Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Lehigh Acres Healthcare & Rehab Center during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with significant mobility limitations sustained a left heel fracture when staff failed to properly position her feet during a transfer with a manual lift. Staff lacked recent training and competency evaluations for lift use, and documentation of such training was missing for multiple CNAs. Observations showed continued improper lift use and use of damaged equipment, while the facility's investigation and incident reporting were incomplete.
A resident with significant physical limitations sustained a heel fracture when staff failed to properly position her foot during a transfer using a manual lift. The facility lacked documentation of staff training and competency in lift use, and additional observations revealed improper transfer techniques and use of damaged equipment. The incident was not promptly or thoroughly investigated, and assessments of residents' transfer abilities were inadequately documented, resulting in Immediate Jeopardy.
A resident with significant mobility limitations suffered a fractured heel after staff failed to properly position her foot during a transfer with a manual sit-to-stand lift. Review of staff files and interviews revealed that CNAs and licensed nurses lacked current training and competency assessments for safe use of manual and mechanical lifts. Observations showed improper transfer techniques and use of damaged slings, in violation of manufacturer instructions and facility policy, placing multiple residents at risk of serious harm.
A resident with significant mobility limitations suffered a fractured heel when staff failed to properly position her foot during a transfer using a manual sit-to-stand lift. The facility did not investigate the incident, lacked documentation of staff training or competency in lift use, and did not ensure staff followed incident reporting protocols. Observations revealed additional unsafe transfer practices and use of damaged equipment, placing all residents requiring lift transfers at risk.
Staff failed to follow infection prevention protocols by leaving uncovered and unlabeled wash basins, bedpans, and urinals in shared bathrooms, including on grab bars and the floor. Residents reported that staff placed these items in unsanitary locations, and the Infection Preventionist confirmed that proper labeling and storage procedures were not followed.
A resident with COPD was prescribed oxygen at 3 L/min via nasal cannula with humidifier, but was repeatedly observed receiving 4 L/min without humidification. The resident depended on staff to set the oxygen correctly. Staff confirmed the order was not followed and admitted to not checking the settings during shift changes.
Two residents with cognitive and self-care deficits did not receive necessary assistance with shaving, despite care plans and facility policy requiring staff support for grooming. Observations and interviews confirmed that shaving was not performed or documented, and one resident's family had to pay for outside help. Staff interviews revealed inconsistent practices and lack of documentation regarding this aspect of ADL care.
A resident with significant risk factors developed stage II pressure ulcers after staff failed to consistently implement care plan interventions, including regular repositioning and use of a functional pressure-reducing mattress. The resident's reports of a damaged mattress were not addressed, and wound care was performed incorrectly, with improper use of cleansing products, lack of hand hygiene, and improper storage of care equipment, contributing to the deficiency.
A resident with multiple health conditions and a history of weight loss did not receive the prescribed fortified foods at two observed meals and experienced difficulty chewing and swallowing without timely staff intervention or reporting. Documentation failed to accurately reflect the resident's nutritional risk factors and interventions, and the need for a speech therapy evaluation was not identified until after surveyor observation.
A resident with COPD was observed receiving oxygen at a higher flow rate than prescribed and without the required humidification. Despite staff awareness of the correct order, the oxygen settings were not checked at shift change, leading to the resident not receiving the ordered respiratory care.
Surveyors found that the facility's emergency power plan designated three cool zones for resident evacuation during power disruptions, but only a limited number of emergency power outlets were available in these areas. The Maintenance Director was unaware of this limitation, and the deficiency was cited due to the potential impact on residents reliant on electronic medical equipment.
Surveyors found that the facility did not maintain its automatic fire sprinkler system in accordance with NFPA standards, as the gauges on the backflow and riser were last dated in 2019 and there was no documentation of required five-year gauge testing. The Maintenance Director was unaware if the gauges had been tested, and photographic evidence supported these findings.
