county without a documented medical reason that met regulatory criteria for transfer or discharge. A psychiatric progress note described the resident as unstable with episodes of agitation related to situational concerns about being transferred to a new nursing home. The discharge summary indicated he was being discharged to another nursing home, and a discharge order was entered without specifying the reason for transfer, level of care, or assistance needed. The written transfer and discharge notice given to the resident stated that his health had improved sufficiently so he no longer needed the services of the facility, but the resident refused to sign the form. The Social Services Assistant confirmed that the resident was not given a 30-day written notice and only received an undocumented verbal notice of about three weeks. The NHA stated that the resident was transferred because the facility was transitioning to more short-term beds, and the ADON confirmed there was no medical reason for the transfer, that the resident still needed LTC, and that the receiving facility did not provide any additional care beyond what the discharging facility could provide. The resident reported he had been told he would be evicted if he did not choose a place, that he selected one facility but was transported to another, and that after subsequent hospitalization the new facility would not readmit him, leaving him to arrange and pay for his own transportation and live in hotels.
Plan Of Correction
F627 Appropriate Discharge (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident #1 was discharged from the facility. On , Resident #2 was discharged from the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. On , NHA/Designee completed a quality review of residents discharged in the previous 30 days to ensure appropriate transportation was provided and to ensure residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice for non-emergent situations are provided a full 30 day notice with an appropriate reason. Any concerns noted were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. By , The NHA/Designee completed education with current social services staff and IDT team members on ensuring appropriate transportation was provided and to ensure residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice for non-emergent situations are provided a full 30 day notice with an appropriate reason. Any concerns noted were immediately corrected. Newly hired Social Services staff and IDT team members will be educated on ensuring appropriate transportation was provided and to ensure residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice for non-emergent situations are provided a full 30 day notice with an appropriate reason. Any concerns noted were immediately corrected. NHA/designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The DON/Designee will audit 5 random discharged residents to ensure appropriate transportation was provided and to ensure residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice for non-emergent situations are provided a full 30 day notice with an appropriate reason. Any concerns noted were immediately corrected. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Timely Refund Full Balance Owed After Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to refund the full amount of funds owed to a discharged resident within 30 days, as required by 42 CFR 483.10(g)(17)-(18) and the facility’s own policy. The facility policy stated that when a credit balance exists on a resident’s private account, and all insurance, Medicaid, and third-party payers are paid with no remaining deductibles or copays, a refund will be issued by check within 30 days of confirmation. Record review showed that one resident was discharged with a credit balance of $7,582.31 from prepaid charges after applicable copays were paid. The Business Office Manager confirmed that the resident had prepaid $11,067.31 and that $7,582.31 was due back to the resident upon discharge as an overpayment. The Business Office Manager also stated that the typical turnaround time for issuing a refund from the facility is about 30–60 days, which exceeds the 30-day requirement. Documentation provided showed that the facility issued one refund check for $4,011.31 and a second refund check for $1,112.00 to the resident, but as of the survey date, the facility still owed a remaining refund amount of $2,459.00, which had not been returned within 30 days of discharge.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. F582 Medicaid/ Medicare Coverage / Liability Notice (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? By , Resident #3 refund was sent. