Below 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 Fort Myers Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A Dietary Aide was observed submerging dishes in the sanitizing solution for only 1-2 seconds instead of the required 60 seconds, then placing them to dry improperly. Interviews with dietary management confirmed the correct procedure was not followed, and the staff member was unable to describe the proper process.
Two residents with cognitive impairments and documented preferences for activities were repeatedly observed unengaged in their rooms, with no activity items or meaningful stimulation, despite care plans and activity calendars indicating the need for individualized and group activities. Activity records showed minimal or no participation, and staff interviews revealed challenges in providing consistent engagement due to limited training and staffing.
The facility assigned an unqualified staff member as Activity Director, with both the Activity Director and Activity Assistant lacking the required training and certification for the role. The Administrator confirmed the absence of necessary qualifications for the individual directing the activities program.
Surveyors found that three residents with indwelling urinary catheters did not have their catheters properly secured to their legs, resulting in taut and pulling tubing, and drainage bags not placed in privacy covers. In one case, a resident's catheter tubing and drainage bag were observed on the floor, and staff interviews confirmed inconsistent use of securement devices and lapses in sanitary practices.
Two residents with cognitive impairments were observed repeatedly unengaged in their rooms, despite care plans requiring staff assistance with activities. Initial electronic records showed little or no activity participation, and staff interviews revealed limited training and inability to reach all residents daily. The Activity Director later updated records to show daily participation, attributing this to late entries, but could not explain discrepancies between documentation and direct observations.
Multiple residents experienced barriers to a clean, comfortable, and homelike environment, including soiled items left in rooms, personal belongings out of reach, improper room layouts restricting access to bathrooms and personal devices, and unaddressed requests for assistance. Staff did not consistently respond to residents' needs for room adjustments, organization, or cleanliness, resulting in discomfort and reduced independence.
A resident with a new diagnosis of schizophrenia, as evidenced by psychiatric notes and an order for Seroquel, was not referred for a Level II PASRR screening after the condition was identified. The PASRR process was not updated to reflect the new or suspected mental disorder, resulting in a failure to coordinate appropriate assessments and referrals.
A resident with significant physical and cognitive impairments was repeatedly observed with long, untrimmed fingernails pressing into the palm, despite being dependent on staff for personal hygiene. Staff interviews and documentation indicated that nail care was not consistently offered or documented as refused, and the care plan did not specifically address nail care refusals.
A resident with End Stage Renal Disease and a DNR order experienced a lack of accurate communication and coordination between facility staff and the dialysis center. The communication binder used to share information contained outdated orders and incorrectly listed the resident as full code, while instructions for self-administration of medication conflicted with the resident's assessment. Staff interviews revealed confusion about responsibilities and schedules, highlighting failures in ongoing collaboration for dialysis care.
Surveyors observed multiple failures in infection prevention and control, including catheter drainage bags left on the floor and not in dignity bags for two residents, and staff not wearing required gowns during wound care for a resident under enhanced barrier precautions. Staff interviews revealed knowledge of proper procedures but inconsistent adherence, and PPE supplies were found to be lacking near the resident's room.
Improper Dish Sanitization in Dietary Department
Penalty
Summary
The facility failed to follow proper sanitation procedures for the 3-compartment sink in the dietary department, as observed during a survey. Staff O, a full-time Dietary Aide, was seen submerging dishes in the sanitizing solution for only 1-2 seconds, rather than the required 60 seconds as stated in the facility's posted instructions and policy. After this brief submersion, the staff member shook off excess water and placed the dishes on a rubber mat to dry, instead of allowing them to air dry on the designated metal rack above the sink. During interviews, Staff O was unable to accurately describe the correct process for washing, rinsing, and sanitizing dishes, and had to read the posted instructions aloud. The Assistant Certified Dietary Manager (ACDM) and the Certified Dietary Manager also reviewed the posted instructions and confirmed that the dishes should be submerged in the sanitizer for 60 seconds, not less. The ACDM acknowledged that Staff O had incorrectly sanitized the dishes, failing to meet the established sanitation protocol.
Failure to Provide Ongoing Activity Program for Residents
Penalty
Summary
The facility failed to provide an ongoing activity program that met the interests and supported the physical, mental, and psychosocial well-being of two residents reviewed for activity involvement. Observations and record reviews revealed that both residents, who had cognitive impairments and care plans specifying the need for encouragement and assistance with activities, were repeatedly found in their rooms unengaged, with no activity items, music, or television available. Activity calendars listed group and individual activities, but the residents were not observed participating, and documentation showed minimal or no attendance in activity programs over a 30-day period. One resident, with diagnoses including dementia, anxiety, and adjustment disorder, expressed preferences for reading materials, music, and pet therapy, and required encouragement to participate in activities. Despite these documented needs and preferences, the resident was observed multiple times alone in her room, facing a closet with an empty tray table and no meaningful engagement. The activity records indicated she attended only two activities in the previous month, despite the care plan interventions. Another resident, with severe cognitive impairment and similar diagnoses, also had a care plan calling for staff assistance with activities, including religious services and music. This resident was observed repeatedly in her room, facing a blank wall, with no activity items and minimal interaction. Documentation confirmed that she had not participated in any activity programs in the previous 30 days. Staff interviews revealed that activity staff had limited training, struggled to reach all residents for room visits, and could not provide consistent engagement, especially when short-staffed. The Activity Director acknowledged discrepancies between reported and documented participation.