A resident with severe cognitive impairment and a history of wandering was allowed to leave an LTC facility unsupervised due to staff neglect. Despite exhibiting confusion and a desire to leave, the resident's risk for elopement was not re-evaluated, and adequate supervision was not provided. The resident exited the facility, traveled 16 miles away, and was found in a potentially dangerous situation, highlighting a significant lapse in care and safety protocols.
A resident with severe cognitive impairment and a desire to leave was allowed to exit a facility without proper supervision or identity verification. The resident wandered to a busy road, boarded a bus, and was later hospitalized. Staff failed to recognize the resident's elopement risk, and the care plan did not reflect necessary interventions.
The facility did not have a written transfer agreement with any hospital certified by Medicare or Medicaid. Despite having agreements with various entities, the necessary transfer agreement was missing, as confirmed by interviews with the Assistant Director of Nursing and the administrator.
A facility failed to report an allegation of neglect within the required timeframe after a resident with Alzheimer's disease and mild cognitive impairment eloped. The facility's guidelines require immediate reporting of neglect allegations, but the preliminary report was submitted four days late, and the 5 Day follow-up report was submitted seven days after the incident. The Administrator confirmed the delay in reporting.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Ensure Safe and Competent Use of Lifts Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure ongoing training, competency, and supervision of staff in the safe use of manual and mechanical lifts, resulting in an avoidable accident involving a resident with obesity, a history of multiple strokes, and significant functional limitations. The resident, who was care planned for manual or mechanical lift transfers, sustained a left heel bone fracture after her foot became trapped between the lift and the wheelchair during a transfer. The resident reported that staff did not place her feet correctly on the lift, and despite her attempts to alert them, her foot was not repositioned, leading to the injury. Documentation revealed that the staff member involved had not received recent or adequate training or competency evaluation for lift use, and the facility could not provide evidence of such training for other staff members assigned to similar duties. Observations and interviews indicated that staff continued to use the manual lift for the resident after the incident, and that other residents were also transferred using improper techniques, such as not ensuring feet were fully supported on the lift's footrest. Staff interviews revealed a lack of recent training, with some staff unable to demonstrate or explain proper lift use. Personnel files for multiple CNAs lacked documentation of training, in-service, or competency evaluations related to lift use. Additionally, a worn and damaged sling was observed in use during a transfer, contrary to manufacturer instructions and facility policy, which require slings to be discarded if damaged. The facility's investigation into the incident was incomplete, with missing or insufficient documentation and a lack of comprehensive staff interviews. The Director of Nursing and Administrator were unaware of the incident until days later, and the incident was not properly reported or investigated according to facility policy. Manufacturer instructions for the lift and sling emphasized the need for trained caregivers and proper equipment inspection, which were not followed. These failures created an imminent danger and substantial probability of serious harm for all residents requiring lift transfers.
Plan Of Correction
On 06/20/2025, Resident #48 was assessed by the DON/Designee; no additional issues were identified. On 6/19/2025, the Administrator reported the incident to AHCA, DCF, and law enforcement as required, with a thorough investigation initiated. On 6/30/2025, the Administrator reported the incident involving the lift to the FDA in accordance with the Safe Medical Device Act of 1990. Resident #33's lift pad was immediately taken out of service and replaced upon discovery on 6/21/2025. All current residents requiring the use of mechanical lifts have the potential to be affected. The DON/Designee audited all residents in the facility; 45 residents were identified that require the use of facility lifts. All 45 residents were assessed on 06/20/2025, with no injuries noted. The DON/Designee assessed all mechanical lift slings on 06/21/2025, to ensure all lift slings were in proper working condition, with any findings addressed as identified. The DON/ADON have reviewed, revised, and implemented new competency evaluation forms for all facility lifts to provide more specific instructions on 06/19/2025. The DON/Designee will educate Licensed Nursing Staff, Certified Nursing Assistants, Physical and Occupational Therapists regarding the proper use of all facility lifts by 07/25/2025. All new employees will receive the training as part of their new hire orientation. The DON/Designee will audit ten residents requiring mechanical lifts weekly for four weeks, then five residents requiring mechanical lifts weekly for eight weeks, to ensure the safe use of facility lifts and prevent avoidable accidents. The Administrator/Designee will submit the audit findings to the QAPI Committee monthly for review and further recommendations. Date of completion is 07/25/2025.