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. On , NHA/Designee completed a quality review of residents discharged in the previous 30 days to ensure refunds were provided in a timely manner. Any concerns noted were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. On4/2/2026, Business Office Manager were educated by the NHA/designee on ensuring refunds are provided in a timely manner. Newly hired Business Office Managers will be educated to ensure refunds are provided in a timely manner by the NHA/designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. NHA/Designee to conduct audits of 5 random discharged residents to ensure refunds are provided in a timely manner weekly for 4 weeks then monthly for 2 months.The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Resident Left Unattended in Non-Running Transport Van in Hot Weather
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect during transportation, resulting in the resident being left unattended in a non-running facility transport van in hot weather. The facility’s own Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility’s transportation policy and Fleet Management Manual required that residents remain under continuous supervision during transport, prohibited leaving residents unattended in vehicles, and specified that facility-owned vehicles were to be used only for facility business. Despite these policies, the assigned CNA-driver left the resident alone in the van while he went into a dentist’s office for a personal appointment. The resident involved had been admitted in early March with diagnoses including surgical aftercare following digestive system surgery, chronic kidney disease, and adjustment disorder with mixed anxiety and depressed mood. A BIMS assessment showed intact cognition with a score of 13/15. The care plan identified the resident as being at risk for fluid imbalance related to diuretic use and colostomy, with a goal to remain free from symptoms of dehydration. The resident required maximum assistance of one person for transfers and, according to the ADON and Director of Rehab, was non-ambulatory and always seen in a wheelchair, unable to walk or get out of the wheelchair independently. On the day of the incident, the resident had been seen by urology and was directed to go to the ER due to abnormal labs and concern for a possible fistula, and she had a nephrostomy tube with multiple tubes in place. Instead of proceeding directly to the ER, the CNA-driver diverted to a shopping center where his dentist’s office was located. He parked the facility van in an unshaded area, left the engine off, and left the resident strapped in her wheelchair in the back of the van. The resident reported that all doors and windows were shut and that it became very hot inside the van. The CNA later acknowledged in an interview that he left the resident unattended and strapped in the wheelchair, stating he had a bleeding mouth and stopped for an appointment, and that the window was only “a little open.” A police report documented that officers were dispatched after the resident called 911 stating she was locked in the bus and it was getting warm inside. When police and the Fire Department arrived, the van was not running, only the driver’s window was down and the front passenger door was slightly ajar, the vehicle was not in a shaded area, and the outside temperature was approximately 83°F and felt much warmer inside the van. The resident was visibly sweating, and the Fire Department had difficulty opening the doors, ultimately removing her through the front door. The police report recorded an offense code for crimes against person–neglect of an elderly disabled adult without great harm. The resident later described feeling trapped, becoming very hot, and believing she could have died if not rescued, and her son reported that she became emotional and cried when recounting the incident. The Emergency Department physician note documented that the patient was an elderly female who had been told by urology to go to the ER due to abnormal labs and that she reported feeling weak, with the note explicitly stating that she had been left in the van by the driver. A late-entry nursing progress note from the facility recorded that while being transported to the hospital following her appointment, the resident was left temporarily unattended and called 911, and that she had no signs of distress and was evaluated out of an abundance of caution. The CDC heat health information cited in the investigation noted that even in cool temperatures, cars can heat to dangerous levels quickly and that older adults are more prone to heat-related health problems. Based on these facts, surveyors determined that the facility failed to protect the resident’s right to be free from neglect by not preventing her from being left unattended in a hot, non-running vehicle, leading to an Immediate Jeopardy determination.