Unqualified Staff Assigned as Activity Director
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional, as required by federal, state, and local standards. Review of the job description for the Activity Director indicated that the position is responsible for planning, developing, organizing, implementing, evaluating, and directing activity programs, and that college specialization or certification is preferred. However, interviews with the Activity Assistant and the individual serving as Activity Director revealed that neither had completed the required training or held certification for the position. The Activity Assistant stated she had no qualifications or training for the Activity Director role, and the Activity Director, who had been in the position for four years, confirmed she had not completed training and did not possess the necessary certificate. The Administrator also confirmed that the Activity Director did not have the required qualifications.
Failure to Secure and Maintain Urinary Catheters in a Sanitary Manner
Penalty
Summary
Surveyors identified that the facility failed to provide appropriate care for residents with indwelling urinary catheters, specifically by not securing catheters to prevent pulling and injury, and not maintaining catheters in a sanitary manner. Observations revealed that three residents with urinary catheters did not have their catheters properly secured to their legs as required by facility policy and physician orders. In multiple instances, catheter tubing was found to be taut, pulling, or stretched, and drainage bags were attached to bed frames without privacy covers. One resident reported discomfort and the need to hold the catheter during care to prevent pain, while another resident's catheter tubing was observed wrapped around a bedside table. Staff interviews confirmed that securement devices were not consistently applied, and that some staff believed only nurses, not CNAs, were responsible for securing catheters. Additionally, sanitary practices were not maintained, as one resident's catheter drainage bag, tubing, and valve stem were observed lying on the floor. The same resident requested a dignity bag to facilitate mobility, indicating awareness of proper catheter care. Staff acknowledged that keeping catheters off the floor was part of their training, but this was not consistently practiced. These findings were corroborated by direct observation, resident interviews, and staff statements, demonstrating a failure to follow established protocols for catheter care and infection prevention.
Failure to Maintain Accurate and Complete Activity Participation Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by accepted professional standards. Observations and record reviews revealed that the activity participation of these residents was not properly documented. For one resident with dementia and anxiety, care plans indicated the need for encouragement and assistance with activities such as music, pet therapy, and reading materials. However, during multiple observations, the resident was found alone in her room, unengaged, with no activity items, food, or drink available, and no evidence of participation in scheduled activities. Electronic records initially showed minimal activity participation, inconsistent with the care plan interventions. Another resident, also with dementia and additional diagnoses including severe protein calorie malnutrition and adjustment disorder, was observed repeatedly in her room, facing a blank wall, with no activity items or engagement. This resident expressed confusion and distress, and electronic records indicated no participation in activity programs over the previous 30 days. Staff interviews revealed that activity staff had limited training and were unable to visit all residents daily, despite care plans requiring staff assistance with activities and regular room visits for those unable to attend group programs. When questioned, the Activity Director initially stated that both residents attended daily activities, but upon review, could not explain the lack of documentation or reconcile it with direct observations of the residents in their rooms. Later, the activity participation records were updated to show daily attendance for both residents, but the Activity Director attributed this to "late entries" and could not explain discrepancies between the documentation and observed resident locations. This sequence of events demonstrates a failure to maintain accurate and timely records of resident activity participation, as required by professional standards.
Failure to Maintain Clean, Comfortable, and Accessible Resident Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for multiple residents, as evidenced by direct observations and resident interviews. One resident with moderately impaired cognition was found with a soiled incontinent brief on the bathroom floor, reporting difficulty accessing the bathroom due to the placement of his wheelchair and lack of a trashcan. The resident stated he had requested adjustments to the room layout but was told the wheelchair and bed could not be moved. The Assistant Director of Nursing also experienced difficulty entering the bathroom due to the room's layout but did not attempt to resolve the obstruction. Another resident, dependent on staff for mobility and transfer, had personal possessions out of reach and reported that staff placed facility items in his dresser, leaving no room for his belongings. The resident stated that staff would not help him organize or store his items, and a CNA indicated that since the resident could speak for himself, he only needed to ask for help. Additional observations included a resident requiring a mechanical lift who was found with soiled bedding and an exposed mattress, reporting discomfort and lack of an air mattress as expected. Staff interviews revealed inconsistent bedding changes and a lack of responsiveness to the resident's needs. A further resident with muscle wasting and pressure ulcers was unable to reach his phone charger or room phone due to bed placement and reported that staff would not move the bed or provide alternative solutions. Observations also noted a plastic bag containing a bedpan and paper towels tied to a siderail in a shared bathroom, with staff indicating it was garbage but not promptly removed. These findings collectively demonstrate the facility's failure to maintain a safe, clean, and accessible environment that supports residents' independence and comfort.