Failure to Ensure Safe Use of Lifts and Staff Competency Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that staff were properly trained, competent, and supervised in the safe use of manual and mechanical lifts, resulting in an avoidable accident involving a resident with obesity, a history of multiple strokes, and significant functional limitations. The resident, who was cognitively intact but physically dependent, sustained a left heel bone fracture after her foot became trapped between the lift and her wheelchair during a transfer. The resident reported that her foot was not correctly positioned on the lift, and despite voicing this to staff, her concerns were not addressed, leading to the injury. Review of staff files revealed a lack of documentation for training or competency assessments related to the use of manual and mechanical lifts. The CNA involved in the incident had not received lift training in seven years, and her previous competency assessment was incomplete and unsigned. Other staff files also lacked evidence of lift training or competency evaluations. Observations of additional transfers showed improper use of the lifts, such as residents' feet not being fully supported on the footrests, and the continued use of a worn and damaged sling, contrary to manufacturer instructions and facility policy. The facility did not conduct a timely or thorough investigation of the incident. Key staff, including the DON and Administrator, were unaware of the injury until days later, and initial incident documentation and interviews were incomplete or missing. The therapy department's assessments of residents' transfer abilities were based on staff interviews rather than direct observation, and there was no documentation that residents' abilities to use the lifts were properly evaluated. These failures placed all residents requiring lift transfers at risk of serious harm and resulted in a determination of Immediate Jeopardy.
Failure to Ensure Staff Competency in Safe Use of Lifts Results in Resident Injury
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate training and competencies to safely use manual and mechanical lifts for resident transfers, resulting in a serious injury to a resident. One resident with a history of multiple strokes, obesity, and unilateral functional limitations was care planned for transfer with a manual sit-to-stand lift. The resident sustained a left heel bone fracture after her foot was not properly placed on the lift during a transfer, despite her attempts to alert staff to the improper positioning. Documentation revealed that staff did not have up-to-date or adequate training and competency evaluations for the use of the lifts, and there was no evidence that staff were assessed for competency with the specific equipment in use at the facility. Interviews with staff and review of personnel files showed that several CNAs and licensed nurses had not received recent or documented training on the safe use of manual and mechanical lifts. Some staff reported not having had lift training for several years, and others were unable to demonstrate or explain proper use of the equipment. Observations of transfers revealed improper techniques, such as residents' feet not being fully placed on the footrests, and the use of damaged slings with missing labels and frayed straps, contrary to manufacturer instructions and facility policy. The facility's own policies required staff to be trained and demonstrate competency with each type of lift, and to discard any worn or damaged slings, but these procedures were not followed. The lack of documented training, competency assessment, and adherence to manufacturer and facility protocols placed all residents requiring lift transfers at risk of serious harm. The surveyors determined that these failures resulted in Immediate Jeopardy, as evidenced by the injury to the resident and the ongoing use of unsafe practices and equipment. The facility was unable to provide documentation of staff education, competency verification, or timely investigation and reporting of the incident, further contributing to the deficiency.