Failure to Ensure Safe, Appropriate, and Properly Noticed Discharges for Two Cognitively Intact Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate discharge planning and execution for two cognitively intact residents, resulting in unsafe and inappropriate transfers/discharges. For the first resident, who had diagnoses including pulmonary embolism with acute cor pulmonale, acute respiratory failure, type 2 diabetes, presence of a cardiac pacemaker, anxiety disorder, depression, unspecified affective mood disorder, and Parkinson’s disease without dyskinesia, the facility arranged transportation through an outside transport company to return the resident to an assisted living facility (ALF). The social services director documented that transportation was scheduled for late afternoon on the day of discharge, but the clinical record contained no documentation of the actual pickup time. The transport company later reported that the request was canceled the same day because their required advance notice had not been met. On the day of discharge, the resident was removed from her room and placed in the activities room to wait for transportation. Multiple staff interviews indicated that the resident remained in common areas (activities room, dining room, lobby, and at the nurse’s station) asking about her ride as the afternoon and evening progressed. The assistant director of nursing stated that when he left the facility early in the evening, the resident was still asking about her ride and was told that the ALF was coming to pick her up. He later received text messages from an RN that the resident was anxious and wanted to leave, followed by a message that the resident had left. The nursing home administrator stated that staff assumed the resident had left with her transportation, even though no one actually saw her get into a vehicle and there was no documentation of her departure. The resident later reported that she had been waiting for transportation for hours, that “the big wigs left and the night nurses did not know what to do with her,” and that she eventually pushed open the door and left the building in her wheelchair without staff awareness. She stated she did not know the route to her ALF, did not have her phone, hearing aids, or dentures, and was self-propelling her wheelchair in the road when a couple stopped to help and called 911. An emergency department physician note documented that the resident said she had been waiting all day, became tired of waiting, left, and was found on the side of the street in her wheelchair before being brought to the ER by EMS. The ALF administrator reported that she was informed by the nursing home that the ALF had not picked up the resident, and later learned from a hospital case manager that the resident had been found on the side of the road and transported to the hospital. For the second resident, who had diagnoses including intervertebral disc degeneration, type 2 diabetes, insomnia due to other mental disorder, and depressive episodes, the facility failed to provide appropriate notice and justification for transfer and did not ensure the resident was discharged to the chosen destination. A psychology note shortly before discharge documented that the resident was unstable and having episodes of agitation due to situational concerns about being transferred to a new nursing home the following week. The discharge summary indicated the resident was being discharged to another nursing home in a different county, and a discharge order was entered without specifying the reason for transfer, level of care, or assistance needed. The written transfer and discharge notice given to the resident on the day of discharge stated that the reason for discharge was that the resident’s health had improved sufficiently so that he no longer needed the services provided by the facility, and documented that the resident refused to sign the notice. The resident later reported that he had been given three options of places to go and was told he would be evicted if he did not choose one, and that the facility told him they needed to free up his room because it was being converted to a different type of care. He stated that he chose a nursing home in one city but was instead transported to a nursing home in another city. The social services assistant stated that the resident chose the nursing home where he was sent, but also acknowledged that the resident was not given a 30‑day written notice of transfer and that there was no documentation of the verbal notice she said had been given three weeks earlier. She confirmed that the resident refused to sign the transfer form and that she was unsure why he was transferred. The nursing home administrator stated that the facility gives a 72‑hour notice if they cannot provide the skills or services to meet a resident’s maximum potential and that this resident was transferred because the facility was transitioning to more short‑term beds, and also acknowledged that the forms were not filled out correctly and there was no documentation that the resident agreed to transfer. The assistant director of nursing stated there was no medical reason for the transfer, the resident was not a danger to himself or others, still needed LTC, and that the receiving nursing home did not provide any additional care that their facility could not provide. The resident further reported that two days after arriving at the new nursing home he was hospitalized for medical complications, and that the new nursing home would not accept him back after his hospital stay. He stated that he then had to pay out of pocket for transportation back to his original city and was living in hotels because he had no home. Overall, the record review and interviews showed that the facility did not follow its own transfer and discharge policy requirements for notice, documentation of reasons for transfer, confirmation of transportation, and ensuring that discharges and transfers met residents’ needs and preferences and were carried out safely for both residents involved.