Failure to Refer Resident for Level II PASRR After New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a newly evident or possible serious mental disorder was referred to the appropriate state-designated mental health authority for a Level II PASRR screening. The resident was originally admitted with a Level I PASRR indicating anxiety but no need for further review. Later, a new Level I PASRR was completed due to additional mental health concerns, including suspected mental illness and adjustment disorder with anxiety, and was sent for a second-level review, which determined the resident did not have a serious mental illness. However, subsequent documentation in the resident's medical record showed a new order for Seroquel for schizophrenia and psychiatric provider notes indicating a diagnosis of dementia with behavioral delusions and a rule out for schizophrenia. Despite these new findings, the PASRR was not updated or sent for review for the newly diagnosed or suspected condition of schizophrenia, as confirmed by the Social Services Director during an interview.
Failure to Provide Personal Hygiene and Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for personal hygiene, including nail care, was repeatedly observed with long, untrimmed fingernails pressing into the palm of the left hand. The resident had significant medical conditions, including cerebral infarction, dementia, above-knee amputation, and legal blindness, and was documented as having limited dexterity and range of motion. Despite care plans indicating the need for staff to check, trim, and clean nails on bath days and as necessary, the resident's nails remained untrimmed over several days of observation. The clinical record and CNA documentation showed only a few instances of documented refusal of personal hygiene, and there was no documentation of refusal of nail care specifically. Interviews with staff revealed that while the resident was known to refuse some care, nail care was not consistently offered or documented as refused. The resident reported that staff had only occasionally asked to trim his nails and that he was unable to do so himself. Staff interviews confirmed the resident's nails were long and needed trimming, and that the resident had not refused nail care. The care plan addressed refusal of some care but did not specifically address nail care refusals, and staff did not consistently document or address the ongoing need for nail care.
Failure to Maintain Accurate Communication and Coordination for Dialysis Care
Penalty
Summary
The facility failed to maintain ongoing communication, coordination, and collaboration between the nursing home and the dialysis staff for a resident with End Stage Renal Disease who required dialysis. The resident had a documented Do Not Resuscitate (DNR) order in the facility's electronic medical record, but the dialysis communication binder, which travels with the resident to the dialysis center, incorrectly indicated a full code status and contained outdated physician orders and medication lists. The LPN responsible for updating the binder confirmed that the information was not current, and the DON and Regional Nurse stated that they believed it was the dialysis center's responsibility to manage advanced directives, not the facility's. The dialysis center nurse reported that the communication binder is their primary means of receiving information from the facility and that there was no record of advanced directives or care meetings in their chart. Additionally, the resident was noted to have mild cognitive impairment and episodes of confusion, particularly during dialysis. Despite an assessment indicating the resident should not self-administer medications, the communication binder included instructions for the resident to self-administer Sevelamer at dialysis, and the MAR reflected that the medication was sent with the resident. Staff interviews revealed confusion about the resident's dialysis schedule and medication administration responsibilities, further demonstrating a lack of effective communication and coordination between facility staff and the dialysis center.
Failure to Maintain Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in catheter care and adherence to enhanced barrier precautions. For one resident with a history of bacterial and urinary tract infections, the urinary catheter drainage bag was repeatedly observed lying on the floor and not placed in a dignity bag, contrary to facility policy and physician orders. Staff interviews confirmed awareness of the correct procedures, yet the catheter bag was left unsecured and in direct contact with the floor on more than one occasion. Another resident with multiple diagnoses, including muscle wasting and pressure ulcers, was also observed with a urinary catheter bag, tubing, and valve stem lying on the floor, despite staff acknowledging that this was not in compliance with infection control protocols. Additionally, during wound care for a resident under enhanced barrier precautions, staff failed to wear required personal protective equipment (PPE), specifically gowns, during high-contact care activities. While hand hygiene and glove use were observed, no gowns were worn by the LPN or CNAs assisting with the procedure, and staff expressed uncertainty about the requirements for gown use under enhanced barrier precautions. The PPE drawer near the resident's room was found to be empty at the time of observation, and staff interviews revealed confusion regarding the necessity of gown use during wound care, despite facility leadership providing clarification during the survey.
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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) |
|---|---|---|---|---|
| Cedarbrook Health And Rehabilitation Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Ambassador Healthcare At College Park | 1.7 mi | ★★★★★ | 11 | 2 |
| Page Rehabilitation And Healthcare Center | 1.7 mi | ★★★★★ | 8 | 0 |
| Gulf Coast Medical Center Skilled Nursing Unit | 2.6 mi | ★★★★★ | 0 | 0 |
| Aspire At Evans | 2.7 mi | ★★★★★ | 4 | 0 |
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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.