Failure to Ensure Safe and Competent Use of Lifts Resulting in Resident Injury
Penalty
Summary
Facility administration failed to ensure effective oversight and staff competency in the safe use of manual and mechanical lifts for resident transfers, resulting in a serious injury to a resident with a history of multiple strokes, obesity, and unilateral functional limitations. The resident, who was care planned for a manual sit-to-stand lift, sustained a left heel bone fracture after her foot became trapped between the lift and her wheelchair during a transfer. The resident reported that her foot was not properly positioned on the lift, and despite voicing this to staff, the issue was not corrected. Documentation revealed that the resident was unable to assist with transfers and required extensive staff support, yet staff did not ensure her feet were correctly placed on the lift, directly leading to the injury. The facility did not investigate the incident, failed to document or verify that staff were trained and competent in the use of manual and mechanical lifts, and did not ensure that nursing staff followed facility policies and procedures for incident reporting. Personnel files for multiple CNAs lacked evidence of lift training or competency assessments, and interviews with staff confirmed that some had not received lift training in several years. Observations of other transfers revealed additional unsafe practices, such as residents' feet not being fully on the lift footrest and the use of damaged slings, further indicating a lack of staff competency and oversight. The administration did not maintain an accurate incident log, failed to initiate timely investigations, and did not provide documentation of staff education or reenactments related to the incident. Supervisory staff did not follow up on reports of injury, and incident reporting protocols were not followed. These failures placed all residents requiring lift transfers at risk for serious harm, injury, or death due to improper use of transfer equipment.
Improper Storage of Resident Care Items Compromises Infection Control
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices by not storing resident care items such as wash basins, bedpans, and urinals in a sanitary manner. Multiple observations revealed that these items were left uncovered and unlabeled in shared bathrooms, including being placed on grab bars, the floor, and other unsanitary locations. For example, a Wound Care Nurse was seen cleaning a resident's open wounds and then leaving a wet, uncovered wash basin on a grab bar in a shared shower. Additionally, an uncovered, unlabeled urinal was observed hanging from the grab bar behind a toilet in the same shared bathroom. Further observations in other shared bathrooms showed similar issues, with uncovered and unlabeled bedpans and urinals stored on grab bars, between the wall and grab bars, and on the floor. Residents reported that staff were responsible for placing these items in unsanitary locations and expressed concerns about the cleanliness and appropriateness of the storage. The Infection Preventionist confirmed that staff were trained to label and properly store these items in plastic and in residents' nightstands, but these procedures were not followed as observed.
Failure to Follow Physician's Oxygen Order for Resident with COPD
Penalty
Summary
The facility failed to follow a physician's order for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) who was prescribed oxygen at 3 liters per minute via nasal cannula with humidifier. Multiple observations revealed that the resident was receiving oxygen at 4 liters per minute without the required humidification. The resident reported being unable to check the oxygen settings and relied on staff to ensure accuracy. Staff interviews confirmed awareness of the correct order but acknowledged that the oxygen was set incorrectly and the humidifier was not in use. One LPN admitted to not checking the oxygen settings upon starting her shift.
Plan Of Correction
On 06/18/2025, resident #60 was assessed by the DON/Designee, confirming oxygen delivery is being provided in accordance with physician orders. All residents residing in the facility requiring supplemental oxygen have the potential to be affected. The DON/Designee will review all current residents requiring supplemental oxygen by 07/18/2025 to ensure that oxygen is delivered in accordance with physician orders, with corrective action immediately upon discovery. Licensed nurses will be re-educated by the DON/Designee regarding the delivery of oxygen in accordance with physician orders. This re-education will be completed by 07/25/2025. The DON/Designee will audit ten residents requiring oxygen weekly for four weeks, and then five residents requiring oxygen weekly for eight weeks, to ensure that oxygen delivery is provided in accordance with physician orders. The results of these audits will be submitted to the QAPI committee monthly for review and further recommendations. The overall completion date for these actions is 07/25/2025.