Failure to Provide Required 30-Day Notice for Non-Emergency Transfer
Penalty
Summary
The facility failed to provide a 30‑day advance written notice of a non-emergency transfer or discharge to one cognitively intact long-term care resident, as required by state law. The resident had multiple diagnoses, including a disc condition, Type 2 diabetes, and mental health conditions, and was admitted and cared for as a long-term care resident. A progress note documented that the resident was experiencing agitation related to “situational concerns of being transferred to a new nursing home next week,” indicating awareness of an upcoming move but not formal notice. The discharge summary showed the resident was discharged to another nursing home in a different county, and the physician’s discharge order did not include a reason for transfer, level of care, or assistance needed. The official Nursing Home Transfer and Discharge Notice listed the reason for discharge as the resident’s health having improved so that facility services were no longer needed, and documented that the resident refused to sign the form. In interviews, the resident reported being given three options of places to go and being told he would be evicted if he did not choose one, and that staff said they needed to free up his room because it was being converted to a different type of care. The resident stated he chose a nursing home in Venice, Florida but was instead transported to a facility in Sarasota, Florida, and later had to arrange and pay for his own transportation back to Fort Myers after a hospitalization when the new nursing home would not readmit him. The Social Services Assistant acknowledged that the resident was not given a 30‑day written notice and only received a verbal notice of about three weeks, with no documentation of that verbal notice, and confirmed the resident refused to sign the transfer form. The Nursing Home Administrator stated they typically give a 72‑hour notice when they believe they cannot provide needed services and indicated the resident was transferred because the facility was transitioning to more short-term beds. The ADON confirmed there was no medical reason for the transfer, the resident was not a danger to self or others, still required LTC, and that the receiving facility did not provide any additional care beyond what the current facility could provide.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. N0505 30- Day Notice Required (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident #2 was discharged from the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. On , NHA/Designee completed a quality review of residents discharged in the previous 30 days to ensure residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice for non-emergent situations are provided a full 30 day notice with an appropriate reason. Any concerns noted were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. By [R] , The NHA/Designee completed education with current social services staff and IDT team members on ensuring residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice for non-emergent situations are provided a full 30 day notice with an appropriate reason. Newly hired Social Services staff and IDT team members will be educated on ensuring residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice for non-emergent situations are provided a full 30 day notice with appropriate reason, by the NHA/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; The DON/Designee will audit 5 random non-emergent discharged residents to ensure residents/responsible parties that refuse to sign the Nursing Home Transfer Discharge Notice are provided a full 30 day notice with an appropriate reason, weekly x4 weeks and monthly x 2 months. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Timely Refund Full Prepaid Balance to Discharged Resident
Penalty
Summary
The facility failed to refund the full amount of funds owed to a discharged resident within 30 days, as required by its own policy. The policy, revised January 29, 2024, states that when a credit balance exists on a resident’s private account and all payers (insurance, Medicaid, and/or third-party) are settled with no remaining deductibles or copays, a refund check is to be issued within 30 days. Record review showed that one resident was discharged on 6/9/2025 with a credit balance of $7,582.31 from prepaid charges. The Business Office Manager (BOM) confirmed that the resident had prepaid $11,067.31 on 5/9/2025 and that, after co-pays were applied, $7,582.31 was due back to the resident upon discharge. The BOM stated that the facility’s turnaround time for issuing refunds is about 30–60 days. Documentation showed that only partial refunds of $4,011.31 and $1,112.00 were issued on 7/14/2025 and 10/22/2025, respectively, and as of 3/31/2026 the facility still owed the resident $2,459.00, meaning the full refund was not provided within 30 days of discharge. This deficiency centers on the facility’s noncompliance with its refund policy and the resulting delay in returning the full prepaid balance to the discharged resident, as confirmed through record review and interview with the BOM.
Housekeeping and Maintenance Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to provide housekeeping and maintenance services to ensure a clean environment in 7 of 20 rooms observed on the Memory Care and North units. The facility’s Environmental General Cleaning policy stated that it is the policy of the facility to provide a clean, safe, orderly, comfortable, and attractive homelike environment and to use accepted practices and procedures to keep the facility free from odors, accumulations of dirt, dust, and safety hazards. During observations, surveyors found multiple environmental concerns in resident rooms, including front air conditioning vents coated with multiple spots of a black substance in rooms 135, 139, 138, 203, 204, and 207. In the Memory Care unit, surveyors also observed a missing floor tile, cracked and discolored caulking around toilets, peeling wallpaper with orange discoloration and water damage, stained and cracked bathroom floor tiles, a large gap in tiles, a cracked wall by the air conditioning unit, and embedded dirt in tiles. The Director of Environmental Services was shown the observations and stated he was responsible for cleaning the air conditioning vents, said the vents should not look like that, and acknowledged awareness of the environmental concerns in the Memory Care unit, stating the unit had been slowly worked through to address identified environmental issues.