Failure to Assist Dependent Residents with Shaving as Required
Penalty
Summary
The facility failed to provide necessary assistance with shaving for two dependent residents who required substantial or maximal help with activities of daily living (ADLs), specifically grooming. Both residents had documented cognitive impairments and self-care deficits, with care plans indicating the need for staff to assist with grooming to maintain a clean and neat appearance. Despite these documented needs, observations over several days revealed that both residents had long, unshaven facial hair. Interviews with the residents, their family members, and staff confirmed that shaving was not offered or performed as required, and there was no documentation in the medical records to indicate that shaving had been completed, refused, or that any issues had been reported according to facility policy. For one resident, staff interviews revealed confusion about who was responsible for shaving and when it should be performed, with some staff stating it was done during showers and others admitting they had not provided or documented the care. The other resident's spouse reported having to pay out of pocket for shaving services, as staff had not provided this care. Facility records and progress notes lacked any documentation of shaving or refusals, contrary to the facility's own policy, which requires recording the date, time, and staff involved in the procedure, as well as any refusals or issues encountered.
Failure to Prevent and Properly Manage Pressure Ulcers
Penalty
Summary
A resident with multiple comorbidities, including chronic obstructive pulmonary disease, congestive heart failure, malnutrition, muscle weakness, and peripheral vascular disease, was admitted to the facility and identified as being at risk for pressure ulcers. The resident was always incontinent of urine and frequently incontinent of bowel, but was not on a toileting program. The care plan included interventions such as regular turning and repositioning, use of a pressure-reducing mattress, and proper positioning techniques. Despite these interventions, the resident reported that staff did not always have time to get him out of bed and that ordered Zinc Oxide was not consistently applied to his buttocks. On assessment, the resident was found to have developed stage II pressure ulcers on both buttocks and the sacrum, despite a skin check the previous day indicating intact skin. The resident also reported that his mattress had a hole, causing him to sink through and rest directly on the metal frame, which caused pain. He stated that he had reported this issue to the Maintenance Director multiple times, but no action was taken. Staff interviews confirmed the mattress was in poor condition and that the resident had not been out of bed recently, with the mattress taking the brunt of the pressure. During wound care observation, the Wound Care Nurse failed to rinse the soap from the resident's skin and did not perform hand hygiene between glove changes. The soap used was found to require rinsing according to manufacturer instructions, which was not done. Additionally, the wash basin used for wound care was improperly stored uncovered in a shared shower area, and an unlabeled urinal was also stored improperly, raising infection control concerns. The Wound Care Nurse admitted to not knowing the product in the soap dispenser and acknowledged the error after reading the instructions.
Failure to Provide Prescribed Diet and Address Chewing Difficulties
Penalty
Summary
A resident with multiple diagnoses, including Parkinson's disease, anemia, protein calorie malnutrition, and muscle weakness, was admitted and identified as being at risk for malnutrition and weight loss. The care plan specified the need to provide the prescribed diet, encourage adequate intake, and observe for difficulty chewing, with modifications to diet consistency as needed. Despite these interventions, the resident experienced a significant weight loss over several months, as documented in the weight records. During meal observations, the resident did not receive the prescribed fortified oatmeal at breakfast and was not provided with the ordered ice cream at dinner. The resident was observed having difficulty eating, with no staff assistance provided during breakfast and only partial assistance at dinner. The CNA assisting at dinner noted the resident's inability to chew and had to moisten the sandwich to facilitate eating, but did not report this difficulty to other staff members. Documentation and communication lapses were also identified. The Unavoidable Weight Loss form did not contain information related to the resident's weight loss, focusing instead on pressure ulcers. The Registered Dietitian was unaware of the resident's chewing difficulties until informed by surveyors, and only then was a Speech Therapy evaluation initiated. The lack of timely coordination and accurate documentation contributed to the resident not receiving appropriate interventions for nutrition and swallowing difficulties.
Failure to Provide Prescribed Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a physician's order for oxygen at 3 liters per minute via nasal cannula with humidifier, due to a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), was repeatedly observed receiving oxygen at 4 liters per minute without the required humidification. The resident, who was unable to check the oxygen settings independently, relied on staff to ensure the correct delivery. Multiple observations confirmed the oxygen concentrator was set incorrectly and lacked a humidifier. Staff interviews verified awareness of the correct order but acknowledged the oxygen was not checked at the start of the shift, resulting in the resident not receiving the prescribed respiratory care.
Insufficient Emergency Power Outlets in Designated Cool Zones
Penalty
Summary
The facility failed to provide evidence of an adequate emergency power plan as required by Florida Administrative Code 59A-4.126. During a record review, the emergency power plan was found to describe three designated cool zones for resident evacuation during power disruptions. However, upon touring the facility, it was observed that the number of emergency power outlets available in these cool zones was limited: 10 receptacles in the C-Wing Dining room, 1 in the Main Dining room, and 3 in the Gym. This limited supply of emergency outlets was documented with photographic evidence. The Maintenance Director, when interviewed during the observations, acknowledged the findings and stated he was unaware of the limited number of emergency outlets in the designated cool zones. The deficiency was cited because the lack of sufficient emergency power outlets in these areas could impact the health and comfort of residents who rely on electronic medical equipment during a power disruption. No specific residents or their medical histories were mentioned in the report.
Plan Of Correction
No individual residents appear to be affected as no residents were noted. All residents reliant on electronic medical equipment have the potential to be affected. The DON/designee reviewed all residents to identify those reliant on electronic medical equipment on 07/11/2025, with 58 residents identified. The Administrator will develop and implement a policy and procedure regarding meeting the emergency needs of residents reliant on electronic medical equipment during a power outage by 07/25/2025. The Maintenance Director contacted a third-party vendor to add additional generator-powered outlets to the facility cool zones on 07/15/2025. A quote was received for the additional generator-powered outlet installation, approved and signed by the Administrator on 7/16/2025. Re-education was completed by the Administrator with the maintenance staff regarding Florida Administrative Code 59A-4.126 Emergency Environmental Control for Nursing Homes on 07/15/2025. The Administrator/Designee will audit the facility's Emergency Management Plan monthly for three months to ensure that the plan addresses residents reliant on electronic medical equipment. Results of the audits will be reviewed by the QAPI committee monthly for three months and randomly thereafter. Date of completion: 07/25/2025.
Failure to Maintain and Test Sprinkler System Gauges
Penalty
Summary
During an unannounced Fire & Life Safety relicensure survey, surveyors identified that the facility failed to maintain its automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) 101 standards. Specifically, the sprinkler gauge on the backflow and the gauges on the riser were observed to be dated from 2019, indicating that they had not been replaced or tested within the required five-year interval. Documentation provided by the facility did not include evidence of the mandatory five-year gauge testing. The deficiency was confirmed through record review, direct observation, and staff interviews. The Maintenance Director, who accompanied the surveyors during the facility tour, acknowledged the findings and stated that he was unaware if the gauges had been tested as required. Photographic evidence was obtained to support the observations made during the survey. The report references multiple applicable codes and standards, including NFPA 101 (2021 Edition), NFPA 13 (2019 Edition), and NFPA 25 (2020 Edition), all of which require regular inspection, testing, and maintenance of water-based fire protection systems. The lack of current testing records and outdated gauges constituted a failure to meet these licensure requirements. No information regarding specific residents or their conditions was included in the report.
Plan Of Correction
No individual residents appear to be affected as no residents were noted. All residents have the potential to be affected. The maintenance director contacted a third-party vendor, and all three identified gauges were replaced on 07/10/2025. Re-education will be completed by the administrator with the maintenance staff regarding maintaining the automatic fire sprinkler system in accordance with NFPA 101 standards by 07/25/2025. The Maintenance Director will audit the sprinkler system to ensure it is maintained in accordance with NFPA 101 standards monthly for three months. Results of the audits will be reviewed by the QAPI committee monthly for three months and randomly thereafter. Date of completion 07/25/2025.