Failure to Communicate Significant Weight Loss to Physician
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when it did not communicate a significant weight loss to the physician for one resident. The resident’s documented weights showed a decline from 185.0 lbs. in February 2025 to 161.4 lbs. in August 2025, including a 13% loss of 24 lbs. over 180 days. The resident had a dietary order for a regular diet with large portions for weight loss, was not receiving supplements, and dietary notes documented usual intake of 51% to 75% and 76% to 100% with good appetite. The resident was also taking Donepezil and Memantine, which were noted as medications associated with weight change and a possible contributing factor. A dietary progress note on 8/17/25 stated the resident was being evaluated for significant weight change and included “Defer to MD,” but the clinical record did not show that the physician/provider was notified of the significant weight loss. Although provider progress notes repeatedly documented that the resident’s weight was stable and the review of systems was negative for weight loss, the record review and staff interviews showed the weight loss had not been effectively communicated. The Regional Dietitian stated the communication box was checked on the 7/31/25 dietary note but not on the 8/17/25 note, and later said there was no way to verify that the physician reviewed the communication reports. The APRN stated she noticed the weight difference when reviewing the system and asked staff to reweigh the resident because one weight had been obtained standing and others sitting.
Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete a Comprehensive Minimum Data Set (MDS) assessment within 14 calendar days of admission for Resident #70. The resident was admitted with diagnoses including muscle wasting and atrophy, Type II Diabetes Mellitus, and pulmonary disease. Review of the admission MDS showed it was completed on 3/27/25, which was 21 days after admission. During an interview on 8/20/2025, MDS coordinators RN Staff C and LPN Staff D verified the admission date and confirmed the MDS assessment was not completed until 21 days after admission. LPN Staff D stated the assessment should have been completed by 3/20/25 and was unsure why it was not completed within the required 14-day timeframe, noting that the facility follows the RAI manual requirement for completion within 14 days of admission.
Inadequate Supervision Leads to Multiple Falls and Injuries
Penalty
Summary
The facility failed to provide adequate supervision to prevent multiple falls and major injuries for a resident with severe cognitive impairment and a history of falls. The resident, who was admitted with conditions including dementia, seizures, and unsteady gait, experienced five documented falls within a short period. Despite having a care plan in place that included interventions such as encouraging the use of a call bell and wearing appropriate footwear, the resident continued to fall, resulting in significant injuries including a right hip fracture and a right humerus fracture. The facility's documentation and staff interviews revealed gaps in the implementation of the fall prevention plan. The resident was found on the floor multiple times, often confused and unable to explain how the falls occurred. Staff interventions, such as frequent rounding, were not clearly defined or consistently executed, as evidenced by the lack of documentation on how supervision was provided. The Director of Nursing confirmed that there was no adequate definition of frequent rounds, which contributed to the resident's repeated falls. The interdisciplinary team identified the resident's psychotic state as a contributing factor to one of the falls, but the facility did not adjust the care plan effectively to address the ongoing risk. The lack of clear and consistent supervision, combined with the resident's cognitive and physical limitations, led to repeated falls and serious injuries, highlighting deficiencies in the facility's fall prevention and supervision protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 99 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Gulf Coast Medical Center Skilled Nursing Unit | 1.1 mi | ★★★★★ | 0 | 0 |
| The Preserve | 2.5 mi | ★★★★★ | 1 | 0 |
| Fort Myers Rehabilitation And Nursing Center | 3 mi | ★★★★★ | 0 | 0 |
| Ambassador Healthcare At College Park | 3.5 mi | ★★★★★ | 11 | 2 |
| Page Rehabilitation And Healthcare Center | 4.2 mi | ★★★★★ | 8 | 0 |
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