Neglect in Preventing Resident Elopement
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from neglect, specifically in preventing unsafe wandering and elopement. The resident, diagnosed with Alzheimer's disease and dementia, was admitted to the facility and initially assessed as not at risk for elopement. However, the resident exhibited behaviors such as confusion and a desire to leave the facility, which were not adequately addressed by the staff. Despite the resident's severe cognitive impairment and expressed intent to leave, the facility did not re-evaluate the resident's risk for elopement or implement sufficient supervision. On the day of the incident, the resident was observed wandering and expressing a desire to go home. The staff, including a Licensed Practical Nurse (LPN) and a receptionist, failed to take appropriate actions to prevent the resident from leaving the facility. The receptionist, who did not verify the resident's identity, allowed the resident to exit the facility, mistaking him for a visitor. The resident subsequently left the premises, walked to a busy road, and boarded a bus, traveling approximately 16 miles away from the facility. The facility's neglect in reassessing the resident's elopement risk and providing adequate supervision resulted in the resident's unsupervised departure, posing a significant risk to his safety. The clinical record lacked documentation of any re-evaluation of the resident's risk for elopement, despite clear indications of cognitive decline and unsafe wandering behavior. This oversight led to a determination of Immediate Jeopardy, highlighting the facility's failure to ensure the safety of cognitively impaired residents.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to recognize and adequately supervise a resident with severe cognitive impairment, confusion, wandering behavior, and poor safety awareness, who expressed a desire to leave the facility. The resident, who had been admitted from an acute care hospital with diagnoses including dementia and Alzheimer's disease, was not identified as at risk for elopement despite exhibiting behaviors such as wandering and expressing a desire to leave. On the day of the incident, the resident was seen sitting in the front lobby with a bag of clothes, and the receptionist allowed him to leave without verifying his identity. The staff were unaware of the resident's exit until over an hour later, during which time the resident had walked to a busy road, boarded a bus, and ended up at a bar where he complained of chest pain and was subsequently admitted to a hospital. The clinical record lacked documentation of adequate supervision or communication of the resident's exit-seeking behavior to the interdisciplinary team. The resident's care plan did not reflect the risk of elopement, and there was no evidence of a detailed monitoring plan to ensure his safety. Interviews with staff revealed that the resident was cognitively impaired and not safe to leave the facility unsupervised. Despite this, there was a failure to implement necessary interventions such as a wander alarm band. The receptionist did not follow protocol to verify the resident's identity, and the licensed nurse failed to provide adequate supervision. The facility's policies and procedures for preventing unsafe wandering and elopement were not effectively implemented, leading to the resident's elopement and subsequent hospitalization.
Lack of Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. During a review of the facility's assessment tool, it was found that while the facility had agreements with multiple entities to ensure smooth operations, these did not include a transfer agreement with any hospital certified by Medicare or Medicaid. This deficiency was confirmed through interviews with the Assistant Director of Nursing and the administrator, both of whom acknowledged the absence of such an agreement.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency within the required timeframe. The incident involved a resident with Alzheimer's disease and mild cognitive impairment who eloped from the facility. The facility's Standards and Guidelines for Abuse, Neglect, and Exploitation investigations require that all allegations of neglect be reported immediately to the Administrator and according to Federal and State Regulations. The preliminary report was submitted four days after the facility became aware of the neglect allegation, and the 5 Day follow-up report was submitted seven days after the incident, both outside the prescribed timeframe. The Administrator confirmed that the report was not submitted within the required timeframe during an interview.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Lehigh Acres
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winkler Court | 10.7 mi | ★★★★★ | 3 | 0 |
| Eagleridge Health And Rehabilitation Center | 11.5 mi | ★★★★★ | 9 | 1 |
| Aspire At Evans | 12.3 mi | ★★★★★ | 4 | 0 |
| Gulf Coast Medical Center Skilled Nursing Unit | 12.6 mi | ★★★★★ | 0 | 0 |
| The Preserve | 12.8 mi | ★★★★★ | 1 | 0 |
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